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DeltaCare USA _comprehensive plan_ Highlights _ Directory

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DeltaCare USA _comprehensive plan_ Highlights _ Directory Powered By Docstoc
					                                                Kaiser Foundation Health Plan of Georgia, Inc.
                                                                           The comprehensive prepaid plan available to
                                                                          FEHBP members for an additional premium.



                                                                  Benefit highlights




Welcome to                                                          Quality
DeltaCare USA                                                       •	 Extensive	benefits	for	you	and	your	family
                                                                       N
                                                                    •	 	 o	restrictions	on	pre-existing	conditions,	
DeltaCare USA is a dental program that provides you and
your family with quality dental benefits at an affordable cost.        except	for	work	in	progress
The DeltaCare USA program is designed to encourage you                 L
                                                                    •	 	 arge,	stable	network	of	dentists,	so	you	can	
and your family to visit the dentist regularly to maintain your        enjoy	a	long-term	relationship	with	your	dentist
dental health.
                                                                    Convenience
When you enroll, you select a contract dentist to provide
services. The DeltaCare USA network consists of private             •	 No	claim	forms	to	complete
practice dental facilities that have been carefully screened           E
                                                                    •	 	 xpanded	business	hours	for	toll-free	customer	
for quality.                                                           service,	from	8	a.m.	to	9	p.m.,	Eastern	time	
These benefits are neither offered nor guaranteed under
contract with the FEHB Program, but are made available to           Cost savings
all enrollees and family members who become members of              •	 No	deductibles	
Kaiser Permanente.                                                  •	 Out-of-pocket	costs	are	clearly	defined
It is important to know when you enroll in this Plan,                  O
                                                                    •	 	 ut-of-area	dental	emergency	coverage	up	to	
services are provided through the Plan’s delivery system, as           $100 per emergency
described in the Plan’s Federal brochure, but the continued            N
                                                                    •	 	 o	annual	or	lifetime	dollar	maximums	except	
participation of any one doctor, hospital or other provider            for accidental injury
cannot be guaranteed.


                                                                                                 HL_DCU_GAA11_5450_V11_11.23.2010
                                                      Highlights of your DeltaCare USA Program

                       Eligibility for you and your family

                       If you meet your group's eligibility requirements for dental coverage, you can enroll in
                       the DeltaCare USA program. You may also enroll eligible dependents.
What if I have         Easy enrollment
questions about
                       Simply complete the enclosed Dental Enrollment Form. Be sure to indicate a dentist
my DeltaCare USA       (from the list of contract dental facilities) for both yourself and your eligible dependents.
                       Include the name of your group.
Program?
                       How your DeltaCare USA program works

                       Your selected contract dentist will take care of your dental care needs. If you require
                       treatment from a specialist, your contract dentist will handle the referral for you.

                       After you have enrolled, you will receive a membership packet that includes an
                       identification card and an Evidence of Coverage that fully describes the benefits of your
                       dental program. Also included in this packet are the name, address and phone number
                       of your contract dentist. Simply call the dental facility to make an appointment.

                       Under the DeltaCare USA program, many services are covered at no cost, while others
                       have copayments (amount you pay your contract dentist) for certain benefits. See the
                       "Description of Benefits and Copayments" for a list of your benefits.

                       Please note: Dental services that are not performed by your selected contract dentist,
                       a contract specialist or are not covered under provisions for emergency care below, are
                       not covered by your DeltaCare USA program.

                       Provisions for emergency care

                       Under your DeltaCare USA program, you and your eligible dependents are covered
                   e



                       for out-of-area dental emergencies (35 or more miles from your contract dentist). Your
                       program pays up to $100 for emergency dental expenses per emergency for each
                       enrollee.

                       Accident injury benefit

                       The DeltaCare USA program provides coverage for accidental injury (caused by
                       external forces) at 100% of the contract dentist's "filed fees" for benefits (less any
                       applicable copayments). The enrollee must be eligible under the DeltaCare USA
                       program when the accident occurs. Accident injury benefits are subject to a $1600
                       maximum, per 12 months, per person.

                       My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA
                       dentists. Can I still receive treatment from this dentist?

                       You must receive treatment from your selected DeltaCare USA contract dentist. Please
                       note that Delta Dental dentists are not necessarily DeltaCare USA dentists.

                       Do my family members receive treatment from the same DeltaCare USA contract
                       dentist?

                       You and your eligible dependents may receive care from the same contract dentist,
                       or if you prefer, you may collectively select up to a maximum of three contract dental
                       facilities.

                       Can I change my contract dentist?

                       You may change contract dentists by notifying us either by phone or in writing, or by
                       visiting our website (www.deltadentalins.com). If you contact us by the 21st of the
                       month, the change will become effective the first of the following month.




                                             1
Highlights of your DeltaCare USA Program

Can I have my teeth whitened under the DeltaCare USA program?

External bleaching is a benefit under your program, subject to certain limitations. Talk to
your contract dentist about your options.

Does my DeltaCare USA program cover tooth-colored fillings and crowns on
molars?

The upgrade to porcelain and other tooth-colored materials on molars is included as a
benefit under your program. The copayment shows you what your out of pocket cost will
be.

How long does it take to get an appointment with a DeltaCare USA dentist?

Two to four weeks is a reasonable amount of time to wait for a routine, non-urgent
appointment. If you require a specific time, you may have to wait longer. Most DeltaCare
USA dentists are in private group practices, which means greater appointment
availability and extended office hours.

Are pre-existing dental conditions and work in progress covered?

Treatment for pre-existing conditions, such as extracted teeth, is covered under the
DeltaCare USA program. However, benefits are not provided for any dental treatment
started before joining the program (that is, work in progress, such as preparations for
crowns, root canals and impressions for dentures). Orthodontic treatment in progress
may be covered for new DeltaCare USA enrollees. See the "Limitations and Exclusions
of Benefits."

How does the DeltaCare USA program encourage preventive care?

Your DeltaCare USA program is designed to encourage regular visits to the dentist by
having no copayments (fees you pay to the contract dentist) on most diagnostic and
preventive benefits. See the enclosed "Description of Benefits and Copayments."
                                                                                              e
                                                                                              e




Does my DeltaCare USA program cover specialists' services?

Your contract dentist will coordinate your specialty care needs for oral surgery,
endodontics, periodontics or pediatric dentistry with an approved contract specialist.
If there is no contract specialist within your service area, there are no benefits for
specialist services.

What if I have questions about my DeltaCare USA program?

Call Customer Service at 800-422-4234. We have multilingual representatives available
from 8 a.m. to 9 p.m. Eastern time, Monday through Friday. Our Customer Service
representatives have worked in dental facilities and can answer benefits questions, as
well as arrange facility transfers and urgent care referrals.


                                                                                                  Our Customer Service
                                                                                                  representatives have
                                                                                                  worked in dental
                                                                                                  facilities and can
                                                                                                  answer benefits
                                                                                                  questions, as well
                                                                                                  as arrange facility
                                                                                                  transfers and urgent
                                                                                                  care referrals.



                                                                       2
   Plan GAA11                   DeltaCare USA                                             Description of Benefits and Copayments

SCHEDULE A
Description of Benefits and Copayments
The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and
exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment
options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and
is not to be interpreted as CDT-2011 procedure codes, descriptors or nomenclature that are under copyright by the American
Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes,
descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.
                                                                                                                                               ENROLLEE
CODE     DESCRIPTION                                                                                                                               PAYS

D0100-D0999       I. DIAGNOSTIC - When referable services are provided by a Contract Specialist, the Enrollee pays 75
                  percent of that Dentist's "filed fees." *
D0120    Periodic oral evaluation - established patient .................................................................................... No Cost
D0140    Limited oral evaluation - problem focused ........................................................................................ No Cost
D0145    Oral evaluation for a patient under three years of age and counseling with primary caregiver ......................... No Cost
D0150    Comprehensive oral evaluation - new or established patient ................................................................. No Cost
D0160    Detailed and extensive oral evaluation - problem focused, by report ....................................................... No Cost
D0170    Re-evaluation - limited, problem focused (established patient; not post-operative visit) ................................. No Cost
D0180    Comprehensive periodontal evaluation - new or established patient ........................................................ No Cost
D0210    Intraoral radiographs - complete series (including bitewings) - limited to 1 series every 24 months ................... No Cost
D0220    Intraoral - periapical first film ........................................................................................................ No Cost
D0230    Intraoral - periapical each additional film .......................................................................................... No Cost
D0240    Intraoral - occlusal film ................................................................................................................ No Cost
D0250    Extraoral - first film .................................................................................................................... No Cost
D0260    Extraoral - each additional film ...................................................................................................... No Cost
D0270    Bitewing radiograph - single film .................................................................................................... No Cost
D0272    Bitewings radiographs - two films .................................................................................................. No Cost
D0273    Bitewings radiographs - three films ................................................................................................ No Cost
D0274    Bitewings radiographs - four films - limited to 1 series every 6 months ..................................................... No Cost
D0277    Vertical bitewings - 7 to 8 films ..................................................................................................... No Cost
D0330    Panoramic film .......................................................................................................................... No Cost
D0460    Pulp vitality tests ....................................................................................................................... No Cost
D0470    Diagnostic casts ........................................................................................................................ No Cost
D0472    Accession of tissue, gross examination, preparation and transmission of written report ................................. No Cost
D0473    Accession of tissue, gross and microscopic examination, preparation and transmission of written report ............ No Cost
D0474    Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence
         of disease, preparation and transmission of written report .................................................................... No Cost
D0999    Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services) ........... $10.00
D1000-D1999        II. PREVENTIVE - When referable services are provided by a Contract Specialist, the Enrollee pays 75
                   percent of that Dentist's "filed fees." *
D1110    Prophylaxis cleaning - adult - 1 per 6 month period ............................................................................ $10.00
D1120    Prophylaxis cleaning - child - 1 per 6 month period ............................................................................ $10.00
D1203    Topical application of fluoride - child - to age 19; 1 per 6 month period .................................................... No Cost
D1206    Topical fluoride varnish; therapeutic application for moderate to high caries risk patients - child to age 19; 1 per
         6 month period ......................................................................................................................... No Cost
D1310    Nutritional counseling for control of dental disease ............................................................................. No Cost
D1330    Oral hygiene instructions ............................................................................................................. No Cost
D1351    Sealant - per tooth - limited to permanent molars through age 15 .......................................................... $18.00
D1352    Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent
         molars through age 15 ................................................................................................................ $18.00
D1510    Space maintainer - fixed - unilateral ............................................................................................... $100.00
D1515    Space maintainer - fixed - bilateral ................................................................................................. $100.00
D1520    Space maintainer - removable - unilateral ........................................................................................ $100.00
D1525    Space maintainer - removable - bilateral ......................................................................................... $100.00


