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HomeMy WebLinkAboutCity of Tamarac Resolution R-2009-154Temp. Reso. #11720 - November 4, 2009 Page 1 CITY OF TAMARAC, FLORIDA RESOLUTION NO. R-2009- 15-Ill A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF TAMARAC, FLORIDA, AUTHORIZING THE APPROPRIATE CITY OFFICIALS TO EXECUTE THE AGREEMENT OF THE CITY'S DENTAL INSURANCE PROGRAM WITH UNITED HEALTHCARE INSURANCE COMPANY FOR PLAN YEAR EFFECTIVE JANUARY 1, 2010; PROVIDING FOR PLAN DESIGN AND PREMIUM RATES; PROVIDING FOR THE CONTINUATION OF THE EXISTING COST ALLOCATION OF THE DENTAL INSURANCE PREMIUM BETWEEN THE CITY AND EMPLOYEES; PROVIDING FOR CONFLICTS; PROVIDING FOR SEVERABILITY; AND PROVIDING FOR AN EFFECTIVE DATE. WHEREAS, the City's contract with Aetna, Inc. is scheduled to expire on December 31, 2009; and WHEREAS, on September 15, 2009, the City contracted with Willis Employee Benefits to competitively market, analyze and recommend alternatives to the City's dental plan; and WHEREAS, as a result of the marketing of the dental plan, Willis Employee Benefits presented the City with seven proposals: Aetna, Inc., CIGNA, Delta Dental, Florida Combined Life, Guardian, Humana and United Healthcare; and WHEREAS, the City reviewed its dental insurance plan design and determined that plan design changes are necessary for 2010, as described in Temp. Reso. #11720 - November 4, 2009 Page 2 Exhibit I, Dental Rates and Benefits, attached hereto and made a part hereof, and WHEREAS, the City staff has worked with representatives of Willis Employee Benefits to evaluate alternatives and negotiate the most comprehensive and cost effective dental plan for the City's employees and their dependents; and WHEREAS, after careful evaluation of all aspects of the proposals by the Benefits Specialist and Director of Human Resources, with assistance from representatives of Willis Employee Benefits, it was determined that United Healthcare Insurance Company provided the most comprehensive dental insurance program; and WHEREAS, as a result of these negotiations, the end result represents an overall decrease of 42% from the approved costs in 2009; and WHEREAS, the City will continue the existing cost allocation of the dental insurance premium between the City and the employees; and WHEREAS, it is the recommendation of the City Manager and the Director of Human Resources that the City execute the employer application, attached as Exhibit II and made a part hereof, and the dental insurance contract documents with United Healthcare Insurance Company, attached as Exhibits III and IV attached hereto and made a part hereof, subject to final completion of the Group Policy and Schedule of Benefits documents, incorporating Exhibit I, Dental Rates and Benefits, and any revisions as may be negotiated by and between the City Temp. Reso. #11720 - November 4, 2009 Page 3 staff and United Healthcare Insurance Company and as approved by the City Manager and City Attorney effective January 1, 2010; and WHEREAS, available funds exist in the appropriate Governmental Funds which are in the approved FY2010 Budget; and WHEREAS, the City Commission has deemed it to be in the best interest of the health, safety and welfare of citizens and residents of the City of Tamarac to contract with United Healthcare Insurance Company to provide dental insurance for City of Tamarac employees and their dependents. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF TAMARAC, FLORIDA: SECTION 1: That the foregoing "WHEREAS" clauses are hereby ratified and confirmed as being true and correct and are hereby made a specific part of this Resolution. All exhibits attached hereto are incorporated herein and made a specific part of this Resolution. SECTION 2: That the appropriate City officials are here - authorized to execute the employer application, attached as Exhibit i# andjnao. a part hereof, and the dental insurance contract documents with United _- Healthcare Insurance Company, attached as Exhibits III and IV attached hereto and made a part hereof, subject to final completion of the Group Policy and Schedule of Benefits documents, incorporating Exhibit I, Dental Rates and Benefits, and any revisions as may be negotiated by and between the City staff and United Healthcare Insurance Company and as approved by the City Manager and City Attorney effective January 1, 2010. Temp. Reso. #11720 - November 4, 2009 Page 4 SECTION 3: That the appropriate City officials are hereby authorized to continue the existing cost allocation of the dental insurance premium between the City and the employees. SECTION 4: That all resolutions or parts of resolutions in conflict herewith are hereby repealed to the extent of such conflict. SECTION 5: That if any clause, section, or other part or application of this Resolution is held by any court of competent jurisdiction to be unconstitutional or invalid, in part or application, it shall not affect the validity of the remaining portions or applications of this Resolution. SECTION 6: This Resolution shall become effective immediately upon adoption. PASSED, ADOPTED AND APPROVED this %� day of .ATTEST: __ = ION SdVE 4SON, CM CITY -CLERK I HEREBY CERTIFY that I have approved this RESOLUTION as to form. uaxwx'� MUEL S. G REN CITY ATTO NEY BETH FLANSBAUM-TALABISCO MAYOR RECORD OF COMMISSION VOTE: MAYOR FLANSBAUM-TALABISCO DIST 1: COMM BUSHNELL DIST 2: VM ATKINS-GRAD [j&L"l DIST 3: COMM. GLASSER DIST 4: COMM. DRESSLER L 1 -I -I -I -I D = 7' S_ _ (D C N (n a U w n00 5. m m 0 U) m (D w -n WI � — —i� o Cm Q Z0 0-Dm 0 0 0 a w O { 0 O N � X 2 O �. OR N C O Z x DTry 0 _� » O O O 3 z v C: z m O O W m 0 y- 0 z o 7< W (D m p N 0 CD 0 m V1 (11 CD O CD 0 () CD 0 m c N 0 m m m m C?DM 0vv0 ;(vp C m max ;o cD 3 A CD ao p p CO v �mv • �i y (D pp 0 0 J. a d o m m m m `G 40c -ita CD to O o �j m r� 7 x (K N (ND �' ,. td m i Z O tD s �tp (U G .M 0 N * k In(o N , Or C Vi 0 U) O (N m x o D CD ID o o " w' (n m 0 cn f ° C) N :$ N CD �(Q� .W•� N °� '. .n+ 7 r N CD� m �;,0 CDm O. CL a,3 °Q _ 0 ° CD w CD ; Sa) ;.. Yp d'Mr. Xd+yY > r`k3 Ala a O a' s � ,,� r.a ,o _ h,+ a #` z x Z Z,�? Z Z Z d * +; Z a' (�. co W N N N W W N.p N N 49 6o N n n s tQ 0 n n Z z z Z Z «Q rn o co::W C (Nn (Nil Ui } cc" (c'n o m y CDm u; m D?i D D D> > U;, ,.ccn (3 (a (D (D (D CD co t 3 0 m m m O �w a' ) 0 0 (D m W a o o- ae 4 '4•P J 7C � CD ^JN o �"... (D oN Da oN < c RL m N Q O EXHIBIT 11 Insured Employer Application �m UritedHe&hcare° A UnitedHealth Group Company To avoid processing delays, please make sure you: 1. Answer all questions completely and accurately. 2. DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL. 3. Include a deposit check in the amount of the estimated first month's premium; such amount will be returned in the event coverage does not become effective and will be applied against the first month's premium if coverage does become effective. Requested Effective Date January_ 1 __201 0 Group's/Company's Legal Name Citv of Tamarac Street Address ^- Tax ID ~� — _ 7525 NW 88th Avenue _ _ _ —� 591039552 City State Zip Code �- County Tamarac, —� - -- --_- ^ —FL Contact Person Telephone Fax Email Address _ _ Maria Swanson 954-597-3600 954-597-3610 marias@tamarac.org Billing Address (if different) -- same Multi -location group/company? # of LocationsAddress (es) (or list on additional sheet of paper) Yes X_ No # of Years in Business Nature of Business Industry Code municil2ality # Hours per week Waiting Period X.; lst of Policy Month following Date of Hire Waiting Period waived for initial to be eligible for new hires 1 st of Policy Month following -- [months] [days] of employment enrollees X_ Yes __1 No Date of Hire (no waiting period) 25 [months] [days] of employment following Date of Hire Other Number of Persons currently on COBRA/Continuation: Number of Employees Termed Classes Excluded None Union Hourly (employees/dependents) in last 12 Months ? Non -Management . = Non -Owners # Applying # Full Time Employees Medical # Part Time Employees Life # Ineligible Employees Dental Total # Employees Vision Other for: # Waiving Medical Life Dental Vision Other for:_,jjjME=1 Medical Employer % Em to ee°/a Y Em to er % for De y �— Life X Dental _ --__ Vision Other �— Name of Current Medical Carrier # Yrs with the Current Carrier Name of Current Dental Carrier T Yrs with the Current Carrier ---- Aetna -------...-- - —. ---- --8 Aetna_ _ Name of Worker's Comp Carrier I Names of Owners/Partners not covered by Workers Compensation — Florida League of Cities Yes :XNo In the past 36 months, has the Group/Company or any affiliated entity filed for protection or operated under federal/state bankruptcy laws? (Chapter 7 or 11) Yes :XNo In the past 36 months, has any creditor filed or threatened to file a petition requesting the Group/Company or any affiliated entity be placed voluntarily into bankruptcy? Note: Life Insurance premiums for totally disabled insureds are waived for 6 months. Yes L No Acceptance of this application will replace existing life insurance coverage Coverage Provided by "United Health care and Affiliates": Medical coverage provided by United HealthCare Insurance Company or United HealthCare of Florida, Inc, or Neighborhood Health Partnership, Inc. Dental coverage provided by United HealthCare Insurance Company or United HealthCare of Florida, Inc, or Neighborhood Health Partnership, Inc. Life Insurance coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company Vision coverage provided by United HealthCare Insurance Company or Unimerica Insurance Company LG.ER.07.FL 09/07 page 1 of 3 213.3640 10/07 Agent Name Agency Agent Code(rax ID Number Printed Agent Name Email Address Social Security # Phone Number _ _ — Date �^ Rep Name Rap # Commissions payable to — —�— Agent Commission Schedule Std Scale of % Agent Signature Florida License ID# "i Yes :- No To the best of my knowledge, acceptance of this application will replace existing life insurance coverage. *See next page for important disclosure regarding agent compensation. --- Disclosures Answer the following questions to the best of your knowledge for all eligible employees and dependents (proprietors, partners, corporate officers, employees, spouses and dependent children). Please provide details to "Yes" answers in the space provided. IMPORTANT. Your answers to these questions must include all C0BRA and State Continued individuals covered by your present plan. Yes No t. Within the past 5 years, has an employee or dependent filed a claim for short-term disability, long term disability, social security disability income, workers' compensation, Medicare, or Medicaid benefits or any other type of disability benefits on any policy? Yes L:. No 2. During the past 5 years, has any employee or dependent had life, disability or health insurance declined, postponed, changed, cancelled or withdrawn? "i Yes �7 No 3. Except for a maternity or paternity leave, within the past years, has any employee applied for a family or medical leave of more than 2 weeks due to injury, disability or illness of the employee or dependent? Yes No 4. Within the pasts years, has any employee been absent from work for more than 2 consecutive weeks due to injury, disability or illness Yes "7 No 5. Except for a mentalhealth admission, during the past 5 years, has any employee or dependent had a hospital stay lasting more than 5 days? Yes No 6. Is any employee or dependent currently hospitalized? Yes No 7. Except for allergy -related, birth -control or infertility medication, during the past 5 years, has any employee or dependent taken a prescription medication for a period lasting more than 6 months. Yes : No 8. Is any employee or dependent currently taking a prescription medication that will be taken for more than 6 months? Yes ; No 9. During the past 5 years, has any employee or dependent been treated for OR diagnosed by a physician as having one of the following conditions: i :I Cancer (any type) L Lung disease or respiratory problem (any type) i Heart disease or disorder (any type) Organ, tissue or cell transplant i._ Liver disease (any type) -'. Kidney disease (any type) Pancreatic disorder (any type) ri Diabetes Hepatitis L7 Morbid obesity Congenital abnormality * Vascular disease (any type) U Neurological disorder (any type) i.." Immunological disorder (reportable types) L:i Alcohol or drug addiction or abuse If you have answered "Yes' to any of the questions above, please provide the requested information for each individual. If necessarv, use additional sheets of oaoer. Question Number Check On Employee 10ependent Age Date of Recovery Date of Treatment/ Condition Nature of Medication Name of Condition S Amount of Claims Prognosis u Current Treatment page 2 of 3 The Group/Company certifies that the information provided above is complete and accurate. The Group/Company shall notify UnitedHealthcare and Affiliates promptly of any changes in this information that may affect the eligibility of employees or their dependents, including the addition of any newly eligible employees or dependents. Prior to receiving notification of approval, the Group/Company shall notify UnitedHealthcare and Affiliates promptly of any significant changes in the health status of an eligible employee or dependent including any inpatient hospital admissions. UnitedHealthcare and Affiliates shall be entitled to rely on the most current information in its possession regarding the eligibility and health status of employees and their dependents in providing coverage under the policy/policies for which application is being made. I represent to the best of my knowledge the information I have furnished is accurate, and includes any employees and dependents who have elected continuation of insurance benefits. I understand that material omissions misrepresentations or misstatements in the information requested on this form can result in the adjustment of rating or voiding of insurance. Upon receipt by UnitedHealthcare and Affiliates of this signed employer application and payment of the required policy charges, the group policy is deemed executed. The deposit check in the estimated amount of the first month's premium is not considered payment of the required policy charges. UnitedHealthcare disclosure regarding agent compensation: We pay agents compensation for their services in connection with the sale of our insured products, in compliance with applicable law. We pay "base commissions' based on factors such as product type, amount of premium, group size and number of employees. These commissions are reflected in the premium rate. In addition, we may pay bonuses pursuant to bonus programs established from 6me to time which are designed to encourage the introduction of new products and provide incentives to achieve production targets, persistency levels, growth goals or other objectives. Bonuses are not reflected in the premium rate but are paid from our general administrative expenses. In general, our total bonuses are less than 10% of total agent compensation paid. It is our policy not to pay commissions to agents with respect to a product for which the customer is also paying the agent a commission or other fee. Please note we also make payments from time to time to agents for services other than those relating to the sale of policies (for example, compensation for services as a general agent or as a consultant). Agent compensation is subject to disclosure on Schedule A of the ERISA Form 5500 for customers governed by ERISA. We provide Schedule A reports to our customers. We also have taken steps to ensure that agents properly disclose their compensation arrangements to their customers, but we cannot guarantee the agent's compliance. For general information on our agent payment arrangements, including the approximate percentage of total compensation that total bonus payments comprise, please go to http://www.uhc.com and click on the drop down box for employers under "View Our Programs - Producer Payment Programs." For specific information about the compensation payable with respect to your particular policy, please contact your agent. Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. is Signature (Form must be signed) Group/Company Signature Date DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL. page 3of3 EXHIBIT III. United HlealthCare Insurance Company Dental Certificate of Coverage This Certificate of Coverage ("Certificate") sets forth your rights and obligations as a Covered Person. It is important that you READ YOUR CERTIFICATE CAREFULLY and familiarize yourself with its terms and conditions. The Policy may require that the Subscriber contribute to the required Premiums. Information regarding the Premium and any portion of the Premium cost a Subscriber must pay can be obtained from the Enrolling Group, United HealthCare Insurance Company ("Company") agrees with the Enrolling Group to provide Coverage for Dental Services to Covered Persons, subject to the terms, conditions, exclusions and limitations of the Policy. The Policy is issued on the basis of the Enrolling Group's application and payment of the required Policy Charges, The Enrolling Group's application is made a part of the Policy. The Company will not be deemed or construed as an employer for any purpose with respect to the administration or provision of benefits under the Enrolling Group's benefit plan. The Company will not be responsible for fulfilling any duties or obligations of an employer with respect to the Enrolling Group's benefit plan. The Policy will take effect on the date specified in the Policy and will be continued in force by the timely payment of the required Policy Charges when due. subject to termination of the Policy as provided. All Coverage under the Policy will begin at 12:01 a.m. and end at 12:00 midnight at the Enrolling Group's address. The Policy is delivered in and governed by the laws of the State of ALABAMA . DCOC.CER.06.XX Introduction to Your Certificate You and any of your Enrolled Dependents, are eligible for Coverage under the Policy if the required Premiums have been paid. The Policy is referred to in this Certificate as the "Policy" and is designated on the identification ("ID") card. Coverage is subject to the terms, conditions, exclusions, and limitations of the Policy. As a Certificate , this document describes the provisions of Coverage under the Policy but does not constitute the Policy. You may examine the entire Policy at the office of the Enrolling Group during regular business hours. For Dental Services rendered after the effective date of the Policy, this Certificate replaces and supersedes any Certificate , which may have been previously issued to you by the Company. Any subsequent Certificates issued to you by the Company will in turn supersede this Certificate. The employer expects to continue the group plan indefinitely. But the employer reserves the right to change or end it at any time. This would change or end the terms of the Policy in effect at that time for active or retired employees. Haw To Use This Certificate This Certificate should be read and re -read in its entirety. Many of the provisions of this Certificate and the attached Schedule of Covered Dental Services are interrelated; therefore, reading just one or two provisions may not give you an accurate impression of your Coverage. Your Certificate and Schedule of Covered Dental Services may be modified by the attachment of Riders and/or Amendments. Please read the provision described in these documents to determine the way in which provisions in this Certificate or Schedule of Covered Dental Services may have been changed. Many words used in this Certificate and Schedule of Covered Dental Services have special meanings. These words will appear capitalized and are defined for you in Section 1: Definitions. By reviewing these definitions, you will have a clearer understanding of your Certificate and Schedule of Covered Dental Services. When we use the words "we," "us," and "our" in this document, we are referring to United HealthCare Insurance Company. When we use the words "you" and "your" we are referring to people who are Covered Persons as the term is defined in Section 1: Definitions. From time to time, the Policy may be amended. When that happens, a new Certificate , Schedule of Covered Dental Services or Amendment pages for this Certificate or Schedule of Covered Dental Services will be sent to you. Your Certificate and Schedule of Covered Dental Services should be kept in a safe place for your future reference. Network and Non -Network Benefits This Certificate describes both benefit levels available under the Policy. Network Benefits - These benefits apply when you choose to obtain Dental Services from a Network Dentist. Section 10: Procedures for Obtaining Benefits describes the procedures for obtaining Covered Dental Services as Network Benefits. Unless otherwise noted in the Schedule of Covered Dental Services or Section 11: Covered Dental Services, Network Benefits are subject to payment of any Deductible and any applicable Waiting Period and generally require you to pay less to the provider than Non -Network Benefits. Network Benefits are determined based on the contracted fee for each Covered Dental Service. In no event, will you be required to pay a Network Dentist an amount for a Covered Dental Service in excess of the contracted fee. Non -Network Benefits - These benefits apply when you decide to obtain Dental Services from Non -Network Dentists. Section 10: Procedures for Obtaining Benefits describes the procedures for obtaining Covered Dental Services as Non -Network Benefits. Unless otherwise noted in the Schedule of Covered Dental Services or Section 11, Covered Dental Services. Non -Network Benefits are subject to a Deductible and generally require you to pay more than Network Benefits. Non -Network Benefits are determined based on the Usual and Customary fee for similarly situated Network Dentists for each Covered Dental Service. The actual charge made by a Non -Network Dentist for a Covered Dental Service may exceed the Usual and Customary fee. As a result, you may be required DCOC.INT.06.XX 2 to pay a Non -Network Dentist an amount for a Covered Dental Service in excess of the Usual and Customary fee. In addition, when you obtain Covered Dental Services from Non -Network Dentists, you must file a claim with the Company to be reimbursed for Eligible Expenses. The information in Section 1: Definitions through Section 9: Continuation of Coverage applies to both levels of Coverage. Section 10: Procedures for Obtaining Benefits, the Schedule of Covered Dental Services and Section 11: Covered Dental Services explain the procedures you must follow to obtain Coverage for Network Benefits and Non -Network Benefits. The Schedule of Covered Dental Services or Section 11: Covered Dental Services describe which Dental Services are Covered. Unless otherwise specified, the exclusions and limitations that appear in Section 12: General Exclusions apply to both levels of benefits. The Schedule of Covered Dental Services or Section 11., Covered Dental Services describe what Copayments are required, if any, and to what extent any limitations apply. Dental Services Covered Under the Policy In order for Dental Services to be Covered as Network Benefits, you must obtain all Dental Services directly from or through a Network Dentist. You must always verify the participation status of a provider prior to seeking services. From time to time, the participation status of a provider may change. You can verify the participation status by calling the Company and/or provider. If necessary, the Company can provide assistance in referring you to Network Dentists. If you use a provider that is not a participating provider, you will be required to pay the entire bill for the services you received. Only Necessary Dental Services are Covered under the Policy. The fact that a Dentist has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment, for a dental disease does not mean that the procedure or treatment is Covered under the Policy The Company has sole and exclusive discretion in interpreting the benefits Covered under the Policy and the other terms, conditions, limitations and exclusions set out in the Policy and in making factual determinations related to the Policy and its benefits. The Company may, from time to time, delegate discretionary authority to other persons or entities providing services in regard to the Policy. The Company reserves the right to change, interpret, modify, withdraw or add benefits or terminate the Policy; in its sole discretion, as permitted by law, without the approval of Covered Persons. No person or entity has any authority to make any oral changes or amendments to the Policy. The Company may, in certain circumstances for purposes of overall cost savings or efficiency and in its sole discretion, provide Coverage for services, which would otherwise not be Covered. The fact that the Company does so in any particular case will not in any way be deemed to require it to do so in other similar cases. The Company may, in its sole discretion, arrange for various persons or entities to provide administrative services in regard to the Policy, including claims processing and utilization management services. The identity of the service providers and the nature of the services provided may be changed from time to time in the Company's sole discretion and without prior notice to or approval by Covered Persons. You must cooperate with those persons or entities in the performance of their responsibilities. Similarly, the Company may, from time to time, require additional information from you to verify your eligibility or your right to receive Coverage for services under the Policy. You are obligated to provide this information. Failure to provide required information may result in Coverage being delayed or denied. Important Note About Services The Company does not provide Dental Services or practice dentistry. Rather, the Company arranges for providers of Dental Services to participate in a Network. Network Dentists are independent practitioners and are not employees of the Company. The Company, therefore, makes payment to Network Dentists through various types of contractual arrangements. These arrangements may include financial incentives to promote the delivery of dental care in a cost efficient and effective manner. Such financial incentives are not intended to impact your access to Necessary Dental Services. The payment methods used to pay any specific Network Dentist vary. The method may also change at the time providers renew their contracts with the Company. If you have questions about whether there are any financial incentives in your Network Dentist's contract with the Company, please contact the Company at the telephone DCOC.INT.06.XX 3 number on your ID card, The Company can advise you whether your Network Dentist is paid by any financial incentive, however, the specific terms, including rates of payment, are confidential and cannot be disclosed. The Dentist -patient relationship is between you and your Dentist. This means that: • You are responsible for choosing your own Dentist. • You must decide if any Dentist treating you is right for you. This includes Network Dentists who you choose or providers to whom you have been referred. • You must decide with your Dentist what rare you should receive. • Your Dentist is solely responsible for the quality of the care you receive. The Company makes decisions about eligibility and if a benefit is a Covered benefit under the Policy. These decisions are administrative decisions. The Company is not liable for any act or omission of a provider of Dental Services. Important Information Regarding Medicare Coverage under the Policy_ is not intended to supplement any coverage provided by Medicare, but in some circumstances Covered Persons who are eligible for or enrolled in Medicare may also be enrolled for Coverage under the Policy. If you are eligible for or enrolled in Medicare, please