Dental Plan BenefitsAugust, 2010

Administered by Delta Dental of New Mexico

Delta Dental PPOSM Delta Dental Premier®

Select a Delta Dental PPO dentist to help reduce patient out-of-pocket costs.

Select a Delta Dental Premier dentist if your dentist or specialist only participates in this network.

Find a Dentist

UNM Hospitals Dental PlanProvider Network Overview – Point-of-Service Plan

One Plan, two network choices! Plan Participants can select any dentist in either the Delta Dental Premier or

Delta Dental PPO network at the time dental services are received.

817 points of access in New Mexico

Over 138,900 dentist locations nationally

Almost 220,000 dentist locations nationally

Over 1,180 points of access in New Mexico

Log on to deltadentalNM.com to search for a dentist. Pre-selection of a dentist is not required and every member of your family may

visit a different dentist. There is no need to contact Delta Dental to change your dentist; you may

change as often as you like. Whenever possible, use in-network dentists.

Lower out-of-pocket costs, and important member protections apply when services are received in-network!

UNM Hospitals Dental PlanDental Plan Benefits Overview

Separate Lifetime Maximums apply to Orthodontic Services

Calendar Year Deductibles$50 per enrolled person

$150 aggregate per family • Does not apply to Diagnostic & Preventive Services• Does not apply to Orthodontic Services

Calendar Year Maximums • $1,200 per enrolled person per benefit period

Out-of-network dentists may balance bill patients for amounts over Maximum Approved Fees.

Delta Dental PPOSM Delta Dental Premier®

Diagnostic and Preventive Services – No Deductible

Covered Oral Exams & Cleanings (2 per Calendar Year), X-rays, Fluoride Application, Emergency Treatment, Sealants, Space Maintainers, and Diagnostic Casts

Delta DentalPays 100%

YouPay 0%

Delta DentalPays 100%

YouPay 0%

Basic Services

Fillings, Stainless steel crowns, Extractions, Oral Surgery, Root canals, Periodontics (surgical or non-surgical), and General Anesthesia

Delta Dental Pays 80%

YouPay 20%

Delta DentalPays 80%

YouPay 20%

Major Services

Onlays, Crowns, Bridges, Partials or Complete dentures, Specified Implant Procedures

Delta Dental Pays 50%

YouPay 50%

Delta DentalPays 50%

YouPay 50%

UNM Hospitals Dental PlanDental Plan Benefits Overview

Out-of-network dentists may balance bill patients for amounts over Maximum Approved Fees.

UNM Hospitals Dental PlanOrthodontic Benefit Overview

ORTHODONTIC SERVICES (child and adult)

No deductible

Delta Dental Pays 50%up to $1,000

lifetime maximum

Enrollees Pay 50% plus balance of costup to the applicable Delta Dental

Maximum Approved Fee

UNM Hospitals Dental PlanPredetermination of Benefits

ASK YOUR DENTIST FOR A PREDETERMINATION OF BENEFITS

when more costly procedures are anticipated.

Patient Disclosure –You’re entitled to it!

An advance estimate of benefits

before dental care services are

received

Not required but strongly

recommended

No charge for this service.

UNM Hospitals Dental PlanSpecial Eligibility Provisions

Please remember…

If you enroll one dependent (spouse/domestic partner/child), you

must enroll all dependents except children under the age of 3

with proof of other coverage.

Children are covered through age 18

Full-time students are covered through

age 24 (verification of full-time student

status must be provided to UNMH

Human Resources)

UNM Hospitals Dental PlanInformation Available 24/7!

Enrollees have 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

Subscriber Materials are accessed with the UNMH group number (4101).

Enrollees may view, print, or save coverage documents:

Summary of Benefits

Dental Benefit Plan Provisions

Provider Directory

Consumer Toolkit

Enrollees may also select Consumer Toolkit and sign in to:

• 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

UNM Hospitals Dental PlanCustomer Service

Dental plan claims and administration services provided in New Mexico

Experienced Benefit Representatives

• Available Monday – Friday 8:00am-4:30pm

• Albuquerque 505-855-7111

• Toll free 1-877-395-9420

• Over 95% of calls answeredin fewer than 45 seconds

UNM Hospital Dental RatesPer Pay Period(24/Year)

COVERAGE TYPEEE COST Full Time

EE COST Part Time

Employee $ 0.00 $ 6.10

Employee + 1 $ 17.50 $ 23.60

Employee + 2 or more $ 33.50 $ 39.60