                                                                            3
   Plan GAA11                    DeltaCare USA                                             Description of Benefits and Copayments

D1550 Re-cementation of space maintainer ............................................................................................... $18.00
D1555 Removal of fixed space maintainer ................................................................................................ $18.00
D2000-D2999        III. RESTORATIVE - When referable services are provided by a Contract Specialist, the Enrollee pays 75
                   percent of that Dentist's "filed fees." *
- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.
D2140    Amalgam - one surface, primary or permanent .................................................................................. $28.00
D2150    Amalgam - two surfaces, primary or permanent ................................................................................ $32.00
D2160    Amalgam - three surfaces, primary or permanent .............................................................................. $35.00
D2161    Amalgam - four or more surfaces, primary or permanent ..................................................................... $40.00
D2330    Resin-based composite - one surface, anterior (tooth colored) .............................................................. $36.00
D2331    Resin-based composite - two surfaces, anterior (tooth colored) ............................................................. $42.00
D2332    Resin-based composite - three surfaces, anterior (tooth colored) ........................................................... $47.00
D2335    Resin-based composite - four or more surfaces or involving incisal angle (anterior) (tooth colored) .................. $53.00
D2390    Resin-based composite crown, anterior ........................................................................................... $78.00
D2391    Resin-based composite - one surface, posterior (tooth colored) ............................................................. $75.00
D2392    Resin-based composite - two surfaces, posterior (tooth colored) ............................................................ $80.00
D2393    Resin-based composite - three surfaces, posterior (tooth colored) .......................................................... $85.00
D2394    Resin-based composite - four or more surfaces, posterior (tooth colored) ................................................. $110.00
                                        1, 2
D2510    Inlay - metallic - one surface       .................................................................................................... $290.00
                                         1, 2
D2520    Inlay - metallic - two surfaces       ................................................................................................... $300.00
                                                         1, 2
D2530    Inlay - metallic - three or more surfaces              ...................................................................................... $310.00
                                           1, 2
D2542    Onlay - metallic - two surfaces         .................................................................................................. $308.00
                                              1, 2
D2543    Onlay - metallic - three surfaces         ................................................................................................ $318.00
                                                         1, 2
D2544    Onlay - metallic - four or more surfaces               ...................................................................................... $326.00
                                                       1
D2610    Inlay - porcelain/ceramic - one surface .......................................................................................... $390.00
                                                         1
D2620    Inlay - porcelain/ceramic - two surfaces ......................................................................................... $410.00
                                                                        1
D2630    Inlay - porcelain/ceramic - three or more surfaces ............................................................................ $425.00
                                                           1
D2642    Onlay - porcelain/ceramic - two surfaces ....................................................................................... $425.00
                                                              1
D2643    Onlay - porcelain/ceramic - three surfaces ..................................................................................... $445.00
                                                                        1
D2644    Onlay - porcelain/ceramic - four or more surfaces ............................................................................ $470.00
                                                                                    1
D2650    Inlay - resin-based composite - one surface (tooth colored) ................................................................ $260.00
                                                                                      1
D2651    Inlay - resin-based composite - two surfaces (tooth colored) ............................................................... $300.00
                                                                                                  1
D2652    Inlay - resin-based composite - three or more surfaces (tooth colored) ................................................... $330.00
                                                                                        1
D2662    Onlay - resin-based composite - two surfaces (tooth colored) .............................................................. $340.00
                                                                                          1
D2663    Onlay - resin-based composite - three surfaces (tooth colored) ............................................................ $355.00
                                                                                                 1
D2664    Onlay - resin-based composite - four or more surfaces (tooth colored) ................................................... $385.00
                                                           1
D2710    Crown - resin-based composite (indirect) ....................................................................................... $160.00
                                                                          1
D2710    Crown - resin-based composite (indirect) - (molars) .......................................................................... $310.00
                                                                1
D2712    Crown - ¾ resin-based composite (indirect) .................................................................................... $160.00
                                                                              1
D2712    Crown - ¾ resin-based composite (indirect) - (molars) ...................................................................... $310.00
                                                   1
D2720    Crown - resin with high noble metal ............................................................................................. $430.00
                                                                     1
D2720    Crown - resin with high noble metal - (molars) ................................................................................ $580.00
                                                                   1
D2721    Crown - resin with predominantly base metal .................................................................................. $330.00
                                                                                 1
D2721    Crown - resin with predominantly base metal - (molars) ..................................................................... $480.00
                                            1
D2722    Crown - resin with noble metal ................................................................................................... $330.00
                                                            1
D2722    Crown - resin with noble metal - (molars) ...................................................................................... $480.00
                                                    1
D2740    Crown - porcelain/ceramic substrate ............................................................................................. $330.00
                                                                     1
D2740    Crown - porcelain/ceramic substrate - (molars) ................................................................................ $480.00
                                                                 1
D2750    Crown - porcelain fused to high noble metal ................................................................................... $430.00
                                                                               1
D2750    Crown - porcelain fused to high noble metal - (molars) ...................................................................... $580.00
                                                                             1
D2751    Crown - porcelain fused to predominantly base metal ....................................................................... $330.00
                                                                                            1
D2751    Crown - porcelain fused to predominantly base metal - (molars) .......................................................... $480.00
                                                        1
D2752    Crown - porcelain fused to noble metal ......................................................................................... $330.00
                                                                        1
D2752    Crown - porcelain fused to noble metal - (molars) ............................................................................ $480.00
                                               1
D2780    Crown - ¾ cast high noble metal ................................................................................................. $430.00

                                                                             4
   Plan GAA11                    DeltaCare USA                                           Description of Benefits and Copayments
                                                             1
D2781     Crown - ¾ cast predominantly base metal ..................................................................................... $330.00
                                          1
D2782     Crown - ¾ cast noble metal ....................................................................................................... $330.00
                                            1
D2783     Crown - ¾ porcelain/ceramic ...................................................................................................... $330.00
                                                        1
D2783     Crown - ¾ porcelain/ceramic - (molars) ......................................................................................... $480.00
                                                 1
D2790     Crown - full cast high noble metal ............................................................................................... $430.00
                                                             1
D2791     Crown - full cast predominantly base metal .................................................................................... $330.00
                                            1
D2792     Crown - full cast noble metal ...................................................................................................... $330.00
                            1
D2794     Crown - titanium ...................................................................................................................... $430.00
D2910     Recement inlay, onlay or partial coverage restoration .......................................................................... $18.00
D2915     Recement cast or prefabricated post and core .................................................................................. $18.00
D2920     Recement crown ....................................................................................................................... $18.00
D2930     Prefabricated stainless steel crown - primary tooth ............................................................................. $100.00
D2931     Prefabricated stainless steel crown - permanent tooth ......................................................................... $100.00
D2932     Prefabricated resin crown - anterior primary tooth .............................................................................. $116.00
D2933     Prefabricated stainless steel crown with resin window - anterior primary tooth ........................................... $100.00
D2940     Protective restoration .................................................................................................................. $30.00
D2950     Core buildup, including any pins .................................................................................................... $34.00
D2951     Pin retention - per tooth, in addition to restoration .............................................................................. $34.00
                                                                            2
D2952     Post and core in addition to crown, indirectly fabricated ..................................................................... $85.00
                                                                          2
D2953     Each additional indirectly fabricated post - same tooth ...................................................................... $85.00
D2954     Prefabricated post and core in addition to crown ............................................................................... $70.00
D2957     Each additional prefabricated post - same tooth ................................................................................ $70.00
D2970     Temporary crown (fractured tooth) - palliative treatment only ................................................................. $18.00
D2971     Additional procedures to construct new crown under existing partial denture framework ............................... $66.00
D2980     Crown repair, by report ............................................................................................................... $45.00
D3000-D3999        IV. ENDODONTICS - When referable services are provided by a Contract Specialist, the Enrollee pays 75
                   percent of that Dentist's "filed fees." *
D3110     Pulp cap - direct (excluding final restoration) .................................................................................... $18.00
D3120     Pulp cap - indirect (excluding final restoration) .................................................................................. $18.00
D3220     Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and
          application of medicament ........................................................................................................... $25.00
D3221     Pulpal debridement, primary and permanent teeth ............................................................................. $44.00
D3222     Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development. ............................. $25.00
D3230     Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) .................................. $44.00
D3240     Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) ................................ $44.00
                                                                                                  3
D3310     Root canal - endodontic therapy, anterior tooth (excluding final restoration) ............................................. $156.00
                                                                                                   3
D3320     Root canal - endodontic therapy, bicuspid tooth (excluding final restoration) ............................................ $212.00
                                                                                        3
D3330     Root canal - endodontic therapy, molar (excluding final restoration) ...................................................... $288.00
                                                                       3
D3346     Retreatment of previous root canal therapy - anterior ........................................................................ $176.00
                                                                        3
D3347     Retreatment of previous root canal therapy - bicuspid ....................................................................... $232.00
                                                                    3
D3348     Retreatment of previous root canal therapy - molar .......................................................................... $308.00
                                                           3
D3410     Apicoectomy/periradicular surgery - anterior ................................................................................... $180.00
                                                                          3
D3421     Apicoectomy/periradicular surgery - bicuspid (first root) ..................................................................... $180.00
                                                                      3
D3425     Apicoectomy/periradicular surgery - molar (first root) ......................................................................... $180.00
                                                                            3
D3426     Apicoectomy/periradicular surgery (each additional root) .................................................................... $80.00
                                       3
D3430     Retrograde filling - per root ........................................................................................................ $84.00
                                                                                                3
D3450     Root amputation, per root - not covered in conjunction with a hemisection .............................................. $96.00
D4000-D4999         V. PERIODONTICS - When referable services are provided by a Contract Specialist, the Enrollee pays 75
                    percent of that Dentist's "filed fees." *
- Includes preoperative and postoperative evaluations and treatment under local anesthetic.
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant .............. $210.00
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant ............... $100.00
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $210.00


                                                                            5
   Plan GAA11                    DeltaCare USA                                           Description of Benefits and Copayments