read the following information carefully. If you are eligible for Medicare, you must enroll for and maintain coverage under both Medicare Part A and Part B. If you don't enroll, and if the Company is the secondary payer as described in Section 7. Coordination of Benefits of this Certificate . the Company will pay benefits under the Policy as if you were covered under both Medicare Part A and Part B and you will incur a larger out of pocket cost for Health Services. If, in addition to being enrolled for Coverage under the Policy, you are enrolled in a Medicare Advantage (Medicare Part C) plan, you must follow all rules of that plan that require you to seek services from that plan's participating providers. When the Company is the secondary payer, we will pay any benefits available to you under the Policy as if you had followed all rules of the Medicare Advantage plan. If the Company is the secondary plan and you don't follow the rules of the Medicare Advantage plan, you will incur a larger out of pocket cost for Dental Services. If, in addition to being enrolled for Coverage under the Policy, you are enrolled in a Medicare Prescription Drug (Medicare Part D) plan through either a Medicare Advantage plan with a prescription drug benefit (MA-PD), a special -needs plan (SNP-PD) or a stand alone Prescription Drug Plan (PDP), you must follow all rules of that plan that require you to seek services from that plan's participating pharmacies. When this Company is the secondary payer, we will pay any benefits available to you under the Policy as if you had followed all rules of the Medicare Part D plan. If this Company is the secondary plan and you don't follow the rules of the Medicare Part D plan, you will incur a larger out of pocket cost for prescription drugs. Identification ("ID") Card You must show your ID card every time you request Dental Services. If you do not show your card, the providers have no way of knowing that you are Covered under a Policy issued by the Company and you may receive a bill for Network Benefits. Contact the Company Throughout this Certificate you will find statements that encourage you to contact the Company for further information. Whenever you have a question or concern regarding Dental Services or any required procedure, please contact the Company at the telephone number stated on your ID card. DCOC.INT.06.XX 4 DENTAL CERTIFICATE OF COVERAGE TABLE OF CONTENTS Section1: Definitions...................................................................................................... 6 Section 2: Enrollment and Effective Date of Coverage........................................................... 10 Section 3: Termination of Coverage................................................................................... 12 Section 4: Reimbursement.............................................................................................. 14 Section 5: Complaint Procedures..................................................................................... 15 Section 6: General Provisions......,'............................................. ........... ....... ............. I ..... . 16 Section 7: Coordination of Benefits................................................................................... 18 Section 8: Subrogation and Refund of Expenses................................................................ 22 Section 9: Continuation of Coverage................................................................................ 24 Section 10: Procedures for Obtaining Benefits ......... ......... ............................................ ..:..... 27 Section 11: Covered Dental Services.................................................................................. 29 Section 12: General Exclusions .... ...... ........ ................ ................... -.......... ........ ............ ..... 31 DCOC.TOC.06.XX 5 Section 1: Definitions This Section defines the terms used throughout this Certificate and Schedule of Covered Dental Services and is not intended to describe Covered or uncovered services. Amendment - any attached description of additional or alternative provisions to the Policy. Amendments are effective only when signed by an officer of the Company. Amendments are subject to all conditions, limitations and exclusions of the Policy except for those which are specifically amended. CDT Codes - mean the Current Dental Terminology for the current Code on Dental Procedures and Nomenclature (the Code). The Code has been designated as the national standard for reporting dental services by the Federal Government under the Health Insurance and Portability and Accountability Act of 1996 (HIPAA), and is currently recognized by third party payors nationwide. Congenital Anomaly - a physical developmental defect that is present at birth and identified within the first twelve months from birth. Copayment - the charge you are required to pay for certain Dental Services payable under the Policy. A Copayment may either be a defined dollar amount or a percentage of Eligible Expenses. You are responsible for the payment of any Copayment for Network Benefits directly to the provider of the Dental Service at the time of service or when billed by the provider. Coverage or Covered - the entitlement by a Covered Person to reimbursement for expenses incurred for Dental Services covered under the Policy, subject to the terms, conditions, limitations and exclusions of the Policy. Dental Services must be provided: (1.) when the Policy is in effect; and (2.) prior to the date that any of the individual termination conditions as stated in Section 3: Termination of Coverage occur; and (3.) only when the recipient is a Covered Person and meets all eligibility requirements specified in the Policy. Covered Person - either the Subscriber or an Enrolled Dependent, while Coverage of such person under the Policy is in effect. References to you and your throughout this Certificate are references to a Covered Person. Deductible - the amount a Covered Person must pay for Dental Services in a calendar year before the Company will begin paying for Network or Non -Network Benefits in that calendar year. Dental Service or Dental Procedures - dental care or treatment provided by a Dentist to a Covered Person while the Policy is in effect, provided such care or treatment is recognized by the Company as a generally accepted form of care or treatment according to prevailing standards of dental practice. Dentist - any dental practitioner who is duly licensed and qualified under the law of jurisdiction in which treatment is received to render Dental Services, perform dental surgery or administer anesthetics for dental surgery. Dependent - (1.) the Subscriber's legal spouse or (2.) an unmarried dependent child of the Subscriber or the Subscriber's spouse (including a natural child, stepchild, a legally adopted child, a child placed for adoption, or a child for whom legal guardianship has been awarded to the Subscriber or the Subscriber's spouse). The term child also includes a grandchild of either the Subscriber or the Subscriber's spouse. To be eligible for coverage under the Policy, a Dependent must reside within the United States. The definition of Dependent is subject to the following conditions and limitations: A. The term Dependent will not include any unmarried dependent child 19 years of age or older, except as stated in the next paragraph, or as stated in Section 3. Termination of Coverage, sub -section 3.2: Extended Coverage for Handicapped Children. B. The term Dependent will include an unmarried dependent child who is 19 years of age or older, but less than 25 years of age as defined under Full-time Student, if evidence satisfactory to the Company of the following conditions is furnished upon request: 1. the child is not regularly employed on a full-time basis; and 2. the child is a Full-time Student: and 3. the child is primarily dependent upon the Subscriber for support and maintenance. DC©C.DEF.06.XX The Subscriber agrees to reimburse the Company for any Dental Services provided to the child at a time when the child did not satisfy these conditions. The term Dependent also includes a child for whom dental care coverage is required through a Qualified Medical Child Support Order or other court or administrative order. The Enrolling Group is responsible for determining if an order meets the criteria of a Qualified Medical Child Support Order. The term Dependent does not include anyone who is also enrolled as a Subscriber, nor can anyone be a Dependent of more than one Subscriber. Eligible Expenses - Eligible Expenses for Covered Dental Services, incurred while the Policy is in effect, are determined as stated below: A. For Network Benefits, when Covered Dental Services are received from Network Dentists, Eligible Expenses are the Company's contracted fee(s) for Covered Dental Services with that provider. B. For Non -Network Benefits, when Covered Dental Services are received from Non -Network Dentists, Eligible Expenses are the Company's contracted fee(s) for Covered Dental Services with a Network Dentist in the same geographic area. In the event that a provider routinely waives Copayments and/or the Deductible for Non -Network benefits, Dental Services for which the Copayments and/or the Deductible are waived are not considered to be Eligible Expenses, Eligible Person - an employee of the Enrolling Group or other person whose connection with the Enrolling Group meets the eligibility requirements specified in both the application and the Policy. Emergency - a dental condition or symptom resulting from dental disease which arises suddenly and, in the judgment of a reasonable person, requires immediate care and treatment, and such treatment is sought or received within 24 hours of onset, Enrolled Dependent - a Dependent who is properly enrolled for Coverage under the Policy. Enrolling Group - the employer or other defined or otherwise legally constituted group to whom the Policy is issued. Experimental, Investigational or Unproven Services - medical, dental, surgical, diagnostic, or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the Company makes a determination regarding coverage in a particular case, is determined to be: A. Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use; or B. Subject to review and approval by any institutional review board for the proposed use; or C. The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or D. Not demonstrated through prevailing peer -reviewed professional literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed. Foreign Services- are defined as services provided outside the U.S. and U.S. territories. Full-time Student - a person who is enrolled in and attending, full-time, a recognized course of study or training at: A. An accredited high school; B. An accredited college or university: or C. A licensed vocational school, technical school, beautician school, automotive school or similar training school. Full-time Student status is determined in accordance with the standards set forth by the educational institution. A person ceases to be a Full-time Student at the end of the calendar month during which the person graduates or otherwise ceases to be enrolled and in attendance at the institution on a full-time basis. A person continues to be a Full-time Student during periods of regular vacation established by the institution. If the person does not continue as a Full-time Student immediately following the period of vacation, the Full-time DCOC.DEF.06.XX 7 Student designation will end on the last day of the calendar month in which the person was enrolled and in attendance at the institution on a full-time basis. Initial Eligibility Period - the initial period of time, determined by the Company and the Enrolling Group, during which Eligible Persons may enroll themselves and Dependents under the Policy. Maximum Benefit - the maximum amount paid for Covered Dental Services during a calendar year for a Covered Person under the Policy or any Policy, issued by the Company to the Enrolling Group, that replaces the Policy. The Maximum Benefit is stated in Section 11 Covered Dental Services. Medicare - Parts A; B, C. and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended. Necessary - Dental Services and supplies which are determined by the Company through case -by -case assessments of care based on accepted dental practices to be appropriate; and A. necessary to meet the basic dental needs of the Covered Person; and B. rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the Dental Service; and C. consistent in type, frequency and duration of treatment with scientifically based guidelines of national clinical, research, or health care coverage organizations or governmental agencies that are accepted by the Company; and D. consistent with the diagnosis of the condition; and E. required for reasons other than the convenience of the Covered Person or his or her Dentist: and F. demonstrated through prevailing peer -reviewed dental literature to be either: 1. safe and effective for treating or diagnosing the condition or sickness for which their use is proposed: or 2. safe with promising efficacy a. for treating a life threatening dental disease or condition; and b. in a clinically controlled research setting; and c. using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health. (For the purpose of this definition, the term life threatening is used to describe dental diseases or sicknesses or conditions, which are more likely than not to cause death within one year of the date of the request for treatment.) The fact that a Dentist has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular dental disease does not mean that it is a Necessary Covered Dental Service as defined in this Certificate. The definition of Necessary used in this Certificate relates only to Coverage and differs from the way in which a Dentist engaged in the practice of dentistry may define necessary, Network - a group