Simply Blue SM  - Dental - Benefits and Rates - (Effective September 23, 2010)

B e n e f i t s
Your Coverage*	Plan A $250 annual deductible with $1,250 annual coverage maximum	Plan B $100 annual deductible with $1,250 annual coverage maximum	Plan C $100 annual deductible with $1,250 annual coverage maximum. Plan includes coverage for major restorative services.
Services covered immediately
Diagnostic/ preventive – routine exams and cleanings, including periodontal cleaning	100% No deductible for routine checkups	100% No deductible for routine checkups	100% No deductible for routine checkups
Prosthodontic – (denture) repairs and adjustments	80%	80%	80%
Basic restorative – fillings and sealants	80%	80%	80%
Oral surgery – including extractions	50%	50%	50%
Endodontics – root canals	50%	50%	50%
Services covered after a 12-month period
Periodontal care – Treatment of gum disease	Not covered	Not covered	50%
Crown and cast restorations	Not covered	Not covered	50%
Prosthodontics – dentures, partial dentures and bridges	Not covered	Not covered	50%

R a t e s
Plan A	Monthly	Quarterly	Annual
Subscriber age 18 – 49	$15.66	$46.98	$187.92
Subscriber age 50+	$14.02	$42.06	$168.24
Plan B
Subscriber age 18 – 49	$28.55	$85.65	$342.60
Subscriber age 50+	$25.50	$76.50	$306.00
Plan C
Subscriber age 18 – 49	$45.83	$137.49	$549.96
Subscriber age 50+	$40.94	$122.82	$491.28

* Coverage at non-network dentists is subject to the maximum amount payable (MAP), which is the maximum amount Delta Dental will pay for a given procedure. If you receive care from a non-network dentist who charges more than the MAP, you’ll be responsible for the additional amount. Delta Dental network dentists agree not to charge more than the MAP.