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $210.00
D4249 Clinical crown lengthening - hard tissue .......................................................................................... $200.00
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $400.00
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $400.00
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same
      anatomical area) ....................................................................................................................... $100.00
D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12
      consecutive months ................................................................................................................... $78.00
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12
      consecutive months ................................................................................................................... $78.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12
      consecutive months ................................................................................................................... $78.00
D4910 Periodontal maintenance - limited to 1 treatment each 6 month period .................................................... $62.00
D5000-D5899 VI. PROSTHODONTICS (removable)
D5110 Complete denture - maxillary 4, 5 .................................................................................................... $420.00
D5120 Complete denture - mandibular 4, 5 ................................................................................................. $420.00
D5130 Immediate denture - maxillary 4, 5 ................................................................................................... $480.00
D5140 Immediate denture - mandibular 4, 5 ................................................................................................ $480.00
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 4, 5 .......................... $416.00
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) 4, 5 ....................... $416.00
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps,
                         4, 5
       rests and teeth)       .................................................................................................................... $450.00
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps,
                         4, 5
       rests and teeth)       .................................................................................................................... $450.00
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) 4, 5 ....................................... $500.00
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) 4, 5 .................................... $500.00
D5410 Adjust complete denture - maxillary 4 .............................................................................................. $18.00
D5411 Adjust complete denture - mandibular 4 ........................................................................................... $18.00
D5421 Adjust partial denture - maxillary 4 ................................................................................................. $18.00
D5422 Adjust partial denture - mandibular 4 ............................................................................................... $18.00
D5510 Repair broken complete denture base ............................................................................................ $40.00
D5520 Replace missing or broken teeth - complete denture (each tooth) .......................................................... $18.00
D5610 Repair resin denture base ........................................................................................................... $40.00
D5620 Repair cast framework ................................................................................................................ $40.00
D5630 Repair or replace broken clasp ..................................................................................................... $40.00
D5640 Replace broken teeth - per tooth ................................................................................................... $18.00
D5650 Add tooth to existing partial denture ............................................................................................... $18.00
D5660 Add clasp to existing partial denture ............................................................................................... $18.00
D5670 Replace all teeth and acrylic on cast metal framework (maxillary) .......................................................... $220.00
D5671 Replace all teeth and acrylic on cast metal framework (mandibular) ........................................................ $220.00
D5710 Rebase complete maxillary denture 6 .............................................................................................. $144.00
D5711 Rebase complete mandibular denture 6 ........................................................................................... $144.00
D5720 Rebase maxillary partial denture 6 ................................................................................................. $144.00
D5721 Rebase mandibular partial denture 6 ............................................................................................... $144.00
D5730 Reline complete maxillary denture (chairside) 6 ................................................................................. $84.00
D5731 Reline complete mandibular denture (chairside) 6 .............................................................................. $84.00
D5740 Reline maxillary partial denture (chairside) 6 ..................................................................................... $84.00
D5741 Reline mandibular partial denture (chairside) 6 .................................................................................. $84.00
D5750 Reline complete maxillary denture (laboratory) 6 ................................................................................ $144.00
D5751 Reline complete mandibular denture (laboratory) 6 ............................................................................. $144.00
D5760 Reline maxillary partial denture (laboratory) 6 .................................................................................... $144.00
D5761 Reline mandibular partial denture (laboratory) 6 ................................................................................. $144.00
D5820 Interim partial denture (maxillary) 4 ................................................................................................. $40.00

                                                                            6
   Plan GAA11                   DeltaCare USA                                          Description of Benefits and Copayments

D5821 Interim partial denture (mandibular) 4 .............................................................................................. $40.00
D5850 Tissue conditioning, maxillary 4, 6 ................................................................................................... $40.00
D5851 Tissue conditioning, mandibular 4, 6 ................................................................................................. $40.00
D5900-D5999        VII. MAXILLOFACIAL PROSTHETICS - Not Covered

D6000-D6199        VIII. IMPLANT SERVICES - Not Covered

D6200-D6999        IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture
                   [bridge])
                                             7
D6210    Pontic - cast high noble metal .................................................................................................... $430.00
                                                      7
D6211    Pontic - cast predominantly base metal ......................................................................................... $330.00
                                    7
D6212    Pontic - cast noble metal ........................................................................................................... $330.00
                                                             7
D6240    Pontic - porcelain fused to high noble metal ................................................................................... $430.00
                                                                              7
D6240    Pontic - porcelain fused to high noble metal - (molars) ...................................................................... $580.00
                                                                           7
D6241    Pontic - porcelain fused to predominantly base metal ........................................................................ $330.00
                                                                                    7
D6241    Pontic - porcelain fused to predominantly base metal - (molars) ........................................................... $480.00
                                                      7
D6242    Pontic - porcelain fused to noble metal ......................................................................................... $330.00
                                                                      7
D6242    Pontic - porcelain fused to noble metal - (molars) ............................................................................ $480.00
                                      7
D6245    Pontic - porcelain/ceramic .......................................................................................................... $330.00
                                                 7
D6245    Pontic - porcelain/ceramic - (molars) ............................................................................................ $480.00
                                               7
D6250    Pontic - resin with high noble metal ............................................................................................. $430.00
                                                                 7
D6250    Pontic - resin with high noble metal - (molars) ................................................................................ $580.00
                                                               7
D6251    Pontic - resin with predominantly base metal .................................................................................. $330.00
                                                                                7
D6251    Pontic - resin with predominantly base metal - (molars) ..................................................................... $480.00
                                          7
D6252    Pontic - resin with noble metal .................................................................................................... $330.00
                                                         7
D6252    Pontic - resin with noble metal - (molars) ....................................................................................... $480.00
                                                     7
D6600    Inlay - porcelain/ceramic, two surfaces .......................................................................................... $410.00
                                                                     7
D6601    Inlay - porcelain/ceramic, three or more surfaces ............................................................................. $425.00
                                                           7
D6602    Inlay - cast high noble metal, two surfaces ..................................................................................... $400.00
                                                                           7
D6603    Inlay - cast high noble metal, three or more surfaces ........................................................................ $410.00
                                                                         7
D6604    Inlay - cast predominantly base metal, two surfaces ......................................................................... $300.00
                                                                                  7
D6605    Inlay - cast predominantly base metal, three or more surfaces ............................................................ $310.00
                                                   7
D6606    Inlay - cast noble metal, two surfaces ........................................................................................... $300.00
                                                                   7
D6607    Inlay - cast noble metal, three or more surfaces .............................................................................. $310.00
                                                       7
D6608    Onlay - porcelain/ceramic, two surfaces ........................................................................................ $425.00
                                                                       7
D6609    Onlay - porcelain/ceramic, three or more surfaces ........................................................................... $445.00
                                                             7
D6610    Onlay - cast high noble metal, two surfaces ................................................................................... $408.00
                                                                             7
D6611    Onlay - cast high noble metal, three or more surfaces ...................................................................... $418.00
                                                                           7
D6612    Onlay - cast predominantly base metal, two surfaces ........................................................................ $308.00
                                                                                    7
D6613    Onlay - cast predominantly base metal, three or more surfaces ........................................................... $318.00
                                                     7
D6614    Onlay - cast noble metal, two surfaces ......................................................................................... $308.00
                                                                     7
D6615    Onlay - cast noble metal, three or more surfaces ............................................................................. $318.00
                                               7
D6720    Crown - resin with high noble metal ............................................................................................. $430.00
                                                                 7
D6720    Crown - resin with high noble metal - (molars) ................................................................................ $580.00
                                                               7
D6721    Crown - resin with predominantly base metal .................................................................................. $330.00
                                                                                7
D6721    Crown - resin with predominantly base metal - (molars) ..................................................................... $480.00
                                          7
D6722    Crown - resin with noble metal ................................................................................................... $330.00
                                                         7
D6722    Crown - resin with noble metal - (molars) ...................................................................................... $480.00
                                      7
D6740    Crown - porcelain/ceramic ......................................................................................................... $330.00
                                                 7
D6740    Crown - porcelain/ceramic - (molars) ............................................................................................ $480.00
                                                             7
D6750    Crown - porcelain fused to high noble metal ................................................................................... $430.00
                                                                              7
D6750    Crown - porcelain fused to high noble metal - (molars) ...................................................................... $580.00
                                                                            7
D6751    Crown - porcelain fused to predominantly base metal ....................................................................... $330.00
                                                                                     7
D6751    Crown - porcelain fused to predominantly base metal - (molars) .......................................................... $480.00
                                                      7
D6752    Crown - porcelain fused to noble metal ......................................................................................... $330.00

                                                                         7
   Plan GAA11                  DeltaCare USA                                                Description of Benefits and Copayments
                                                                    7
D6752    Crown - porcelain fused to noble metal - (molars) ............................................................................ $480.00
                                             7
D6780    Crown - ¾ cast high noble metal ................................................................................................. $430.00
                                                         7
D6781    Crown - ¾ cast predominantly base metal ..................................................................................... $330.00
                                        7
D6782    Crown - ¾ cast noble metal ....................................................................................................... $330.00
                                          7
D6783    Crown - ¾ porcelain/ceramic ...................................................................................................... $330.00
                                                     7
D6783    Crown - ¾ porcelain/ceramic - (molars) ......................................................................................... $480.00
                                               7
D6790    Crown - full cast high noble metal ............................................................................................... $430.00
                                                           7
D6791    Crown - full cast predominantly base metal .................................................................................... $330.00
                                          7
D6792    Crown - full cast noble metal ...................................................................................................... $330.00
D6930    Recement fixed partial denture ..................................................................................................... $26.00
                         7
D6940    Stress breaker ........................................................................................................................ $66.00
                                                                                                    2
D6970    Post and core in addition to fixed partial denture retainer, indirectly fabricated .......................................... $85.00
                                                                                            2
D6972    Prefabricated post and core in addition to fixed partial denture retainer .................................................. $70.00
D6973    Core buildup for retainer, including any pins ..................................................................................... $70.00
                                                                        2
D6976    Each additional indirectly fabricated post - same tooth ...................................................................... $85.00
D6977    Each additional prefabricated post - same tooth ................................................................................ $70.00
D6980    Fixed partial denture repair, by report ............................................................................................. $50.00
D7000-D7999        X. ORAL AND MAXILLOFACIAL SURGERY - When referable services are provided by a Contract
                   Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." *
- Includes preoperative and postoperative evaluations and treatment under local anesthetic.
D7111 Extraction, coronal remnants - deciduous tooth ................................................................................. $22.00
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) ............................................. $22.00
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
      mucoperiosteal flap if indicated ..................................................................................................... $48.00
D7220 Removal of impacted tooth - soft tissue .......................................................................................... $84.00
D7230 Removal of impacted tooth - partially bony ....................................................................................... $110.00
D7240 Removal of impacted tooth - completely bony ................................................................................... $135.00
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications ...................................... $155.00
D7250 Surgical removal of residual tooth roots (cutting procedure) .................................................................. $65.00
D7251 Coronectomy - intentional partial tooth removal ................................................................................. $155.00
D7286 Biopsy of oral tissue - soft - does not include pathology laboratory procedures .......................................... $35.00
D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant ...................... $80.00
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant ...................... $80.00
D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant .................. $100.00
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant .................. $100.00
D7471 Removal of lateral exostosis (maxilla or mandible) ............................................................................. $80.00
D7472 Removal of torus palatinus .......................................................................................................... $80.00
D7473 Removal of torus mandibularis ...................................................................................................... $80.00
D7510 Incision and drainage of abscess - intraoral soft tissue ........................................................................ $35.00
D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure                          $90.00
D8000-D8999        XI. ORTHODONTICS
** If a Copayment dollar amount is not listed, Enrollee pays 75 percent of the Contract Orthodontist's "filed fees."
                                                                              8
D8050 Interceptive orthodontic treatment of the primary dentition                 ..................................................................      75% of
                                                                                                                                                            Filed
                                                                                                                                                            Fees
                                                                                    8
D8060 Interceptive orthodontic treatment of the transitional dentition                  ..............................................................    75% of
                                                                                                                                                            Filed
                                                                                                                                                            Fees
D8070 Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 8                           ..................    75% of
                                                                                                                                                            Filed
                                                                                                                                                            Fees
                                                                                                                       8
D8080 Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19                               ............................   75% of
                                                                                                                                                            Filed
                                                                                                                                                            Fees