of Dentists who are subject to a participation agreement in effect with the Company, directly or through another entity, to provide Dental Services to Covered Persons. The participation status of providers will change from time to time. Network Benefits - benefits available for Covered Dental Services when provided by a Dentist who is a Network Dentist, Non -Network Benefits - coverage available for Dental Services obtained from Non -Network Dentists. Open Enrollment Period - after the Initial Eligibility Period, a period of time determined by the Company and the Enrolling Group, during which Eligible Persons may enroll themselves and Dependents under the Policy. Physician - any Doctor of Medicine, M.D., or Doctor of Osteopathy, D.O., who is duly licensed and qualified under the law of jurisdiction in which treatment is received. Plan Allowance - is shown as a fixed dollar amount or percentage of Eligible Expenses after the Deductible is satisfied and is the maximum benefit amount the Company will pay for each particular Dental Procedure shown. DCOC.DEF.06.XX 8 The Subscriber must pay the amount of the Dentist's fee, if any, which is greater than the amount of the Plan Allowance. Policy - the group Policy, the application of the Enrolling Group, Amendments and Riders which constitute the agreement regarding the benefits, exclusions and other conditions between the Company and the Enrolling Group. Policy Charge - the sum of the Premiums for all Subscribers and Enrolled Dependents Covered under the Policy. Premium - the periodic fee required for each Subscriber and each Enrolled Dependent in accordance with the terms of the Policy. Procedure in Progress - all treatment for Covered Dental Services that results from a recommendation and an exam by a Dentist. A treatment procedure will be considered to start on the date it is initiated and will end when the treatment is completed. Rider - any attached description of Dental Services Covered under the Policy, Dental Services provided by a Rider may be subject to payment of additional Premiums and additional Copayments. Riders are effective only when signed by an officer of the Company and are subject to all conditions, limitations and exclusions of the Policy except for those that are specifically amended. Subscriber - an Eligible Person who is properly enrolled for Coverage under the Policy. The Subscriber is the person (who is not a Dependent) on whose behalf the Policy is issued to the Enrolling Group. Usual and Customary - Usual and Customary fees are calculated by the Company based on available data resources of competitive fees in that geographic area. Usual and Customary fees must not exceed the fees that the provider would charge any similarly situated payor for the same services. In the event that a provider routinely waives Copayments and/or the Deductible for benefits, Dental Services for which the Copayments and/or the Deductible are waived are not considered to be Usual and Customary. Usual and Customary fees are determined solely in accordance with the Company's reimbursement policy guidelines. The Company's reimbursement policy guidelines are developed by the Company, in its discretion, following evaluation and validation of all provider billings in accordance with one or more of the following methodologies: As indicated in the most recent edition of the Current Procedural Terminology (publication of the American Dental Association); As reported by generally recognized professionals or publications; As utilized for Medicare; • As determined by medical or dental staff and outside medical or dental consultants: • Pursuant to other appropriate source or determination accepted by the Company. Waiting Period - period of time for which a Covered Person must wait, after the effective date of Coverage, before Dental Services listed in Section 11: Covered Denta/ Services will be Covered. DCOC.DEF.06.XX 9 Section 2.1 Enrollment Eligible Persons may enroll themselves and their Dependents for Coverage under the Policy during the Initial Eligibility Period or during an Open Enrollment Period by submitting a form provided or approved by the Company. In addition, new Eligible Persons and new Dependents may be enrolled as described below. Dependents of an Eligible Person may not be enrolled unless the Eligible Person is also enrolled for Coverage under the Policy. If you enroll for Coverage under the Policy, you must remain enrolled for a period of 12 months. If you disenroll at the end of any 12 month period, you must wait 12 months until you are again eligible for Coverage. If both spouses are Eligible Persons of the Enrolling Group, each may enroll as a Subscriber or be covered as an eligible Dependent of the other, but not both. If both parents of an eligible Dependent child are enrolled as a Subscriber, only one parent may enroll the child as a Dependent. If you fail to enroll yourself or a Dependent during the Initial Eligibility Period or during an Open Enrollment Period, you or your Dependent must wait 12 months before you or your Dependent are eligible to enroll for Dental benefits. Section 2.2 Effective Date of Coverage In no event is there Coverage for Dental Services rendered or delivered before the effective date of Coverage. If an Eligible Person enrolls during the Initial Eligibility Period, Coverage is effective once any required probationary period has been satisfied. Please see your employer for more information, Section 2.3 Coverage for a Newly Eligible Person Coverage for you and any of your Dependents will take effect on the date agreed to by the Enrolling Group and the Company. Coverage is effective only if the Company receives any required Premium and a properly completed enrollment form within 31 days of the date you first become eligible. Section 2.4 Coverage for a Newly Eligible Dependent Coverage for a new Dependent acquired by reason of birth, legal adoption, legal guardianship, placement for adoption, court or administrative order, or marriage will take effect on the date of the event. Coverage is effective only if the Company receives any required Premium and is notified of the event within 31 days. Section 2.5 Change in Family Status You may make Coverage changes during the year for any Dependent whose status as a Dependent is affected by a marriage, divorce, legal separation, annulment, birth, legal guardianship, placement for adoption or adoption, as required by federal law. In such cases you must submit the required contribution of coverage and a properly completed enrollment form within 31 days of the marriage, birth, placement for adoption or adoption. Otherwise, you will need to wait until the next annual Open Enrollment Period, Section 2.6 Special Enrollment Period An Eligible Person and/or Dependent who did not enroll for Coverage under the Policy during the initial Eligibility Period or Open Enrollment Period may enroll for Coverage during a special enrollment period. A special enrollment period is available if the following conditions are met: (a.) the Eligible Person and/or Dependent had existing health coverage under another plan at the time of the Initial Eligibility Period or Open Enrollment Period; and (b.) Coverage under the prior plan was terminated as a result of loss of eligibility (including, without limitation, legal separation, divorce or death), termination of employer contributions, or in the case of COBRA continuation coverage, the coverage was exhausted. A special enrollment period is not available if coverage under the prior plan was terminated for cause or as a result of failure to pay Premiums on a timely basis. Coverage under the Policy is effective only if the Company receives any required Premium and a properly completed enrollment form within 31 days of the date coverage under the prior plan terminated. A special enrollment period is also available for an Eligible Person and for any Dependent whose status as a Dependent is affected by a marriage, birth, placement for adoption or adoption, as required by federal law. In such cases you DCOC.ENR.06.XX 10 must submit the required Premium and a properly completed enrollment form within 31 days of the marriage, birth; placement for adoption or adoption. DCOC.ENR.06.XX 11 Section 3: Termination of Coverage Section 3.1 Conditions for Termination of a Covered Person's Coverage Under the Policy The Company may, at any time, discontinue this benefit plan and/or all similar benefit plans for the reasons specified in the Policy. When your Coverage terminates, you may have continuation as described in Section 9: Continuation of Coverage or as provided under other applicable federal and/or state law. Your Coverage, including coverage for Dental Services rendered after the date of termination for dental conditions arising prior to the date of termination, will automatically terminate on the earliest of the dates specified below. A. The date the entire Policy is terminated, as specified in the Policy. The Enrolling Group is responsible for notifying you of the termination of the Policy. B. The last day of the calendar month in which you cease to be eligible as a Subscriber or Enrolled Dependent. C. The date the Company receives written notice from either the Subscriber or the Enrolling Group instructing the Company to terminate Coverage of the, Subscriber or any Covered Person or the date requested in such notice, if later. D. The date the Subscriber is retired or pensioned under the Enrolling Group's Plan, unless a specific Coverage classification is specified for retired or pensioned persons in the Enrolling Group's application and the Subscriber continues to meet any applicable eligibility requirements. When any of the following apply, the Company will provide written notice of termination to the Subscriber. E. The date specified by the Company that all Coverage will terminate due to fraud or misrepresentation or because the Subscriber knowingly provided the Company with false material information, including, but not limited to, false, material information relating to residence, information relating to another person's eligibility for Coverage or status as a Dependent. The Company has the right to rescind Coverage back to the effective date. F. The date specified by the Company that all Coverage will terminate because the Subscriber permitted the use of his or her ID card by any unauthorized person or used another person's card. G. The date specified by the Company that Coverage will terminate due to material violation of the terms of the Policy. H. The date specified by the Company that your Coverage will terminate because you failed to pay a required Copayment. I. The date specified by the Company that your Coverage will terminate because you have committed acts of physical or verbal abuse which pose a threat to the Company staff, a provider; or other Covered Persons. Section 3.2 Extended Coverage for Handicapped Dependent Children Coverage of an unmarried Enrolled Dependent who is incapable of self-support because of mental retardation or physical handicap will be continued beyond the age listed under the definition of Dependent provided that: A. the Enrolled Dependent becomes incapacitated prior to attainment of the limiting age; and B. the Enrolled Dependent is chiefly dependent upon the Subscriber for support and maintenance; and C. proof of such incapacity and dependence is furnished to the Company within 31 days of the date the Subscriber receives a request for such proof from the Company; and D. payment of any required Premium for the Enrolled Dependent is continued. Coverage will be continued so long as the Enrolled Dependent continues to be so incapacitate d and dependent, unless otherwise terminated in accordance with the terms of the Policy. Before granting this extension, the Company may reasonably require that the Enrolled Dependent be examined at the Company's expense by a Physician designated by the Company. At reasonable intervals, the Company may require satisfactory proof of DCOC.TER.06.XX 12 the Enrolled Dependent's continued incapacity and dependency, including medical examinations at the Company's expense. Such proof will not be required more often than once a year. Failure to provide such satisfactory proof within 31 days of the request by the Company will result in the termination of the Enrolled Dependent's Coverage under the Policy. Section 3.3 Extended Coverage A 30 day temporary extension of Coverage, only for the services shown below when given in connection with a Procedure in Progress, will be granted to a Covered Person on the date the person's Coverage is terminated if termination is not voluntary. Benefits will be extended until the earlier of: (a.) the end of the 30 day period; or (b.) the date the Covered Person becomes covered under a succeeding policy or contract providing coverage or services for similar dental procedures. Benefits will be Covered for: (a.) a Procedure in Progress or Dental Procedure that was recommended in writing and began, in connection with a specific dental disease of a Covered Person while the Policy was in effect, by the attending Dentist; (b.) an appliance, or modification to an appliance, for which the impression was taken prior to the termination of Coverage; or (c.) a crown, bridge or gold restoration, for which the tooth was prepared prior to the termination of Coverage. Section 3.4 Payment and Reimbursement Upon Termination Termination of Coverage will not affect any request for reimbursement of Eligible Expenses for Dental Services rendered prior to the effective date of termination. Your request for reimbursement must be furnished as required in Section 4: Reimbursement. DCOC.TER.06.XX 13 Section 4.1 Reimbursement of Eligible Expenses The Company will reimburse you for Eligible Expenses subject to the terms: conditions, exclusions and limitations of the Policy and as described below. Section 4.2 Filing Claims for Reimbursement of Eligible Expenses You are responsible for sending a request for reimbursement to the