State of New MexicoGeneral Services Department

Risk Management Division

Administered by Delta Dental of New Mexico

Dental Plan BenefitsEffective July, 2008

PPONew Mexico Delta Dental PPO Find a Dentist

“In-Network” providersin New Mexico

Over 750 dentistlocations statewide

These dentists will not billpatients for any amount

over the Planfee allowables.

“In-Network” providers outside of New Mexico

Nationally, over 105,000 dentist

locationsThese dentists will not billpatients for any amount

over the Planfee allowables.

Whenever possible, usein-network dentists.

On-line dentist searchdeltadentalnm.com

Out-of-network dentists may balance bill patients for amounts over the Plan

fee allowables.

Delta Dental has several dentist networks.

In-Network: PPONew Mexico is exclusively available to NMIBAC enrollees, and is exclusively available in New Mexico.

In-Network: Delta Dental PPO dentists are considered in-network when services are received outside New Mexico.

Out-of-Network: Delta Dental Premier. Balance billing will apply, but will be less than if services were received from a dentist who does not participate in Delta Dental Premier.

Higher levels of benefits and lower out-of-pocket costs ALWAYS apply in-network!

GSD/RMD Dental PlanProvider Network Overview

Calendar Year Deductible

Does not apply to Diagnostic & PreventiveServices or Orthodontic Services

$50 per enrolled person $150 aggregate per family

Calendar Year Maximum

$1750 per enrolled person

GSD/RMD Dental Plan

Benefit In-Network Out-of-Network

Diagnostic and Preventive Services

Plan Pays 100%no deductibleYou Pay: 0%

Plan Pays 100%no deductible

You Pay: Any Amount Balance Billed *

Oral Examinations - twice in a calendar year Cleanings - twice in a calendar year X-rays: Full mouth -1 in 5 years / Bitewing - 2 in a calendar year Fluoride Application - through age 18, twice per calendar year Emergency Treatment Space Maintainers - through age 18, 5 year limitation Sealants - through age 15, permanent molars only, 3 year limit

GSD/RMD Dental PlanBenefits Overview

* Out of network dentists may balance bill patients for amounts over Plan fee allowables.

Benefit In-Network Out-of-Network

Basic ServicesPlan Pays 80%

deductible appliesYou Pay: 20%

Plan Pays 55%deductible applies

You Pay: 45% plus Balance Billing *

Amalgam or composite resin fillings Extractions – surgical/non-surgical Periodontics - non-surgical / surgical treatment of gum disease Endodontics - pulp therapy and root canal filling Repair of implants, dentures and bridgework General Anesthesia - intravenous sedation & general anesthesia Oral Surgery Stainless steel crowns

GSD/RMD Dental PlanBenefits Overview

* Out of network dentists may balance bill patients for amounts over Plan fee allowables.

Benefit In-Network Out-of-Network

Major ServicesPlan Pays 60%

deductible appliesYou Pay: 40%

Plan Pays 35%deductible applies

You Pay: 65% plus Balance Billing *

Inlays, Onlays, Crowns and Cast Restorations – when teethcannot be restored with amalgam or composite resin restorations

Prosthodontics – Bridges, partials or complete dentures

Implants – specified services and related prosthodontics,subject to clinical review/approval

GSD/RMD Dental PlanBenefits Overview

* Out of network dentists may balance bill patients for amounts over Plan fee allowables.

Benefit In-Network Out-of-NetworkORTHODONTIC SERVICES

No deductibleChildren -- up to 18th birthday

Plan Pays 75% up to a $2000 lifetime maximum

Adults -- age18 and over

Plan Pays 60%up to a $1750 lifetime maximum

GSD/RMD Dental PlanBenefits Overview

Out of network dentists may balance bill patients for amounts over Plan fee allowables.

Patient Disclosure –You’re entitled to it!

PPONEW MEXICO Dentist’s Guarantee

Upon request, a pre-treatment cost range will be provided by your dentist.

You and your dentist agree.

Pre-determination of benefits from Delta Dental is recommended (not required) for expensive procedures.

GSD/RMD Dental PlanPatient Disclosure

GSD/RMD Dental PlanInformation Available 24/7! 

Online access to personalized benefit information, oral health information,privacy policies and more. No software to purchase or download required.

Featured Plan Information Available at deltadentalnm.com in the Subscriber Section

Go to Subscriber Materials, then sign in with your group number (8523).View, print, or save coverage documents:

Summary of Benefits

Dental Benefit Handbook

Network Information Page

PPONew Mexico Provider Directory

Consumer Toolkit

Select the Consumer Toolkit link, sign in, and:

• Verify eligibility of subscriber and dependents

Confirm status of deductibles and plan maximums

Review how a specific claim was processed

Print a personalized subscriber ID card

www.deltadentalnm.com

Experienced Benefit Service Representatives

Available Monday – Friday 8:00 AM - 4:30 PM (MST)

505-855-7111 or Toll Free 1-877-395-9420

GSD/RMD Dental PlanCustomer Service

All claims and customer services provided locally.

No frustrating phone “menu of options” from which to choose.

Talk to a local representativewithin 45 seconds of calling!

Great service is our way of saying “Thank you for your enrollment.”

www.deltadentalnm.com