                                                                          8
    Plan GAA11                   DeltaCare USA                                           Description of Benefits and Copayments

D8090 Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult                                      75% of
               8
      children    ................................................................................................................................ Filed
                                                                                                                                                    Fees
D8660 Pre-orthodontic treatment visit - not to be charged with any other consultation procedure(s) 9 ......................... No Cost
D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers) 10 ................ 75% of
                                                                                                                                                    Filed
                                                                                                                                                    Fees
D8999 Unspecified orthodontic procedure, by report - includes the START-UP FEE, which includes initial examination,
      diagnosis, consultation and initial banding ........................................................................................ $150.00
D9000-D9999         XII. ADJUNCTIVE GENERAL SERVICES - When referable services are provided by a Contract Specialist,
                    the Enrollee pays 75 percent of that Dentist's "filed fees." *
D9110     Palliative (emergency) treatment of dental pain - minor procedure .......................................................... $18.00
D9211     Regional block anesthesia ........................................................................................................... No Cost
D9212     Trigeminal division block anesthesia ............................................................................................... No Cost
D9215     Local anesthesia in conjunction with operative or surgical procedures ..................................................... No Cost
D9310     Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician ....... $30.00
D9430     Office visit for observation (during regularly scheduled hours) - no other services performed .......................... $5.00
D9440     Office visit - after regularly scheduled hours ..................................................................................... $28.00
D9450     Case presentation, detailed and extensive treatment planning ............................................................... No Cost
D9972     External bleaching - per arch ....................................................................................................... $150.00
D9999     Unspecified adjunctive procedure, by report - includes failed appointment without 24 hour notice - per 15 minutes
          of appointment time ................................................................................................................... $18.00
* If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed
procedures that are not available in the contract facility or that require a Dentist to provide specialized services, may be provided by a
contracted oral surgeon, endodontist, periodontist or pediatric dentist at 75 percent of the Contract Specialist's "filed fees." Specialist
services are only available in areas where there is a DeltaCare USA Contract Specialist, and upon referral by the assigned Contract
Dentist.

Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." "Filed fees" means the
Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department
at 800-422-4234.

Emergency Services - The Contract Dentist is responsible for providing covered emergency dental care while an Enrollee is within
35 miles of the contract facility. If an Enrollee is more than 35 miles from the Contract Dentist's facility, Delta Dental will reimburse the
Enrollee for the cost of covered emergency dental care, less any applicable Enrollee copayments, to a maximum of $100.00 per enrollee,
per emergency. All services are subject to the limitations and exclusions of the program.

Accident Injury Benefit - this program provides coverage for dental accident injuries up to 100 percent of the Dentist's usual fee, less
any applicable Enrollee copayments, to a maximum of $1,600.00 per Enrollee, in any 12-month period. The benefit is subject to the
limitations and exclusions of the program.


FOOTNOTES
1         Replacement is subject to a limitation requiring the existing restoration to be 5+ years old.
2         Base or noble metal is the benefit. If an inlay, onlay or indirectly fabricated post and core is made of high noble metal, an
          additional fee up to $100.00 per tooth will be charged for the upgrade.
3         A benefit for permanent teeth only.
4         Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the
          Enrollee continues to be eligible and the service is provided at the Contract Dentist's facility where the denture was
          originally delivered.
5         Replacement is subject to a limitation requiring the existing denture to be 5+ years old.
6         Limited to 1 per denture during any 12 consecutive months.
7         Replacement is subject to a limitation requiring the existing bridge to be 5+ years old.
8         Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for D8999 (Start-
          up fee), and D8680 (Orthodontic retention). Beyond 24 months, an additional monthly fee not to exceed 75 percent of the
          Contract Orthodontist's "filed fee" applies.
9         In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $50.00 will apply. The Enrollee is
          also responsible for any incurred orthodontic diagnostic record fees.
                                                                           9
     Plan GAA11            DeltaCare USA                                   Description of Benefits and Copayments

10      Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee not to exceed 75 percent of the
        Contract Orthodontist's "filed fee" applies.




                                                               10
                                                                           DENTAL ENROLLMENT FORM
                                                                 DIRECTIONS: Please complete items 1 through 6 on both sides of the page. Indicate your choice of Contract Facilities as well as those of your dependents
     1            Primary Enrollee Information                   (if applicable). Once you have completed items 1 through 2, please indicate one payment option choice on the reverse side.


            Name:
                               (Last)                                                                         (First)                                                                                                      (M.I.)

 Mailing Address:
                      (Street Address)

                                                                                                                                            Home Phone #:      (                )
                      (City)                                                                                  (State)   (Zip Code)

 E-mail Address


 Soc. Security #:                                                              Employee Identification #:                                                Date of Birth:
                                                                                                                                                                             (Month)           (Day)              (Year)

 Dental Facility Name:                                                                                                                                                    Dental Facility #:




                                                                 Note: You may choose up to three separate offices for yourself and all dependent enrollees.
     2              Dependent Information                        (To add additional dependents, please attach a separate sheet.)

                                                             PLEASE LIST ELIGIBLE DEPENDENTS TO BE COVERED IN ADDITION TO YOURSELF

     Relationship                                             Male/
                                        Dependent Name       Female                  Date of Birth                                   Contract Facility Name                                     Contract Facility #:
       Code *
                                                            (Check One)   (Month)    (Day)           (Year)
                                                             M     F

                                                             	

                                                             	

                                                             	

                                                             	

                                                             	

                                                             	

                                                             	
    *Relationship Codes: Place the following two character code in the first column to designate each dependent as follows:
     Spouse - SP      Child - CH


Kaiser Foundation Health Plan for Georgia                                                    Continue on reverse side
                                                                 AUTOMATIC PAYMENT AUTHORIZATION FORM
For your convenience, Delta Dental has made it possible to choose from two payment options. Your monthly premium may be paid directly to Delta Dental or you may choose to elect automatic deduction. Please choose ONE
payment method only.
           3        Automatic Deduction Payment Option                                                                               4          Semi-Annual Payment Option
     1.)   Complete and sign the Automatic Payment                   I choose the Automatic
           Authorization section on the enrollment form.              Deduction Payment Option.
           Be sure to enclose a voided blank check from this
           account.
                                                                     Checking                                                 1.)   Submit the first payment with your enrollment
     2.)   Enclose a check for the first month’s premium.                                                                            form. Once enrolled, you will be billed thereafter.        I choose the Semi-Annual
     3.)   Your monthly dues will be deducted from the               Savings                                                        Dues must be paid in full by the 15th of the month          Payment Option
           account specified on the 15th of each month                                                                               prior to the coverage month or your coverage will
           prior to the coverage month (e.g., April dues will                                                                        be automatically terminated. You cannot break
           be deducted on March 15th). Your coverage will
                                                                     Credit Union account
                                                                                                                                     coverage.
           automatically be terminated if your automatic
                                                                                                              OR
                                                                                                                               2.)   Return the enrollment form and the first payment               SEMI-ANNUAL
           deduction is declined by your bank for insufficient         MONTHLY
                                                                                                                                     by the 15th of the month for coverage to begin the
           funds, a closed account, etc.                         (AUTOMATIC DEDUCTION)                                               1st of the following month.
                                                                                                                                                                                                (PAYMENT BY CHECK)
     4.)   Return the enrollment materials, along with the
           first month’s payment, by the 15th for coverage           Employee                 $ 10.74                                                                                          Employee                     $ 64.44
           to begin the 1st of the following month.                                                                                          Delta Dental of California
                                                                     Employee + Spouse        $ 18.43                                              Dept 0170                                   Employee + Spouse           $ 110.58
                                                                     Employee + Child         $ 18.55                                      Los Angeles, CA 90084-0170                          Employee + Child            $ 111.30
                  Delta Dental of California
                         Dept 0170                                   Employee + 2 or more $ 26.74                                                                                              Employee + 2 or more $ 160.44
                 Los Angeles, CA 90084-0170
                                Rates effective 01/01/2011 - 12/31/2011                                                                                    Rates effective 01/01/2011 - 12/31/2011
      5           Automatic Deduction Payment Authorization (If Automatic Deduction was completed)
               I (we) hereby authorize Delta Dental to charge the applicable monthly dues for dental coverage to my account designated below. I understand that coverage will only become and remain effective if there are
               sufficient funds at the time of the deduction. I understand eligibility begins the first of the month following my initital deduction. This authority to deduct funds from my account is to remain in full force and
  effective until I notify Delta Dental in writing 30 days prior to termination. I also understand there cannot be any lapse of coverage in a 12-month period from the time of my enrollment. I agree to comply with the terms as
  outlined in the Combined Evidence of Coverage and Disclosure Form. (My bank is authorized to make corrections if any should be necessary.)
  Bank or savings and loan name __________________________________________________________ Branch_____________________________________________________________________________________
  Branch telephone number __________________________________________City, State _______________________________________________________________ZIP code ________________________________
  Account number ____________________________________________ ABA (bank routing #)
      6           Signature
                   I hereby enroll in the Group Dental Care Program. I understand that enrollment in the Dental Plan is for a period of one year, and that I will no longer be eligible for coverage if I fail to maintain
                   my membership.
  Signature of Enrollee _____________________________________________________________________________________________________________________                                          Date _______________________________
                                                                                         Limitations and Exclusions of Benefits

SCHEDULE B
Limitations of Benefits

1.   A full mouth x-ray series (including any combination of periapicals or bitewings with a panoramic film) or a series of seven or more
     vertical bitewings is limited to one series every 24 months.