Company's office, on a form provided by or satisfactory to the Company. Requests for reimbursement should be submitted within 90 days after date of service. Unless you are legally incapacitated, failure to provide this information to the Company within 1 year of the date of service will cancel or reduce Coverage for the Dental Service. Claim Forms. It is not necessary to include a claim form with the proof of loss. However, the proof must include all of the following information: • Your name and address • Patient's name and age • Number stated on your ID card • The name and address of the provider of the service(s) • A diagnosis from the Dentist including a complete dental chart showing extractions, fillings or other dental services rendered before the charge was incurred for the claim • Radiographs, lab or hospital reports • Casts, molds or study models • Itemized bill which includes the CPT or ADA codes or description of each charge • The date the dental disease began • A statement indicating that you are or you are not enrolled for coverage under any other health or dental insurance plan or program. If you are enrolled for other coverage you must include the name of the other carrier(s). If you would like to use a claim form, call the Company at the telephone number stated on your ID Card and a claim form will be sent to you. If you do not receive the claim form within 15 days of your request, send in the proof of loss with the information stated above. Proof of Loss. Written proof of loss should be given to the Company within 90 days after the date of the loss. If it was not reasonably possible to give written proof in the time required, the Company will not reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible, but no later than 1 year after the date of service. Payment of Claims. Benefits are payable in accordance with any state prompt pay requirements after the Company receives acceptable proof of loss. When you obtain Covered Dental Services from Non -Network Dentists, you must file a claim with the Company and benefits will be paid directly to you. Benefits will be paid to you unless: A. The provider notifies the Company that your signature is on file assigning benefits directly to that provider, or B. You make a written request at the time the claim is submitted. Subject to written authorization from a Subscriber, all or a portion of any Eligible Expenses due may be paid directly to the provider of the Dental Services instead of being paid to the Subscriber. Section 4.3 Limitation of Action for Reimbursement You do not have the right to bring any legal proceeding or action against the Company to recover reimbursement until 90 days after you have properly submitted a request for reimbursement, as described above. If you do not bring such legal proceeding or action against the Company within 3 years from the date satisfactory written proof of loss was submitted to us, you forfeit your rights to bring any action against the Company. DCOC.REM.06.XX 14 Section 5: Complaint Procedures Section 5.1 Complaint Resolution If you have a concern or question regarding the provision of Dental Services or benefits under the Policy, you should contact the Company's customer service department at the telephone number shown on your ID card. Customer service representatives are available to take your call during regular business hours, Monday through Friday. At other times, you may leave a message on voicemail, A customer service representative will return your call. If you would rather send your concern to us in writing at this point, the Company's authorized representative can provide you with the appropriate address. If the customer service representative cannot resolve the issue to your satisfaction over the phone, he or she can provide you with the appropriate address to submit a written complaint. We will notify you of our decision regarding your complaint within 30 days of receiving it. If you disagree with our decision after having submitted a written complaint, you can ask us in writing to formally reconsider your complaint. If your complaint relates to a claim for payment, your request should include: • The patient's name and the identification number from the ID card • The date(s) of service(s) • The provider's name • The reason you believe the claim should be paid • Any new information to support your request for claim payment We will notify you of our decision regarding our reconsideration of your complaint within 60 days of receiving it. If you are not satisfied with our decision, you have the right to take your complaint to the Office of the Commissioner of Insurance. Section 5.2 Complaint Hearing If you request a hearing, we will appoint a committee to resolve or recommend the resolution of your complaint. If your complaint is related to clinical matters, the Company may consult with. or seek the participation of, medical and/or dental experts as part of the complaint resolution process. The committee will advise you of the date and place of your complaint hearing. The hearing will be held within 60 days following receipt of your request by the Company, at which time the committee will review testimony, explanation or other information that it decides is necessary for a fair review of the complaint. We will send you written notification of the committee's decision within 30 days of the conclusion of the hearing. If you are not satisfied with our decision, you have the right to take your complaint to the Office of the Commissioner of Insurance. Section 5.3 Exceptions for Emergency Situations Your complaint requires immediate actions when your Dentist judges that a delay in treatment would significantly increase the risk to your health. In these urgent situations: • The appeal does not need to be submitted in writing. You or your Dentist should call us as soon as possible. • We will notify you of the decision by the end of the next business day after your complaint is received, unless more information is needed. • If we need more information from your Dentist to make a decision, we will notify you of the decision by the end of the next business day following receipt of the required information. The complaint process for urgent situations does not apply to prescheduled treatments or procedures that we do not consider urgent situations. If you are not satisfied with our decision, you have the right to take your complaint to the Office of the Commissioner of Insurance. DCOC.CPL.06.XX 15 Section 6: General Provisions Section 6.1 Entire Policy The Policy issued to the Enrolling Group, including the Certificate(s), Schedule(s) of Covered Dental Services, the Enrolling Group's application, Amendments and Riders, constitute the entire Policy. All statements made by the Enrolling Group or by a Subscriber will, in the absence of fraud, be deemed representations and not warranties. Section 6.2 Limitation of Action You do not have the right to bring any legal proceeding or action against the Company without first completing the complaint procedure specified in Section 5: Complaint Procedures. If you do not bring such legal proceeding or action against the Company within 3 years of the date the Company notified you of its final decision as described in Section 5: Complaint Procedures, you forfeit your rights to bring any action against the Company. The only exception to this limitation of action is that reimbursement of Eligible Expenses, as set forth in Section 4: Reimbursement, is subject to the limitation of action provision of that Section. Section 6.3 Time Limit on Certain Defenses No statement, except a fraudulent statement, made by the Enrolling Group will be used to void the Policy after it has been in force for a period of 2 years. Section 6.4 Amendments and Alterations Amendments to the Policy are effective upon 31 days written notice to the Enrolling Group. Riders are effective on the date specified by the Company. No change will be made to the Policy unless it is made by an Amendment or a Rider that is signed by an officer of the Company. No agent has authority to change the Policy or to waive any of its provisions. Section 6.5 Relationship Between Parties The relationships between the Company and Network providers and relationships between the Company and Enrolling Groups, are solely contractual relationships between independent contractors. Network providers and Enrolling Groups are not agents or employees of the Company, nor is the Company or any employee of the Company an agent or employee of Network providers or Enrolling Groups. The relationship between a Network provider and any Covered Person is that of provider and patient. The Network provider is solely responsible for the services provided to any Covered Person. The relationship between the Enrolling Group and Covered Persons is that of employer and employee, Dependent or other Coverage classification as defined in the Policy. The Enrolling Group is solely responsible for enrollment and Coverage classification changes (including termination of a Covered Person's Coverage through the Company), for the timely payment of the Policy Charge to the Company, and for notifying Covered Persons of the termination of the Policy. Section 6.6 Information and Records At times the Company may need additional information from you. You agree to furnish the Company with all information and proofs that the Company may reasonably require regarding any matters pertaining to the Policy. If you do not provide this information when the Company requests it we may delay or deny payment of your Benefits. By accepting Benefits under the Policy, you authorize and direct any person or institution that has provided services to you to furnish the Company with all information or copies of records relating to the services provided to you. The Company has the right to request this information at any reasonable time. This applies to all Covered Persons, including Enrolled Dependents whether or not they have signed the Subscriber's enrollment form. The Company agrees that such information and records will be considered confidential The Company has the right to release any and all records concerning dental care services which are necessary to implement and administer the terms of the Policy, for appropriate review or quality assessment, or as the Company is required to do by law or regulation. During and after the term of the Policy, the Company and its DCOC.GPR.06.XX 16 related entities may use and transfer the information gathered under the Policy in a de -identified format for commercial purposes, including research and analytic purposes. For complete listings of your dental records or billing statements the Company recommends that you contact your Dentist. Dentists may charge you reasonable fees to cover their costs for providing records or completing requested forms. If you request dental forms or records from us, the Company also may charge you reasonable fees to cover costs for completing the forms or providing the records. In some cases, the Company will designate other persons or entities to request records or information from or related to you, and to release those records as necessary. The Company's designees have the same rights to this information as the Company has. Section 6.7 ERISA When the Policy is purchased by the Enrolling Group to provide benefits under a welfare plan governed by the Employee Retirement Income Security Act 29 U.S.C. § 1001 et seq., the Company is not the plan administrator or named fiduciary of the welfare plan, as those terms are used in ERISA. Section 6.8 Examination of Covered Persons In the event of a question or dispute concerning Coverage for Dental Services, the Company may reasonably require that a Network Dentist acceptable to the Company examine you at the Company's expense. Section 6.9 Clerical Error If a clerical error or other mistake occurs, that error will not deprive you of Coverage under the Policy. A clerical error also does not create a right to benefits. Section 6.10 Notice When the Company provides written notice regarding administration of the Policy to an authorized representative of the Enrolling Group, that notice is deemed notice to all affected Subscribers and their Enrolled Dependents. The Enrolling Group is responsible for giving notice to Covered Persons. Section 6.11 Workers' Compensation Not Affected The Coverage provided under the Policy does not substitute for and does not affect any requirements for coverage by workers' compensation insurance. Section 6.12 Conformity with Statutes Any provision of the Policy which, on its effective date, is in conflict with the requirements of state or federal statutes or regulations (of the jurisdiction in which delivered) is hereby amended to conform to the minimum requirements of such statutes and regulations. Section 6.13 Waiver/Estoppel Nothing in the Policy, Certificate or Schedule of Covered Dental Services is considered to be waived by any party unless the party claiming the waiver receives the waiver in writing. A waiver of one provision does not constitute a waiver of any other. A failure of either party to enforce at any time any of the provisions of the Policy, Certificate or Schedule of Covered Dental Services , or to exercise any option which is herein provided, shall in no way be construed to be a waiver of such provision of the Policy; Certificate or Schedule of Covered Dental Services. Section 6.14 Headings The headings, titles and any table of contents contained in the Policy, Certificate or Schedule of Covered Dental Services are for reference purposes only and shall not in any way affect the meaning or interpretation of the Policy, Certificate or Schedule of Covered Dental Services, Section 6.15 Unenforceable Provisions If any provision of the Policy, Certificate or Schedule of Covered Dental Services is held to be illegal or unenforceable by a court of competent jurisdiction, the remaining provisions will remain in effect and the illegal or unenforceable provision will be modified so as to conform to the original intent of the Policy. Certificate or Schedule of Covered Dental Services to the greatest extent legally permissible. DCOC.GPR.06.XX 17 Section 7: Coordination of Benefits Section 7.1 Coordination of Benefits Applicability This coordination of benefits (COB) provision applies when a person has health or dental coverage under more than one Coverage Plan. "Coverage Plan" is defined below. The order of benefit determination rules below determine which Coverage Plan will pay as the primary Coverage Plan. The primary Coverage Plan that pays first pays without regard to the possibility that another Coverage Plan may cover some expenses. A secondary Coverage Plan pays after the primary Coverage Plan and may reduce the benefits it pays so that payments from all group Coverage Plans do not exceed 100% of the total allowable expense. Section 7.2 Definitions For purposes of this Section. Coordination of Benefits, terms are defined as follows: A. A"Coverage Plan" is any of the following that provides benefits or services for medical or dental care or treatment, However, if separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same Coverage Plan and there is no COB among those separate contracts. 