Dental Plans

UT SELECT DENTAL Highlights:

• You may see Network of Out-of-Network dentists
• DeltaPreferred Option dentists charge reduced contract fees
• No pre-approval needed to change dentists
• No referral needed to see a specialist
• 161,000 dental locations nationwide
• Delta Dental pays network dentists directly

Understanding Delta Dental's Unique Dentist Networks

DeltaPremier

• No advance billing
• No claim forms
• Dentist fees limited to DeltaPremier "allowance"
• No balance billing
• Out-of-pocket costs limited by Delta Dental's calculation of DeltaPremier "allowance"
• Credentialed dentist network
• Protection under Delta Dental's unique participating dentist agreements offering:
• quality assurance/consultant review
• cost management systems
• benefit of all Delta Dental policies and procedures
• Access to one of the largest dental PPO networks in U.S.
• 161,000 DeltaPremier Dental offices nationwide

DeltaPreferred Option (DPO)

UT SELECT DENTAL subscribers who choose a dentist from the smaller DPO network gain all the advantages of the larger DeltaPremier network plus:

• Out-of-pocket costs lower due to lower DPO "allowance"
• Discounted fee agreements average 30-35% off of submitted charges
• 86,000 DeltaPreferred Option (DPO) Dental Offices

Delta Dental Savings

Procedure: Two surface amalgam filling

Sample Claim	DPO Dentist	DeltaPremier Dentist	Non-Participating Dentist
Billed Charge	$125	$125	$125
Allowable	$76	$101	$101
Savings	$49	$24	$24
80% Benefit Payment	$61	$81	$81
Patient Out of Pocket	$15	$20	$44

Procedure: Porcelain Crown

Sample Claim	DPO Dentist	DeltaPremier Dentist	Non-DeltaPremier Dentist
Billed Charge	$800	$800	$800
Allowable	$533	$710	$710
Savings	$267	$90	$0
50% Benefit Payment	$267	$355	$355
Patient Out of Pocket	$266	$355	$445

*Billed charges are for illustration purposes only

Assurant Dental Maintenance Organization (DMO)

The new plan offered to you by Assurant Employee Benefits is called the Heritage Plus Plan. The chart below provides a comparison of several copayment amounts for the new Heritage Plus plan vs. the Legend Pinnacle plan.

Copayment Comparison

Selecting and changing a dentist

At the time of enrollment you will need to select a Plan Dentist for yourself and each eligible member of your family. Each eligible family member may choose a different Plan Dentist.

Contact customer service at 800-443-2995 for assistance with changing your Plan Dentist.

The dental plan is simple to use when you follow these steps:

• Verify with your Plan Dentist that you are on their roster before making a dental appointment.
• Call early for routine dental care for the best availability of appointment times.
• Be familiar with your copayment schedule to determine your costs for dental services.
• Discuss concerns regarding proposed treatments with your Plan Dentist.
• Register for Online Advantage for Members at www.assurantemployeebenefits.com/UT to view your benefit information online at your convenience!

When you need to see a specialty dentist

All Assurant enrollees are eligible for the Specialty Benefit (SB). The SB offers three benefit options when seeking treatment from a specialty dentist. With your Assurant Heritage Plus plan, a referral is not necessary to seek treatment from a specialty dentist.

Option One:

When seeking treatment by an SB Plan Specialty Dentist including in-network Endodontists, Periodontists or Oral Surgeons who accept the SB Copayment Schedule. Here is how the benefit works:

• For a service listed on the SB Copayment Schedule, all you will pay is a fixed copayment amount which is considerably lower then the normal retail charge.
• For procedures not listed on the SB Copayment Schedule you will receive a 25% discount (15% discount for Endodontist) off the normal retail charge. This includes a 25% discount on orthodontic and pedodontic services.
• To find an SB Specialty Dentist please refer to the provider directory (indicated with an S) or online at www.assurantemployeebenefits.com under For Members – Find a dentist. When making an appointment please confirm that your chosen specialty dentist participates in the SB.

If you do not see a Plan Specialty Dentist who participates in the SB the following options are available to you. It is recommended that you call Customer Service at 800.443.2995 for assistance in determining the best option for you.

Option Two:

When seeking treatment by a network Specialty Dentist who does not participate in the SB you will receive a flat discount on all procedures:

• You will receive a 25% discount off the specialty dentist’s (excluding Endodontist’s) normal retail charge. You will receive a 15% discount off Endodontist’s normal retail charge.
• To find a Plan Specialty Dentist please to the provider directory or online at www.assurantemployeebenefits.com/UT under For Members – Find a dentist.

Option Three:

When seeking treatment by an out-of-network Specialty Dentist you can still receive a benefit under the plan. Plan benefits are provided for procedures listed in the Maximum Non-Plan Specialty Reimbursement. A claim will need to be submitted to Assurant Employee Benefits. Here is how the benefit works:

• At the time of service you will pay the specialty dentist’s normal retail charge for the services performed.
• If the procedure is listed on the SB Schedule you will be reimbursed the amount shown in the Maximum Non-Plan Specialty Reimbursement list or the amount charged by specialty dentist for the procedure, whichever is less. An annual maximum of $2,000 applies.
• No benefits are available for services not listed on the SB Schedule.

You may read additional information about plan features and exclusions in the Dental Plan guides available from your campus Benefits Office.