2.   Bitewing x-rays are limited to not more than one series of four films in any six month period.

3.   Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits.

4.   Prophylaxis or periodontal maintenance is limited to one procedure each six month period.

5.   Benefits for sealants include the application of sealants only to permanent first and second molars with no decay, with no restorations
     and with the occlusal surface intact through age 15. Benefits for sealants do not include the repair or replacement of a sealant on any
     tooth within three years of its application.

6.   Amalgams and composites are benefits for the removal of decay, for minor repairs of tooth structure or to replace a lost or failing
     restoration.

7.   The placement of a crown, inlay or onlay is a benefit when there is insufficient tooth structure to support a filling. Replacement of an
     existing crown, inlay or onlay that is non-functional or non-restorable is a benefit when the existing restoration is five+ years old.

8.   If a porcelain margin is also chosen by the Enrollee for a covered porcelain-fused-to-metal crown, the maximum additional cost for
     this laboratory upgrade is $75.00.

9.   A covered metallic inlay, onlay, or indirectly fabricated post and core using base or noble metal is available for listed Copayment(s). If
     the Enrollee elects to have high noble metal used instead, the maximum additional cost of this material upgrade is $100.00 per tooth.

10. A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a vital primary tooth.

11. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy, apicoectomy, retrofill, etc.) are only
    a benefit on a permanent tooth with pathology.

12. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract Dentist is not performing root canal
    therapy.

13. Clinical crown lengthening - hard tissue is limited to one per tooth per lifetime.

14. Periodontal scaling and root planing are limited to four quadrants during any 12 month period.

15. Full mouth debridement (gross scale) is limited to one treatment in any 12 month period.

16. Coverage for the placement of a fixed partial denture ("bridge") is limited to:
     a.   The initial placement of a bridge when all the following conditions are present:
          -  a single permanent tooth requires prosthetic replacement.
          -  the abutment teeth can adequately support and retain a new bridge.
          -  the missing tooth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture.
          -  no other missing teeth in the same arch require prosthetic replacement with a new removable partial denture; and (for
             a bridge replacing a posterior tooth) one or more of the abutment teeth meet Limitation #7.
     b.   The replacement of an existing bridge that is not serviceable due to decay, fracture or other non-cosmetic defect, if:
          -  the existing bridge is at least five years old; and
          -  the same abutment teeth can adequately support and retain a new bridge; and
          -  no other missing teeth in the same arch require prosthetic replacement.
17. Coverage for a new removable partial or complete denture is limited to:
     a.   The initial placement of removable partial or complete denture in an arch when:
          -   one or more permanent teeth require prosthetic replacement; and
          -   the missing tooth/teeth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial
              denture; and
          -   (for partial dentures only) there are suitable abutment teeth to retain and support a removable partial denture.
     b.   The replacement of an existing removable partial or complete denture with non-cosmetic defect(s) that cause the denture
          to be non-serviceable if:
          -   the existing removable denture is at least five years old; and
          -   the existing removable denture cannot be made serviceable by adjustment, repair, relining or rebasing.

                                                                      11
                                                                                      Limitations and Exclusions of Benefits

18. Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months.

19. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to:
          -   The replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an
              existing partial denture or
          -   The replacement of permanent tooth/teeth for children under 16 years of age.
20. A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional
    cost for the first six months after placement if the Enrollee continues to be eligible and the service is provided at the Contract
    Dentist's facility where the denture was originally delivered.

21. Retained primary teeth shall be covered as primary teeth.

22. Excision of the frenum is a benefit only when it results in limited mobility of the tongue, it causes a large diastema between teeth or it
    interferes with a prosthetic appliance.

23. External bleaching is limited to fabrication of one bleaching tray per arch; bleaching gel for two weeks of patient self treatment; and
    no more than one treatment per arch, per 36 months.

24. Benefits provided by a contract pediatric Dentist are available at 75 percent of the specialist's "filed fees." Referral by the assigned
    Contract Dentist is required before services are received.

25. Soft tissue management programs include, but are not limited to, periodontal pocket charting, root planing, scaling, curettage, oral
    hygiene instruction, periodontal maintenance and/or prophylaxis. If an Enrollee declines non-covered services within a soft tissue
    management program, it does not eliminate or alter the benefit for covered services.

26. Emergency Services - The Contract Dentist is responsible for providing covered emergency dental care while an Enrollee is within
    35 miles of the Contract Dentist's facility. If an Enrollee requires emergency dental care and is more than 35 miles from the Contract
    Dentist's facility, then Delta Dental will reimburse the Enrollee for the cost of covered emergency dental care, less any applicable
    Enrollee copayments, to a maximum of $100.00 per Enrollee, per emergency. Emergency dental care is limited to listed procedures
    required to alleviate severe pain, swelling and/or bleeding or to avoid placing the Enrollee's health in serious jeopardy. Any further
    treatment of the cause of such emergency dental care must be preauthorized by Delta Dental or provided by the assigned Contract
    Dentist. All services are subject to the limitations and exclusions of the program.

27. Accident Injury Benefit - An accident injury is damage to the hard and soft tissue of the mouth caused directly and independently of
    all other causes by external forces. Damage to the hard and soft tissue of the mouth from normal chewing function is covered under
    Schedule A, Description of Benefits and Copayments.

     Delta Dental will pay up to 100 percent of the Dentist's usual fee, for expenses an Enrollee incurs for an accident injury, less
     any applicable Copayment(s), up to a maximum of $1,600.00 in any 12-month period.

     Accident injury benefits include the following procedure in addition to those listed in Schedule A, Description of Benefits and
     Copayments: D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus -
     includes splinting and/or stabilization.

     Payment of accident injury benefits are subject to Schedule B, Limitations and Exclusions of Benefits, excluding Limitations
     #7, 16, and 17. Benefits are limited to services provided as a result of an accident that occurred:
     a.   while the Enrollee was covered under the DeltaCare USA program, or
     b.   while the Enrollee was covered under another DeltaCare USA program, provided benefits for the expenses incurred
          would have been paid had the Enrollee continued to be eligible under that program.
28. An Optional procedure is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need
    as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of the Program. The applicable
    charge to the Enrollee is the difference between the Contract Dentist's "filed fee" for the Optional procedure and the "filed fee" for the
    covered procedure, plus any applicable Copayment for the covered procedure.

"Filed fees" mean the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the
Customer Service department at 800-422-4234.



Exclusions of Benefits
1.   Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments.

2.   Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or
     developmental malformation of teeth.


                                                                      12
                                                                                       Limitations and Exclusions of Benefits

3.   Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16
     years of age.

4.   Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).

5.   Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment
     of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint
     (TMJ).

6.   Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth,
     precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and
     personalization and characterization of complete and partial dentures.

7.   An initial treatment plan which involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns,
     onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare
     USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered Benefits. This
     exclusion does not eliminate the benefit for other covered services.

8.   Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and
     periodontal treatment.

9.   Extraction/removal of an erupted, partially erupted or impacted tooth:
     a.   Solely for orthodontic purposes.
     b.   When the tooth exhibits no signs or symptoms of infection, cystic degeneration, fracture, caries and/or having caused
          damage to an adjacent tooth; or
     c.   When the extraction or removal would be inconsistent with generally accepted professional standards.
10. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent.

11. Consultations for non-covered benefits.

12. Replacement of restorations, crowns, bridges, dentures or prosthetic teeth to enhance cosmetics and/or better match bleached teeth.

13. Dental services received from any dental facility other than the assigned Contract Dentist including the services of an out-of-network
    dental specialist, unless expressly authorized by Delta Dental or as cited under Emergency Services.

14. Any procedure that in the professional opinion of the Contract Dentist:
     a.   has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or
          surrounding structures, or
     b.   is inconsistent with generally accepted standards for dentistry.
15. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care
    facility.

16. Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and dentinal dysplasias, etc.), except for the
    treatment of newborn children with congenital defects or birth abnormalities.

17. Dispensing of drugs not normally utilized in the delivery of dental services.

18. Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA
    program. Examples include: teeth prepared for crowns, root canals in progress, orthodontics (unless qualified for the orthodontic
    treatment in progress provision).

19. Dental expenses incurred in connection with any dental procedure started after termination of eligibility for coverage.

20. Dental conditions arising out of and due to Enrollee's employment for which Workers' Compensation is paid. Services that are
    provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality,
    county or other subdivision.

21. Treatment required by reason of war declared or undeclared.



Orthodontic Limitations
The DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract Orthodontists. Start-
up fees, retention fees, and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and
Copayments and subject to the following:
1.   Orthodontic treatment must be provided by the selected Contract Orthodontist.
                                                                       13
                                                                                        Limitations and Exclusions of Benefits

2.   Orthodontic Copayments are listed on Schedule A, Description of Benefits and Copayments for both interceptive and comprehensive
     orthodontic treatment. Additional fees will be charged for start-up and retention.

3.   Benefits cover 24 months of active interceptive orthodontic treatment.

4.   Benefits cover 24 months of active comprehensive orthodontic treatment, including initial banding, de-banding and any commonly
     used appliances such as headgear.

5.   Following benefited interceptive or comprehensive orthodontic treatment, retention is covered up to a maximum of 24 months.
     Retention includes the initial construction, placement and adjustment to removable retainers and office visits.

6.   Treatment plans extending beyond 24 months of active interceptive or comprehensive orthodontic treatment, or 24 months of
     retention, will be subject to a monthly office visit fee to the Enrollee not to exceed 75 percent of the Contract Orthodontist's "filed fee"
     per month.