1. "Plan" includes: group insurance, closed panel or other forms of group or group -type coverage (whether insured or uninsured); medical benefits under group or individual automobile contracts; and Medicare or other governmental benefits, as permitted by law. 2. "Plan" does not include: individual or family insurance; closed panel or other individual coverage (except for group -type coverage); school accident type coverage; benefits for non -medical components of group long-term care policies; Medicare supplement policies, Medicaid policies and coverage under other governmental plans, unless permitted by law, Each contract for coverage under (1.) or (2.) is a separate Coverage Plan. If a Coverage Plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate Coverage Plan. B. The order of benefit determination rules determine whether this Coverage Plan is a "primary Coverage Plan" or "secondary Coverage Plan" when compared to another Coverage Plan covering the person. When this Coverage Plan is primary, its benefits are determined before those of any other Coverage Plan and without considering any other Coverage Plan's benefits. When this Coverage Plan is secondary, its benefits are determined after those of another Coverage Plan and may be reduced because of the primary Coverage Plan's benefits. C. "Allowable expense" means a health care service or expense, including deductibles and copayments, that is covered at least in part by any of the Coverage Plans covering the person. When a Coverage Plan provides benefits in the form of services, (for example a dental HMO) the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense or service that is not covered by any of the Coverage Plans is not an allowable expense. The following are examples of expenses or services that are not allowable expenses: 1. If a person is covered by 2 or more Coverage Plans that compute their benefit payments on the basis of Usual and Customary fees, any amount in excess of the highest of the Usual and Customary fees for a specific benefit is not an allowable expense. 2. If a person is covered by 2 or more Coverage Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense. 3. If a person is covered by one Coverage Plan that calculates its benefits or services on the basis of Usual and Customary fees and another Coverage Plan that provides its benefits or services on the basis of negotiated fees, the primary Coverage Plan's payment arrangements will be the allowable expense for all Coverage Plans. DCOC.COB.06.XX 18 D. "Claim determination period" means a calendar year. However, it does not include any part of a year during which a person has no coverage under this Coverage Plan, or before the date this COB provision or a similar provision takes effect. E. "Closed panel Coverage Plan" is a Coverage Plan that provides health or dental benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the Coverage Plan, and that limits or excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member. F. "Custodial parent" means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation. Section 7.3 Order of Benefit Determination Rules When two or more Coverage Plans pay benefits, the rules for determining the order of payment are as follows: A. The primary Coverage Plan pays or provides its benefits as if the secondary Coverage Plan or Coverage Plans did not exist. B. A Coverage Plan that does not contain a coordination of benefits provision that is consistent with this provision is always primary. There is one exception: coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage will be excess to any other parts of the Coverage Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base Coverage Plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel Coverage Plan to provide out -of -network benefits. C. A Coverage Plan may consider the benefits paid or provided by another Coverage Plan in determining its benefits only when it is secondary to that other Coverage Plan. D. The first of the following rules that describes which Coverage Plan pays its benefits before another Coverage Plan is the rule to use. 1. Non -Dependent or Dependent. The Coverage Plan that covers the person other than as a dependent, for example as an employee, member. Subscriber or retiree is primary and the Coverage Plan that covers the person as a dependent is secondary. However, if the person is a Medicare beneficiary and, as a result of federal law. Medicare is secondary to the Coverage Plan covering the person as a dependent; and primary to the Coverage Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the two Coverage Plans is reversed so that the Coverage Plan covering the person as an employee, member, Subscriber or retiree is secondary and the other Coverage Plan is primary. 2. Child Covered Under More Than One Plan. The order of benefits when a child is covered by more than one Coverage Plan is: a. The primary Coverage Plan is the Coverage Plan of the parent whose birthday is earlier in the year if: 1.) The parents are married: 2.) The parents are not separated (whether or not they ever have been married); or 3.) A court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage. If both parents have the same birthday. the Coverage Plan that covered either of the parents longer is primary. b. If the specific terms of a court decree state that one of the parents is responsible for the child's health or dental care expenses or health or dental care coverage and the Coverage Plan of that parent has actual knowledge of those terms, that Coverage Plan is primary. This rule applies to claim determination periods or Coverage Plan years commencing after the Coverage Plan is given notice of the court decree. DCOC.COB.06.XX 19 c. If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the order of benefits is: 1.) The Coverage Plan of the custodial parent; 2.) The Coverage Plan of the spouse of the custodial parent: 3.) The Coverage Plan of the noncustodial parent; and then 4.) The Coverage Plan of the spouse of the noncustodial parent. 3. Active or inactive employee. The Coverage Plan that covers a person as an employee who is neither laid off nor retired is primary. The same would hold true if a person is a dependent of a person covered as a retiree and an employee. If the other Coverage Plan does not have this rule, and if, as a result, the Coverage Plans do not agree on the order of benefits, this rule is ignored. Coverage provided an individual as a retired worker and as a dependent of an actively working spouse will be determined under the rule labeled D.(1.). 4. Continuation coverage. If a person whose coverage is provided under a right of continuation provided by federal or state law also is covered under another Coverage Plan, the Coverage Plan covering the person as an employee, member, Subscriber or retiree (or as that person's dependent) is primary, and the continuation coverage is secondary. If the other Coverage Plan does not have this rule, and if, as a result, the Coverage Plans do not agree on the order of benefits, this rule is ignored, 5. Longer or shorter length of coverage. The Coverage Plan that covered the person as an employee, member, Subscriber or retiree longer is primary. 6. If a husband or wife is covered under this Coverage Plan as a Subscriber and as a Covered Dependent, the dependent benefits will be coordinated as if they were provided under another Coverage Plan, this means the person's Subscriber benefit will pay first. 7. If the preceding rules do not determine the primary Coverage Plan, the allowable expenses will be shared equally between the Coverage Plans meeting the definition of Coverage Plan under this provision. In addition, this Coverage Plan will not pay more than it would have paid had it been primary. Section 7.4 Effect on the Benefits of This Coverage Plan A. When this Coverage Plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Coverage Plans during a claim determination period are not more than 100 percent of total allowable expenses. When this Coverage Plan is the secondary carrier, this Coverage Plan will only pay up to the allowable amount but never more than what this Coverage Plan would have paid as primary. B. If a covered person is enrolled in two or more closed panel Coverage Plans and if, for any reason, including the provision of service by a non -panel provider. benefits are not payable by one closed panel Coverage Plan, COB will not apply between that Coverage Plan and other closed panel Coverage Plans. C. This Coverage Plan reduces its benefits as described below for Covered Persons who are eligible for Medicare when Medicare would be the primary Coverage Plan. Medicare benefits are determined as if the full amount that would have been payable under Medicare was actually paid under Medicare, even if: • The person is not enrolled for Medicare. Medicare benefits are determined as if the person were covered under Medicare Parts A and B. • The person is enrolled in a Medicare Advantage (Medicare Part C) plan and receives non -covered services because the person did not follow all rules of that plan. Medicare benefits are determined as if the services were covered under Medicare Parts A and B. • The person receives services from a provider who has elected to opt -out of Medicare. Medicare benefits are determined as if the services were covered under Medicare Parts A and B and the provider had agreed to limit charges to the amount of charges allowed under Medicare rules. DCOC.COB.06.XX 20 The services are provided in a Veterans Administration facility or other facility of the federal government. Medicare benefits are determined as if the services were provided by a non -governmental facility and covered under Medicare. The person is enrolled under a plan with a Medicare Medical Savings Account. Medicare benefits are determined as if the person were covered under Medicare Parts A and B. The person is enrolled in a Medicare Prescription Drug (Medicare Part D) plan and receives non -covered prescription drugs because the person did not follow all rules of that plan. If the drug is a Part D drug covered by the Medicare Prescription Drug plan, Medicare benefits are determined as if the services were provided by a network pharmacy and covered under Medicare Part D. Section 7.5 Right to Receive and Release Needed Information Certain facts about health or dental care coverage and services are needed to apply these COB rules and to determine benefits payable under this Coverage Plan and other Coverage Plans. The Company may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this Coverage Plan and other Coverage Plans covering the person claiming benefits. The Company need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Coverage Plan must give the Company any facts it needs to apply those rules and determine benefit payable. If you do not provide the Company the information it needs to apply these rules and determine the benefits payable, your claim for benefits will be denied. Section 7.6 Payments Made A payment made under another Coverage Plan may include an amount that should have been paid under this Coverage Plan. if it does, the Company may pay that amount to the organization that made the payment. That amount will then be treated as though it was a benefit paid under this Coverage Plan. The Company will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash value of the benefits provided in the form of services, Section 7.7 Right of Recovery If the amount of the payments made by the Company is more than it should have paid under this COB provision; it may recover the excess from one or more of the persons it had paid or for whom it has paid; or any other person or organization that may be responsible for the benefits or services provided for the covered person. The "amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services. DCOC.COB.06.XX 21 SectionSubrogation Subrogation is the substitution of one person or entity in the place of another with reference to a lawful claim, demand or right. The Company will be subrogated to and will succeed to all rights of recovery, under any legal theory of any type, for the reasonable value of services and benefits provided by the Company to you from: (i.) third parties, including any person alleged to have caused you to suffer injuries or damages; (ii.) your employer; or (iii.) any person or entity obligated to provide benefits or payments to you, including benefits or payments for underinsured or uninsured motorist protection (these third parties and persons or entities are collectively referred to as "Third Parties"), You agree to assign to the Company all rights of recovery against Third Parties, to the extent of the reasonable value of services and benefits provided by the Company, plus reasonable costs of collection. Company in You will cooperate with the protecting the Company's legal rights to subrogation and reimbursement, and acknowledge that the Company's rights will be considered as the first priority claim against Third Parties, to be paid before any other claims by you are paid. You will do nothing to prejudice the Company's rights under this provision, either before or after the need for services or benefits under the Policy. The Company may, at its option, take necessary and appropriate action to preserve its rights under these subrogation provisions, including filing suit in your name. For the reasonable value of services provided under the Policy, the Company may collect, at its option, amounts from the proceeds of any settlement (whether before or after any determination of liability) or judgment that may be recovered by you or your legal representative, regardless of whether or not you have been fully compensated. You will hold in trust any proceeds of settlement or judgment for the benefit of the Company under these subrogation provisions and the Company will be entitled to recover reasonable attorney fees from you incurred in collecting proceeds held by you. You will not accept any settlement that does not fully compensate or reimburse the Company without the written approval of the Company. You agree to execute and deliver such documents (including a written confirmation of assignment, and consents to release dental records), and provide such help (including responding to requests for information about any accident or injuries and making court appearances) as may be reasonably requested by the Company. Refund of Overpayments. If the Company pays benefits for expenses incurred on account of a Covered Person, that Covered Person or any other person or organization that was paid must make a refund to the Company if: A. All or some of the expenses were not paid by the Covered Person or did not legally have to be paid by the Covered Person, B. All or some of the payment made by the Company exceeded the benefits under the Policy, or C. All or some of the payment was made in error. The refund equals the amount the Company paid in excess of the amount it should have paid under the Policy. If the refund is due from another person or organization, the Covered Person agrees to help the Company get the refund when requested. If the Covered Person, or any other person or organization that was paid, does not promptly refund the full ble under the Policy. The amount, the Company may reduce the amount of any future benefits that are paya Company may also reduce future benefits under any other group benefits plan administered by the Company for the Enrolling Group, The reductions will equal the amount of the required refund. The Company may have other rights in addition to the right to reduce future benefits. Reimbursement of Benefits Paid. If the Company pays benefits for expenses incurred on account of a Covered Person, the Subscriber or any other person or organization that was paid must make a refund to the Company if all or some of the expenses were recovered from or paid by a source other than the Policy as a result of claims against a third party for negligence, wrongful acts or omissions. The refund equals the amount of the recovery or payment, up to the amount the Company paid. If the refund is due from another person or organization, the Covered Person agrees to help the Company get the refund when requested. ull If the Covered Person, ma any reduce other t person or amount of future t benefits that ahat was paid, fire payable oes not promptly o fiery the Po rcY e the aniza amount, the Company y DCOC.SUB.06.XX 22 Company may also reduce future benefits under any other group benefits plan administered by the Company for the Enrolling Group. The reduction will equal the amount of the required refund. The Company may have other rights in addition to the right to reduce future benefits. DCOC.SUB.06.XX 23 Section 9: Continuation of Coverage Section 9.1 Continuation Coverage A Covered Person whose Coverage would otherwise end under the Policy may be entitled to elect continuation Coverage in accordance with federal law (under COBRA) and as outlined in Sections 9.2 through 9.5 below. Continuation Coverage under COBRA will be available only to Enrolling Groups which are subject to the provisions of COBRA. Covered Persons should contact the Enrolling Groups plan administrator to determine if he or she is entitled to continue Coverage under COBRA. Continuation Coverage for Covered Persons who selected continuation coverage under a prior plan which was replaced by Coverage under the Policy will terminate as scheduled under the prior plan or in accordance with the terminating events set forth in Section 9.5 below. whichever is earlier. In no event will the Company be obligated to provide continuation Coverage to a Covered Person if the Enrolling Group or its designated plan administrator fails to perform its responsibilities under federal law. These responsibilities include but are not limited to notifying the Covered Person in a timely manner of the right to elect continuation Coverage and notifying the Company in a timely manner of the Covered Person's election of continuation Coverage, The Company is not the Enrolling Group's designated Plan Administrator and does not assume any responsibilities of a Plan Administrator pursuant to federal law. A Covered Person whose Coverage would otherwise end under the Policy may be entitled to elect continuation Coverage in accordance with federal law, as outlined in Sections 9,2 through 9.5 below. Section 9.2 Continuation Coverage Under Federal Law In order to be eligible for continuation coverage under federal law, the Covered Person must meet the definition of a "Qualified Beneficiary". A Qualified Beneficiary is any of the following persons who were covered under the plan on the day before a Qualifying Event: • A Subscriber. • A Subscriber',s Enrolled Dependent, including with respect to the Subscriber's children, a child born to or placed in adoption with a Subscriber during a period of continuation of coverage, or • A Subscriber's former spouse. Section 9.3 Qualifying Events for Continuation Coverage Under Federal Law If a Qualified Beneficiary's Coverage will ordinarily terminate due to one of the following Qualifying Events, he or she is entitled to continue Coverage. The Qualified Beneficiary is entitled to elect to continue the same Coverage that he or she had at the time of the Qualifying Event, A. Termination of the Subscriber from employment with the Enrolling Group (for any reason other than gross misconduct) or reduction of hours; or B. Death of the Subscriber; or C. Divorce or legal separation of the Subscriber; or D, Loss of eligibility by an Enrolled Dependent who is a child: or E. Entitlement of the Subscriber to Medicare benefits; or F. The Enrolling Group filing for bankruptcy, under Title XI, United States Code.. on or after July 1, 1986, but only for a retired Subscriber and his or her Enrolled Dependents. This is also a qualifying event for any retired Subscriber and his or her Enrolled Dependents if there is a substantial elimination of coverage within one year before or after the date the bankruptcy was filed. DCOC.CNT.06.XX 24 Section 9.4 Notification Requirements and Election Period for Continuation Coverage Under Federal Law The Subscriber or Qualified Beneficiary must notify the Enrolling Group's designated plan administrator within 60 days of his or her divorce. legal separation or an Enrolled Dependent's loss of eligibility as an Enrolled Dependent. If the Subscriber or Qualified Beneficiary fails to notify the designated plan administrator of these events within the 60 day period the Enrolling Group and its plan administrator are not obligated to provide continuation Coverage to the affected Qualified Beneficiary. A Subscriber who is continuing Coverage under Federal Law must notify the Enrolling Group's designated plan administrator within 60 days of the birth or adoption of a child. Continuation must be elected by the later of 60 days after the Qualifying Event occurs; or 60 days after the Qualified Beneficiary receives notice of the continuation right from the Enrolling Group's designated plan administrator. A Qualified Beneficiary whose Coverage was terminated due to a qualifying event must pay the initial Premium due to the Enrolling Group's designated plan administrator on or before the 45th day after electing continuation, Section 9.5 Terminating Events for Continuation Coverage Under Federal Law Continuation under the Policy will end on the earliest of the following dates: A. Eighteen months from the date of a Qualifying Event for a Qualified Beneficiary whose Coverage would have otherwise ended due to termination of employment (for reasons other than gross misconduct ) or a reduction in hours. A Qualified Beneficiary who is determined to be disabled at the time during the first 60 days of continuation Coverage may extend continuation Coverage to a maximum of 29 months from the date of the Qualifying Event described in Section 9.3. If the Qualified Beneficiary entitled to the additional 11 months of Coverage has non -disabled family members who are also entitled to continuation Coverage, those non -disabled family members are also entitled to the additional 11 months of continuatio n Coverage. A Qualified Beneficiary who is determined to have been disabled within the first 60 days of continuation Coverage for Qualifying Event (A.) must provide notice of such disability within 60 days after the determination of the disability, and in no event later than the end of the first 18 months, in order to extend Coverage beyond 18 months. If such notice is provided, the Qualified Beneficiary's Coverage may be extended up to a maximum of 29 months from the date of the Qualifying Event described in Section 9.3 A or until the first month that begins more than 30 days after the date of any final determination that the Qualified Beneficiary is no longer disabled. Each Qualified Beneficiary must provide notice of any final determination that the Qualified Beneficiary is no longer disabled within 30 days of such determination.. B. Thirty-six months from the date of the Qualifying Event for an Enrolled Dependent whose Coverage ended because of the death of the Subscriber, divorce or legal separation of the Subscriber, loss of eligibility by an Enrolled Dependent who is a child. in accordance with qualifying events (B.), (C.), or (D.) described in Section 9.3. C. For the Enrolled Dependents of a Subscriber who was entitled to Medicare prior to a Qualifying Event that was due to either the termination of employment or work hours being reduced, eighteen months from the date of the Qualifying Event, or if later, 36 months from the date of the Subscriber's Medicare entitlement. D. The date Coverage terminates under the Policy for failure to make timely payment of the Premium. E. The date, after electing continuation Coverage.. that coverage is obtained under any other group health plan. If such coverage contains a limitation or exclusion with respect to any preexisting condition of the Qualified Beneficiary, continuation will end on the date such limitation or exclusion ends. The other group health coverage will be primary for all health services except those health services that are subject to the preexisting condition limitation or exclusion. F. The date, after electing continuation Coverage; that the Qualified Beneficiary first becomes entitled to Medicare, except that this will not apply in the event the Qualified Beneficiary's Coverage was terminated because the Enrolling Group filed for bankruptcy, in accordance with qualifying event (F.) described in Section 9.3. G. The date the entire Policy ends. N. The date Coverage would otherwise terminate under the Policy. DCQC.CNT.06.XX 25 If a Qualified Beneficiary is entitled to 18 months of continuation and a second Qualifying Event occurs during that time, the continuation Coverage of a Qualified Beneficiary who is an Enrolled Dependent may be extended up to a maximum of 36 months from the Qualifying Event described in Section 9.3 A. If a Qualified Beneficiary is entitled to continuation because the Enrolling Group filed for bankruptcy, in accordance with Qualifying Event (F.) described in Section 9.3 and the retired Subscriber dies during the continuation period, the Enrolled Dependents will be entitled to continue Coverage for 36 months from the date of death. Terminating events (B.) through (G.) described in this Section 9.5 will apply during the extended continuation period. Continuation Coverage for Qualified Beneficiaries whose continuation Coverage terminates because the Subscriber becomes entitled to Medicare may be extended for an additional period of time. Such Qualified Beneficiaries should contact the Enrolling Group's designated plan administrator for information regarding the continuation period. DCOC.CNT.06.XX 26 Section 10: Procedures for Obtaining Benefits Section 10.1 Dental Services You are eligible for Coverage for Dental Services listed in the Schedule of Covered Dental Services and Section 11: Covered Dental Services of this Certificate if such Dental Services are Necessary and are provided by or under the direction of a Dentist or other provider. All Coverage is subject to the terms, conditions, exclusions and limitations of the Policy. Network Benefits Dental Services must be provided by a Network Dentist in order to be considered Network Benefits When Dental Services are received from a Non -Network Provider as a result of an Emergency, the Copayment will be the Network Copayment. Enrolling for Coverage under the Policy does not guarantee Dental Services by a particular Network Dentist on the list of providers. The list of Network Dentists is subject to change. When a provider on the list no longer has a contract with the Company, you must choose among remaining Network