7.   Should an Enrollee's coverage be cancelled or terminated for any reason, and at the time of cancellation or termination the Enrollee
     is receiving orthodontic treatment, the Enrollee will be solely responsible for payment for treatment provided after cancellation or
     termination. In this event the Enrollee's obligation shall be based on 100 percent of the Contract Orthodontist's "filed fee." The
     Contract Orthodontist will prorate the amount over the number of months remaining in the initial 24 months of treatment. The Enrollee
     will make payments based on an arrangement with the Contract Orthodontist.

8.   If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by
     the Contract Orthodontist, the Enrollee will be charged a consultation fee of $50.00 in addition to diagnostic record fees.

9.   Three recementations or replacements of a bracket/band on the same tooth or a total of five rebracketings/rebandings on different
     teeth during the covered course of treatment are Benefits. If any additional recementations or replacements of brackets/bands are
     performed, the Enrollee is responsible for the cost at the Contract Orthodontist's usual fee.

10. The Copayment is payable to the Contract Orthodontist who initiates banding in a course of orthodontic treatment. If, after banding
    has been initiated, the Enrollee changes to another Contract Orthodontist to continue orthodontic treatment, the Enrollee:
     a.   will not be entitled to a refund of any amounts previously paid; and
     b.   will be responsible for all payments, up to and including the full Copayment, that are required by the new Contract
          Orthodontist for completion of the orthodontic treatment.
11. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are
    in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the
    DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees
    subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental
    plan for qualifying orthodontic cases.



Orthodontic Exclusions
1.   Pre-, mid- and post-treatment records that include cephalometric x-rays, tracings, photographs and study models.

2.   Lost, stolen or broken orthodontic appliances.

3.   Changes in treatment necessitated by accident of any kind, and/or lack of Enrollee cooperation.

4.   Surgical procedures incidental to orthodontic treatment.

5.   Myofunctional therapy.

6.   Surgical procedures related to cleft palate, micrognathia or macrognathia.

7.   Treatment related to temporomandibular joint disturbances.

8.   Supplemental appliances not routinely used in comprehensive orthodontics, including, but not limited to: palatal expander, habit
     control appliance, pendulum, quad helix or herbst.

9.   Restorative work caused by orthodontic treatment.

10. Extractions solely for the purpose of orthodontics.

11. Treatment in progress at inception of eligibility, unless qualified for the orthodontic treatment in progress provision.

12. Patient initiated transfer after bands have been placed.

13. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard
    fixed and removable orthodontic appliances.


                                                                       14
                                                                                      Participating DeltaCare USA Dental Offices
                                                                                   Consultorios dentales de la red DeltaCare USA
                                                                            Kaiser Foundation Health Plan of Georgia

Open Offices/ Consultorios abiertos                             October through December 2010 / Octubre a Diciembre de 2010
ACWORTH                                 #010552                                     #888901                                 #032150
#010551                                 COAST DENTAL OF BUCKHEAD                    HORACE GUNN, DDS                        MAGNOLIA RIDGE DTL ASSOC
COAST DENTAL OF ACWORTH                 3330 PIEDMONT RD NE STE 16, 30305‑1726      2150 METROPOLITAN PKWY SW, 30315‑6220   3331 HAMILTON ML RD STE 2200,
3509 BAKER RD NW STE 401, 30101‑6305    (404) 237‑5330                              (404) 768‑4343                          30519‑7228
(770) 917‑8943                          F/T 2 P/T 3                                 F/T 1                                   (678) 541‑0770
F/T 2                                                                                                                       F/T 1 P/T 1
                                        #010577                                     #032613
#008951                                 COAST DENTAL OF NORTHLAKE                   JERRY NUTT DDS & ASSOCIATES             CARTERSVILLE
LAKE POINT DENTAL                       4805 BRIARC RD NE STE 104, 30345‑2737       1571 PHOENIX BLVD STE 8, 30349‑5536     #029885
3950 COBB PKWY NW STE 402, 30101‑9528   (770) 414‑9282                              (770) 996‑7700                          A SMILE 4 U
(770) 966‑9396                          F/T 1 P/T 2                                                                         509 N TENNESSEE ST STE 107, 30120‑2890
F/T 3                                                                                                                       (678) 387‑2783
                                        #010578                                     #010489                                 F/T 1 P/T 2
ALBANY                                  COAST DENTAL OF PERIMETER                   LEONARD J ROUTENBERG
#030630                                 1100 HAMMOND DR NE STE 210, 30328‑8153      4511 CHAMBL DUNWDY RD STE A2,           #028914
WEST ALBANY DTL & MED CTR               (770) 399‑9300                              30338‑6243                              CARTERSVILLE DENTAL GROUP
1412 W OAKRIDGE DR, 31707‑5307          F/T 1 P/T 3                                 (770) 394‑6778                          22 FELTON PL, 30120‑2152
(229) 435‑2421                                                                      F/T 1                                   (770) 387‑1277
F/T 1                                   #010582                                                                             F/T 1
                                        COAST DENTAL OF SANDY SPRINGS               #010463
ALPHARETTA                              7539 ROSWELL RD, 30350‑4838                 PACES DENTISTRY                         COLUMBUS
#002202                                 (678) 443‑9300                              3200 DOWNWOOD CIR NW STE 130,           #029636
ALPHARETTA DENTAL ASSOC PC              F/T 1 P/T 4                                 30327‑1611                              PATTERSON DENTAL GROUP
2795 OLD MILTON PKWY STE 900,                                                       (404) 355‑1150                          7413 WHITESVILLE RD, 31904‑3227
30009‑2207                              #010576                                     F/T 1                                   (706) 256‑1312
(770) 754‑1155                          COAST DTL NORTH DRUID HILLS                                                         F/T 1
P/T 1                                   2484 BRIARCLIFF RD NE STE 29, 30329‑3011    #024769
                                        (404) 315‑7375                              SOUTHSIDE MEDICAL CENTER INC            CONYERS
#032599                                 F/T 2 P/T 4                                 1046 RIDGE AVE SW, 30315‑1640           #010553
ALPHARETTA HIGHWAY DENTAL                                                           (404) 688‑1350                          COAST DENTAL OF CONYERS
401 S MAIN ST STE B5, 30009‑1958        #017600                                     F/T 1                                   1910 HIGHWAY 20 SE # 100 # E, 30013‑2074
(770) 663‑8717                          COLLINS FAMILY DENTISTRY                                                            (770) 602‑4733
                                        759 MLK DR NW STE 200, 30314‑4153           #008935                                 F/T 3 P/T 3
                                        (404) 588‑0464                              SPELIOS AND ASSO MORROW PC
#024856                                 F/T 1                                       4920 ROSWELL RD STE 13A, 30342‑2605     #010400
BLUE VALLEY DENTAL PC                                                               (404) 261‑2211                          SPELIOS AND ASSOC CONYERS PC
980 BIRMINGHAM RD STE 507, 30004‑4418   #017204                                     F/T 2                         (SP)      2390 WALL ST SE STE 120, 30013‑2151
(678) 507‑0140                          DENTAL ONE ASSOCIATES                                                               (770) 929‑3411
F/T 1 P/T 1                             1901 PHOENIX BLVD STE 100, 30349‑5062       #010488                                 P/T 2
                                        (770) 991‑0913                              VINCENT L SMALLS & COMPANY PC
#010569                                 F/T 4                                       80 PEYTON RD SW, 30311‑1710             CUMMING
COAST DTL OF HOLCOMB BRIDGE                                                         (404) 696‑6675                          #024491
8465 HOLCOMB BRG RD STE 140,            #025281                                     F/T 1                                   CASTLEBERRY DENTAL LLC
30022‑8516                              DENTAL ONE ASSOCIATES                                                               5905 IRON GATE TRCE, 30040‑5801
(770) 594‑2616                          600 W PEACHTREE ST NW # 750, 30308‑3613     AUGUSTA                                 (770) 888‑8834
F/T 3 P/T 2                             (404) 876‑7200                              #001897                                 F/T 1                       (FR, PE)
                                        F/T 4                                       WILLIAM MARESKA, DDS
#010398                                                                             3802 WASHINGTON RD, 30907‑5144          DECATUR
FLYNN CROSSING DENTAL                   #032600                                     (706) 863‑7642                          #031025
5230 MCGINNIS FERRY RD, 30005‑3921      DUNWOODY DENTAL GROUP                       F/T 1                                   DECATUR FAMILY DENTURE CTR
(678) 527‑1130                          1720 OLD SPRING HOUSE LN 315,                                                       2458 WESLEY CHAPEL RD STE B, 30035‑3423
P/T 2                                   30338‑6215                                  AUSTELL                                 (770) 322‑0059
                                        (770) 451‑7041                              #008952                                 F/T 1                          (SP)
#028016                                 F/T 1                                       ANISA HAILEY, DDS
KIMBALL BRIDGE DENTAL                                                               4760 AUSTELL RD, 30106‑2007             #010014
4380 KIMBALL BRIDGE RD, 30022‑1460      #020090                                     (770) 941‑9995                          DENTAL HEALTH ASSOCIATES
(678) 256‑6304                          GA DENTISTRY LLC                            F/T 1                                   2853 CANDLER RD STE 101, 30034‑1421
P/T 1                                   2460 CUMB PKWY SE STE 210, 30339‑5038                                               (404) 244‑1166
                                        (770) 433‑2414                              #032565                                 F/T 2                          (FR)
#029883                                 F/T 2                                       AUSTELL DENTAL CENTER PC
MAIN STREET DENTISTRY                                                               3845 MEDICAL PARK DR, 30106‑1109        #032539
366 N MAIN ST STE 200, 30009‑8381       #024096                                     (770) 739‑2100                          LAWRENCEVILLE HWY DENTAL GRP
(770) 475‑6136                          GENTLE DENTAL CARE                          P/T 1                                   2785 LVILLE HWY STE 103, 30033‑2515
P/T 1                                   545 EDGEWOOD AVE SE, 30312‑1936                                                     (770) 491‑1132
                                        (404) 524‑8444                              BRASELTON
#028530                                 P/T 1                                       #032151
SUMMIT DTL GRP AT N POINT                                                           ELAN DENTAL ASSOC                       #028153
4000 N POINT PKWY STE 500, 30022‑8803   #958601                                     5744 OLD WINDER HWY STE E, 30517‑1637   METRO DECATUR DENTAL GROUP
(770) 777‑0911                          GREAT EXPRESSIONS DENTAL CTR                (770) 965‑3530                          4570 MEMORIAL DR, 30032‑1447
F/T 1 P/T 2                 (KO, SP)    4800 BRIARC RD NE STE 2037, 30345‑2741      F/T 1 P/T 1                             (404) 292‑3133
                                        (770) 493‑1242                                                                      P/T 1
ATLANTA                                 P/T 4                                       BUFORD
#031599                                                                             #029172                                 DOUGLASVILLE
ART OF THE SMILE                        #016534                                     BUFORD DENTAL GROUP                     #010566
3280 HOWELL ML RD NW STE 112,           GREAT EXPRESSIONS DTL CENTER                4271 S LEE ST # 101, 30518‑3658         COAST DENTAL OF DOUGLASVILLE
30327‑4107                              675 W PEACHTREE ST NW # 120, 30308‑1989     (678) 546‑1500                          3308 GEORGIA HWY 5 STE E, 30135
(404) 355‑5332                          (404) 874‑2038                              F/T 1 P/T 1                  (SP, CH)   (770) 947‑0006
F/T 1                                   F/T 1 P/T 3                                                                         F/T 2
                                                                                    #027911
#010464                                 #010393                                     LANIER DENTAL ASSOCIATES                #959601
CLEVELAND DENTAL CARE PC                HARANDI HARANDI SPELIOS ASSOC               4850 GOLDEN PARKWAY SUITE 3E, 30518     GREAT EXPRESSIONS DENTAL CTR
1029 CLEVELAND AVE, 30344‑6719          3365 PIEDMONT RD NE STE 1110,               (770) 831‑0559                          3387 HIGHWAY 5 STE E, 30135‑6900
(404) 761‑1542                          30305‑1708                                  F/T 2                         (SP)      (770) 489‑6200
F/T 1                          (VI)     (404) 237‑3070                                                                      P/T 7
                                        P/T 2
#032612                                   #008936                                    MABLETON                                   PEACHTREE CITY
JERRY NUTT/ASSOC                          SPELIOS AND ASSO MORROW PC                 #010574                                    #016473
8505 HOSPITAL DR STE 7, 30134‑2414        2292 MOUNT ZION RD, 30236‑2528             COAST DENTAL OF MABLETON                   GREAT EXPRESSIONS DTL CENTER
(770) 489‑6735                            (770) 961‑8300                             4875 FLOYD RD SW STE 113, 30126‑1379       320 STEVENS ENTRY, 30269‑1325
F/T 1 P/T 1                               F/T 1 P/T 1                  (SP)          (770) 732‑0900                             (770) 486‑0110
                                                                                     F/T 3                                      F/T 2 P/T 1
#023936                                   KENNESAW
TIMOTHY BYRD, DMD                         #958301                                    MACON                                      POWDER SPRINGS
6740 DOUGLASVILLE BL STE A, 30135         GREAT EXPRESSIONS DTL CENTER               #019562                                    #010580
(770) 949‑5600                            400 E W BARR PKWY NW STE 607,              NORTH MACON DENTAL ASSOC                   COAST DTL OF POWDER SPRINGS
F/T 3                                     30144‑4997                                 4020 ELNORA DR, 31210‑1823                 3709 NEW MACLAND RD STE 210,
                                          (770) 425‑1324                             (478) 477‑1228                             30127‑1966
DULUTH                                    P/T 7                                      F/T 1                                      (770) 222‑3300
#010567                                                                                                                         F/T 2
COAST DENTAL OF DULUTH                    #032580                                    MARIETTA
3870 PCHTREE IND BLVD, 30096‑1422         NORTH ROBERTS RD DTL GROUP PC              #010583                                    RIVERDALE
(770) 476‑9004                            1301 SHILOH RD NW BLDG 600, 30144‑7147     COAST DENTAL OF SPRAYBERRY                 #010460
F/T 3 P/T 1                               (770) 423‑9699                             2550 SANDY PLAINS RD STE 145, 30066‑7221   ZOOM DENTAL
                                          P/T 1                                      (770) 321‑2755                             207 UPPER RIVERDALE RD SW, 30274‑2585
#010579                                                                              F/T 2 P/T 1                                (770) 751‑8887
COAST DENTAL OF PLEASANT HILL             LAKE CITY                                                                             F/T 1                       (SP, RU)
1630 PLEASANT HL RD STE 200, 30096‑5828   #010570                                    #010575
(770) 381‑7878                            COAST DENTAL ‑ MORROW                      COAST DTL OF MARIETTA TRADE                ROSWELL
F/T 2 P/T 1                               5656 JONESBORO RD STE 103, 30260‑3853      270 COBB PKWY S STE A13, 30060‑9301        #016533
                                          (678) 422‑6967                             (770) 425‑6333                             GREAT EXPRESSIONS DTL CENTER
#032051                                   F/T 2                                      F/T 2 P/T 3                                910 MARIETTA HWY STE 200, 30075‑6750
DENTAL ONE ASSOCIATES                                                                                                           (770) 642‑6777
1950 PLEASANT HILL RD A, 30096‑4626       LAWRENCEVILLE                              #029563                                    F/T 1 P/T 7
(770) 418‑1550                            #010571                                    DENTAL WORLD OF MARIETTA
F/T 1 P/T 1                               COAST DENTAL OF LAWRENCEVILLE              2468 WINDY HL RD SE STE 400, 30067‑8631    #016536
                                          650 GWINNETT DR STE 210, 30046‑7439        (770) 984‑9000                             GREAT EXPRESSIONS DTL CENTER
DUNWOODY                                  (770) 963‑5999                             F/T 2                       (RU, SP)       1150 GRIMES BDGE RD STE 400, 30075
#017729                                   F/T 1 P/T 3                                                                           (770) 642‑4066
MICHELLE JACQUES, DDS                                                                #009328                                    F/T 1 P/T 7
1853 PEELER RD STE A, 30338‑5951          #959501                                    GREAT EXPRESSIONS DTL CENTER
(770) 391‑9212                            GREAT EXPRESSIONS DTL CENTER               2209 ROSWELL RD STE 300, 30062‑9300        #032088
F/T 1                          (RU)       555 OLD NORCROSS RD STE 120,               (678) 560‑2970                             WEI‑YEN CHANG, DDS
                                          30046‑8703                                 P/T 1                                      415 E CROSSVILLE RD STE A, 30075‑7626
EAST POINT                                (770) 277‑9700                                                                        (678) 461‑4875
#029884                                   P/T 5                                      #032556                                    F/T 1                           (CH)
A SMILE 4 U                                                                          JERRY NUTT, DDS
2788 BAYARD STREET, 30344                 #010396                                    1545 PWRS FY RD SE STE 220, 30067‑9401     SAVANNAH
(678) 387‑2783                            GRIFFITH DENTAL LLC                        (770) 980‑9404                             #012133
P/T 1                                     2003 RIVERSIDE PKWY STE 104, 30043‑5941                                 (RU, TR)      JAMES MELVIN, DMD
                                          (770) 822‑3400                                                                        7001 HODGSON DR STE 4, 31406‑2549
FAYETTEVILLE                              F/T 1 P/T 1                                #898901                                    (912) 355‑1307
#010568                                                                              JOHN GRAHAM, DDS                           F/T 1
COAST DENTAL OF FAYETTVILLE               #033698                                    50 PLAZA WAY NW STE G, 30060‑1141
805 GLYNN ST S STE 131, 30214‑2010        JERRY NUTT/ASSOC                           (770) 427‑4778                             #958401
(770) 460‑6651                            1699 DULUTH HWY, 30043‑5010                F/T 1                                      JAMES WILLIAMS, DDS
F/T 1 P/T 2                               (770) 338‑1963                                                                        310 EISENHOWER DR # 2 # BLD, 31406‑2632
                                          F/T 2                                      #008934                                    (912) 351‑0615
#032614                                                                              SPELIOS AND ASSOC DELK RD PC               F/T 1
FAYETTEVILLE DENTAL GROUP                 #015953                                    2900 DELK RD SE STE 1450, 30067‑5322
141 BANKS STA STE 121‑122, 30214‑7504     S ALABA FAWOLE, DDS MD PC                  (770) 951‑1133                             #032617
(770) 716‑9778                            719 SCENIC HWY STE B, 30046‑6379           F/T 1 P/T 1                                OAKPARK DENTAL GROUP
                                          (678) 377‑6830                                                                        132 SOUTHERN BLVD, 31405‑7414
                                                                                     #008908                                    (912) 356‑5444
#010399                                                                              SPRAYBERRY DENTAL ASSOC                    F/T 3
SPELIOS & ASSOC FAYETTEVILLE              #010397                                    2663 SANDY PLAINS RD, 30066‑4256
395 N JEFF DAVIS DR STE A, 30214‑1672     SPELIOS AND ASSO MORROW PC                 (770) 977‑0827                             #891301
(770) 460‑0870                            4850 SUGARLOAF PKWY STE 204,               F/T 3                                      SAVANNAH DENTAL ASSOCIATES
P/T 2                                     30044‑2861                                                                            413 W DUFFY ST, 31401‑6716
                                          (770) 995‑6109                             MONROE                                     (912) 234‑5003
FOREST PARK                               F/T 1 P/T 1                                #957801                                    F/T 1
#032589                                                                              PATRICIA PASS‑DUDLEY, DDS
FOREST PARKWAY DTL GROUP PC               LILBURN                                    146 MLK BLVD PMB 387, 30655                SNELLVILLE
4930 GOVERNORS DR STE 405, 30297‑6101     #010572                                    (770) 207‑5158                             #010395
(404) 363‑1700                            COAST DENTAL OF LILBURN                    F/T 1                                      SPELIOS AND ASSO MORROW PC
                                          3050 5 FORKS TRK RD SW STE H, 30047‑1877                                              2341 HENRY CLOWER BLVD STE A,
                                          (770) 982‑7533                             MORROW                                     30078‑7420
GAINESVILLE                               F/T 2 P/T 1                                #935801                                    (770) 736‑0099
#032581                                                                              SOUTHLAKE DENTAL ASSOC PC                  P/T 2
LAKESHORE MALL DENTAL GRP                 #016531                                    6630 EXCHANGE PL, 30260‑2310
150 PEARL NIX PKWY STE B10, 30501‑3593    GREAT EXPRESSIONS DTL CENTER               (770) 968‑1710                             STOCKBRIDGE
(770) 536‑1957                            331 ARCADO RD NW, 30047‑2814               P/T 1                        (SP)          #029147
                                          (770) 923‑1814                                                                        SACRED DENTAL & ASSOC
                                          F/T 2 P/T 16                (SP, VI)       NEWNAN                                     4362 N HENRY BLVD, 30281‑3662
GRAYSON                                                                              #032597                                    (770) 474‑9202
#033370                         z         #032602                                    BULLSBORO DRIVE DENTAL GROUP               F/T 1                         (SP)
ROYAL DENTAL CARE                         LILBURN DENTAL CENTER                      148 BULLSBORO DR, 30263‑1018
2594 LOGANVILLE HWY# 102, 30017           4145 LVILLE HWY NW STE 5, 30047‑2807       (770) 251‑4370                             #032616
(678) 672‑1590                            (770) 638‑8090                                                                        STOCKBRIDGE DENTAL GROUP
                                                                       (HI, RO)                                                 330 CORPORATE CENTER CT A, 30281‑6360
                                                                                     NORCROSS                                   (678) 289‑6707
HAPEVILLE                                 #010462                                    #031199
#010394                                   ZOOM DENTAL                                BERKELEY LAKE DENTAL LLC
HARANDI HARANDI SPELIOS ASSOC             4574 LVILLE HWY NW STE 120, 30047‑3605     4720 PEACH IND BLVD STE 5102,              STONE MOUNTAIN
785 VIRGINIA AVE STE A, 30354‑1991        (770) 921‑9000                             30071‑5738                                 #009465
(404) 768‑8700                            F/T 2                                      (770) 807‑8733                             BLOUNTS FAMILY DENTAL
F/T 1 P/T 3                                                                          F/T 1                           (VI)       1825 ROCKBRIDGE RD STE 14C, 30087‑3306
                                          LOGANVILLE                                                                            (770) 482‑7800
JONESBORO                                 #010573                                    #959401                                    F/T 1
#016535                                   COAST DENTAL OF LOGANVILLE                 GREAT EXPRESSIONS DENTAL CTR
GREAT EXPRESSIONS DTL CENTER              4325 ATLANTA HWY STE 9, 30052‑3264         7760 SPALDING DR, 30092‑4207               #028103
1002 POINTE SOUTH PKWY, 30238‑4324        (770) 466‑0918                             (770) 270‑5700                             BURLIN DENTAL ASSOCIATES
(770) 472‑9399                            F/T 2 P/T 2                                P/T 3                                      4687 ROCKBRIDGE RD STE 7, 30083‑4281
F/T 2 P/T 2                   (SP)                                                                                              (404) 296‑9070
                                                                                     #025250                                    F/T 1
                                                                                     SPALDING DENTAL CENTER
                                                                                     6460 SPALDING DR STE C, 30092‑1805
                                                                                     (770) 263‑8408
                                                                                     F/T 1                       (SP, RU)
#028140                                      #024937                               WOODSTOCK                                 #008928
METRO DEKALB DENTAL GROUP                    DENTAL SMILES AT SUWANEE              #010584                                   TIMOTHY BYRD, DMD
4849 MEMORIAL DR, 30083‑4175                 2133 LAWRENCVIL SWANE RD #13, 30024   COAST DENTAL OF WOODSTOCK                 2035 TOWNE LAKE PKWY STE 130,
(404) 296‑4119                               (678) 377‑6453                        12195 HIGHWAY 92 STE 148, 30188‑3603      30189‑5550
P/T 1                                                                      (HI)    (770) 517‑2772                            (770) 926‑8200
                                                                                   F/T 3 P/T 3                               F/T 2                         (SP)
SUWANEE                                      TUCKER
#017230                                      #016532                               #029460
COAST DENTAL                                 GREAT EXPRESSIONS DTL CENTER          METROPOLITAN DTL ASSOC
2855 LAWRENVILE SUWANE RD NW, 30024          4500 HUGH HOWELL RD STE 140,          8294 HIGHWAY 92 STE 200, 30189‑3672
(678) 482‑2197                               30084‑4700                            (770) 928‑2376
F/T 1 P/T 3                                  (770) 938‑9090                        F/T 1                          (PE)
                                             F/T 1 P/T 3




Closed Offices / Consultorios cerrados
These offices are presently serving members, but are closed to further enrollment at this time. These offices may open to new enrollment in




                                       ED
the future if office capacity permits. / Estos consultorios brindan atención a los miembros actuales, pero se encuentran cerrados a nuevas




                                    OS
inscripciones. En el futuro estarán disponibles para nuevas inscripiones, si su capacidad se lo permite.
ATLANTA                                      #001951                               #001903                                   LAGRANGE




                                  CL
#018438                                      EDDIE JOHNSON III, DMD                J A RAY DMD                               #933801
WALTER YOUNG, DDS                            2755 BARTON CHAPEL RD, 30906‑9579     2504 PEACH ORCHARD RD, 30906‑2404         TARA DENNIS, DDS
2265 CASCADE RD SW, 30311‑2861               (706) 790‑9179                        (706) 798‑8300                            1555 DOCTORS DR STE 105, 30240‑4132
(404) 753‑4753                               F/T 1                                 F/T 1                                     (706) 812‑8220
F/T 1                                                                                                                        F/T 1
                                             #001896                               GAINESVILLE
AUGUSTA                                      FREDERICK THIELKE, DMD                #027930                                   TUCKER
#001905                                      3643 WALTON WAY EXT, 30909‑4507       GAINESVILLE DENTAL CENTER                 #937001
DANIEL CROWDEN, DMD                          (706) 738‑7129                        1586 PARK HILL DR, 30501‑1950             MEENA MEHTA, DDS
1208 GEORGE C WILSON DR, 30909‑5708          F/T 1                                 (770) 534‑0697                            3981 LAWRENCEVILLE HWY STE A,
(706) 736‑7050                                                                     P/T 1                                     30084‑4525
F/T 1                                                                                                                        (770) 491‑1138
                                                                                                                             F/T 1
#001908
EAST AUGUSTA DTL CENTER
1039 11TH ST, 30901‑2873
(706) 722‑4008
F/T 1

Visit us at our website/ Visite nuestro sitio de Internet: www.deltadentalins.com

    [1] This office accepts plans GA900, GA903, GA908, GA912 only.                   [1] Esta oficina acepta los planes GA900, GA903, GA908, GA912 solamente
    [2] This office accepts plans GA903, GA908, GA912 only.                          [2] Esta oficina acepta los planes GA900, GA903, GA 908, GA912 solamente
    [3] This office accepts plans GAA11 only.                                        [3] Esta oficina acepta los planes GAA11 solamente.
    [4] This office accepts plans GAA31, GAA36 only.                                 [4] Esta oficina acepta los planes GAA31, GAA36 solamente.
    [5] This office accepts plans GAA31, GAA36, GAM29 only.                          [5]Esta oficina acepta los planes GAA31, GAA36, GAM29 solamente.
    [6] This office does not accept plan GAM62.                                      [6] Esta oficina no acepta el plan GAM62.

    F/T ‑ Full Time Dentist   P/T ‑ Part Time Dentist                                F/T ‑ Dentista de tiempo completo       P/T ‑ Dentista de medio tiempo
     z‑ New Offices                                                                   z‑ Nueva Oficinas
    Foreign languages spoken in the dental office are listed by code in ( ).         Los idiomas que se hablan en la oficina dental estan detallados por códigos
    Below is a key to the foreign language codes.                                    en ( ). Abajo detallamos los códigos a los diferentes idiomas.

                                                                                     HU    ‑                                      RO    ‑   Romanian
    AF    ‑   Afrikaans                           EI    ‑   East Indian                        Hungarian
                                                                                     IN    ‑                                      RU    ‑   Russian
    AR    ‑   Arabic                              FR    ‑   French                             Indonesian
                                                                                     IT    ‑                                      SP    ‑   Spanish / Español
    AM    ‑   Armenian                            GE    ‑   German                             Italian
                                                                                     JA    ‑                                      TA    ‑   Tagalog
    CA    ‑   Cantonese                           GR    ‑   Greek                              Japanese
                                                                                     KO    ‑                                      TH    ‑   Thai
    CH    ‑   Chinese                             HE    ‑   Hebrew                             Korean
                                                                                     PE    ‑                                      TR    ‑   Turkish
    CL    ‑   Creole                              HI    ‑   Hindi                              Persian
                                                                                     PL    ‑                                      VI    ‑   Vietnamese
    CS    ‑   Czech                               HR    ‑   Croatian                           Polish
    LANGUAGE ASSISTANCE: Language capabilities are self‑reported by the individual optometric facilities and not independently verified by Delta Den‑
    tal. If an enrollee requires language assistance to enable communication in a optometric setting, Delta Dental will arrange for professional services
    through a certified interpretation vendor at no cost to the enrollee.


Additional Dental Offices will be added as required. You may call our              Se agregaran mas Oficinas Dentales adicionales conforme se vayan
Customer Service department at 800‑422‑4234 for updates to the                     necesitando. Puede llamar al departamento de Servicio al Cliente
provider list. If any office is closed to further enrollment, Delta Dental         al 800‑422‑4234 para obtener una lista de los proveedores. Delta
reserves the right to assign you another dental office as close to your            Dental se reserva el derecho de asignarle otra oficina dental lo mas
home as possible.                                                                  cercana a su casa como sea posible.

In Georgia, DeltaCare USA is underwritten and administered by Delta                En Georgia, DeltaCare USA es asegurado y administrado por Delta
Dental Insurance Company.                                                          Dental Insurance Company.

NOTE: Contact the provider before making your choice if you have                   NOTA: Contacte al proveedor antes de escogerlo si tiene problemas o
scheduling problems or small children.                                             niños pequeños.

10/07/10                                                                                                           DR_DCU_5450‑2_OCT2010_10.08.2010 PLGAKFG
NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.
                                                                                                            	
The	Group	Dental	Service	Contract	must	be	consulted	to	determine	the	exact	terms	and	conditions	of	coverage.	
An	Evidence	of	Coverage	will	be	sent	to	you	upon	enrollment.	

In Georgia, DeltaCare USA is underwritten and administered by Delta Dental Insurance Company.

Customer Service
800-422-4234
Monday through Friday
8	a.m.	to	9	p.m.,	Eastern	time	

Provided by:

Delta Dental Insurance Company
1130	Sanctuary	Parkway,	Suite	600
Alpharetta,	GA	30009

Administered by:

Delta Dental Insurance Company
P.O. Box 1803
Alpharetta,	GA	30023

www.deltadentalins.com

				
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