Dentists. You are responsible for verifying the participation status of the Dentist, or other provider prior to receiving such Dental Services. You must show your ID card every time you request Dental Services. If you fail to verify participation status or to show your ID card, and the failure results in non-compliance with required Company procedures, Coverage of Network Benefits may be denied. Coverage for Dental Services is subject to payment of the Premium required for Coverage under the Policy, satisfaction of any Deductible, appropriate Waiting Period, payment of any Copayment specified for any service and payment of the percentage of Eligible Expenses shown in the Schedule of Covered Dental Services and Section 11: Covered Dental Services. Non -Network Benefits Non -Network Benefits apply when you obtain Dental Services from Non -Network Dentists. Before you are eligible for Coverage of Dental Services obtained from Non -Network Dentists, you must meet the requirements for payment of any Deductible and appropriate Waiting Period specified in the Schedule of Covered Dental Services and Section 11: Covered Dental Services. Non -Network Dentists may request that you pay all charges when services are rendered. You must file a claim with the Company for reimbursement of Eligible Expenses. The Company reimburses a Non -Network Dentist for a covered Dental Service up to an amount equal to the Usual and Customary fee for the same covered Dental Service received from a similarly situated Network Dentist, Network Dentists The Company has arranged with certain dental care providers to participate in a Network. These Network Dentists have agreed to discount their charges for Covered services and supplies. If Network Dentists are used, the amount of Covered expenses for which a Covered Person is responsible will generally be less than the amount owed if Non -Network Dentists had been used. The Copayment level (the percentage of Covered expenses for which a Covered Person is responsible) remains the same whether or not Network Dentists are used. However, because the total charges for Covered expenses may be less when Network Dentists are used. the portion that the Covered Person owes will generally be less. Covered Persons are issued an identification card (ID card) showing they are eligible for Network discounts. A Covered Person must show this ID card every time Dental Services are given. This is how the provider knows that the patient is Covered under a Network plan. Otherwise, the person could be billed for the provider's normal charge. A Directory of Network Dentists will be made available. A Covered Person can also call customer service to determine which providers participate in the Network. The telephone number for customer services is on the ID card. DCOC.OBT.06.XX 27 Network Dentists are responsible for submitting a request for payment directly to the Company, however, a Covered Person is responsible for any Copayment at the time of service. If a Network Dentist bills a Covered Person, customer services should be called. A Covered Person does not need to submit claims for Network Dentist services or supplies. Section 10.2 Pre -Treatment Estimate If the charge for a Dental Service is expected to exceed $500 or if a dental exam reveals the need for fixed bridgework, you may notify the Company of such treatment before treatment begins and receive a Pre -Treatment Estimate. If you desire a Pre -Treatment Estimate, you or your Dentist should send a notice to the Company, via claim form, within 20 days of the exam. If requested the Dentist must provide the Company with dental x-rays, study models or other information necessary to evaluate the treatment plan for purposes of benefit determination. The Company will determine if the proposed treatment is Covered under the Policy and estimate the amount of payment. The estimate of benefits payable will be sent to the Dentist and will be subject to all terms, conditions and provisions of the Policy. Clinical situations that can be effectively treated by a less costly, clinically acceptable alternative procedure will be assigned a benefit based on the less costly procedure. Pre -Treatment Estimate of benefits is not an agreement to pay for expenses. This procedure lets the Covered Person know in advance approximately what portion of the expenses will be considered for payment. DCOC,OBT.06.XX 28 Dental Services described in this Section and in the Schedule of Covered Dental Services are Covered when such services are: A. Necessary; B. Provided by or under the direction of a Dentist: C. Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure will be assigned a benefit based on the least costly procedure; and D. Not excluded as described in Section 12: General Exclusions. Covered Dental Services are subject to the satisfaction of any applicable Waiting Periods, Deductible, Maximum Benefits and payment of any Copayments as described below and in the Schedule of Covered Dental Services. This Section and the Schedule of Covered Dental Services: (1) describe the Covered Dental Services and any applicable limitations to those services; (2) outline the Copayments that you are required to pay and any applicable Waiting Periods for each Covered Dental Service: and (3) describe any Deductible and any Maximum Benefits that may apply. Network Benefits: When Network Copayments are charged as a percentage of Eligible Expenses, the amount you pay for Dental Services from Network providers is determined as a percentage of the negotiated contract fee between the Company and the provider rather than a percentage of the provider's billed charge. The Company's negotiated rate with the provider is ordinarily lower than the provider's billed charge. A Network provider cannot charge a Covered Person or the Company for any service or supply that is not Necessary as determined by the Company, If a Covered Person agrees to receive a service or supply that is not Necessary the Network provider may charge the Covered Person. However, these charges will not be considered Covered Dental Services and will not be payable by the Company. Non -Network Benefits: When Copayments are charged as a percentage of Usual and Customary fees, the amount you pay for Dental Services from Non -Network providers is determined as a percentage of the Usual and Customary fee plus the amount by which the Non -Network provider's billed charge exceeds the Usual and Customary fee. Deductible Deductible is $ 50 per Covered Person for Network Benefits and $ 50 per Covered Person for Non -Network Benefits per calendar year, not to exceed $ 150 for Network Benefits and $ 150 for Non -Network Benefits for all Covered Persons in a family. The Deductible does not apply to: DIAGNOSTIC SERVICES and/or PREVENTIVE SERVICES. Maximum Benefit Maximum Benefit is $ 1,000 per Covered Person per calendar year. Any required Copayment, Deductible, Waiting Period or Maximum Benefit is waived for a Covered Person in their 2nd or 3rd trimester of pregnancy for the following Covered Dental Services: prophylaxis, scaling and root planing, periodontal maintenance, full mouth debridement. Section 11.1 Credit for Prior Coverage If you are a Covered Person that becomes Covered under this Policy due to a mid -year plan change, you will need to submit evidence of having satisfied any portion of your prior policy's Deductible in order to receive credit under this Policy's applicable Deductible(s). You will also need to submit evidence of the total benefits paid under your prior policy in order to have the amount applied to this Policy's applicable Maximum(s) . Waiting Periods apply to all Covered Persons. Covered Dental Services are subject to the satisfaction of the DCOC.CDS.06.XX 29 appropriate Waiting Periods: which will be waived for all Covered Persons who enroll on the Enrolling Group's Effective Date. All other Covered Persons are subject to the Waiting Periods unless evidence is provided to the Company of uninterrupted prior comparable coverage that satisfies the Waiting Period. DCOC.CDS.06.XX 30 Section 12: General Exclusions Section 12.1 Exclusions Except as may be specifically provided in the Schedule of Covered Dental Services or through a Rider to the Policy, the following are not Covered: A. Dental Services that are not Necessary. B. Hospitalization or other facility charges. C. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) D. Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury. or Congenital Anomaly; when the primary purpose is to improve physiological functioning of the involved part of the body. E. Any Dental Procedure not directly associated with dental disease. F. Any Dental Procedure not performed in a dental setting. G. Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service; treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment. of that particular condition. H. Placement of dental implants: implant -supported abutments and prostheses. I. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit. J. Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare. K. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. L. Treatment of benign neoplasms, cysts,. or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision. M. Replacement of complete dentures, and fixed and removable partial dentures or crowns, and implants, implant crowns, implant prosthesis and implant supporting structures (such as connectors), if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement. N. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment. or treatment for the temporomandibular joint. Q. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice. P. Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy. Q. Fixed or removable prosthodontic restoration procedures or implant services for complete oral rehabilitation or reconstruction. DCOC.EXC.06.XX 31 R. Attachments to conventional removable prostheses or fixed bridgework. This includes semi -precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature. S. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). T. Replacement of crowns, bridges, and fixed or removable prosthetic appliances, and implants, implant crowns, implant prosthesis and implant supporting structures (such as connectors) inserted prior to plan Coverage unless the patient has been Covered under the Policy for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 month period, the plan is responsible only for the procedures associated with the addition. U. Replacement of missing natural teeth lost prior to the onset of plan Coverage until the patient has been Covered under the Policy for 12 continuous months. V. Occlusal guards used as safety items or to affect performance primarily in sports -related activities. W. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability. X. Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child. Y. Dental Services otherwise Covered under the Policy,. but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates. Z. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia. AA. Orthodontic Services. BB. In the event that a Non -Network Dentist routinely waives Copayments and/or the Deductible for a particular Dental Service, the Dental Service for which the Copayments and/or Deductible are waived is reduced by the amount waived by the Non -Network provider. CC. Foreign Services are not Covered unless required as an Emergency. DD, Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. EE. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services. DCOC.EXC.06.XX 32 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. DIAGNOSTIC SERVICES Bacteriologic Cultures 0% 0 ox Viral Cultures 0% 0% Intraoral Bitewing Radiographs 0% 0% Limited to 1 series of films per calendar year. Panorex Radiographs 0% 0% Limited to 1 time per consecutive 36 months, Oral/Facial Photographic Images 0% 0% Limited to 1 time per consecutive 36 months. Diagnostic Casts 0% 0 % Limited to 1 time per consecutive 24 months, Extraoral Radiographs 0% 0% Limited to 2 films per calendar year. Intraoral - Complete Series 0% 0% (including bitewings) Limited to 1 time per consecutive 36 DSCH,IPO.06,XX 33 BENEFIT DESCRIPTION & NETWORK CO LIMITATION shown as a per, Expenses after Deductible is s� months. Vertical bilewings can not be billed in conjunction with a complete series. pulp Vitality Tests 0 0/0 Limited to 1 charge per visit, regardless of how many teeth are Periodic Oral Evaluation 0% Limited to 2 times per consecutive 12 months. r-_ Comprehensive Oral Evaluation 0% 7 L�imited to 2 times per consecutivle 12 months. Not Covered if done in conjunction with other exams, Limited or Detailed Oral Evaluation 0% Limited to 2 times per consecutive 12 months. Only 1 exam is Covered per date of service. Comprehensive Periodontal 0% Evaluation - new or established patient Limited to 2 times per consecutive 12 months. Adjunctive Pre -Diagnostic 1'est that 0% aids in detection of mucosal abnormalities including premalignant and malignant lesions. not to include c olo or bio PAYMENT is NON -NETWORK CCJPAYK0ENTis cepkageofEligible shown as a percentage of Eligible applicable Expenses after applicable zdofied. Deductible is satisfied. You musa also pay the amount of the Dnndo\'a fee. ifany, which is �greater than the Eligible Expenam� 34 O% 8% O% 0% 0% O 96 O % U% BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied, You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. procedures Limited to 1 time per consecutive 12 months. PREVENTIVE SERVICES Dental Prophylaxis 0% 0% Limited to 2 times per consecutive 12 months. Fluoride Treatments - child 0% 0% Limited to Covered Persons under the age of 16 years, and limited to 2 times per consecutive 12 months. Sealants 0% 0% Limited to Covered Persons under the age of 16 years and once per first or second permanent molar every consecutive 36 months. Space M13intainers 0% 0% Limited to Covered Persons under the age of 16 years. once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation. Re -cement Space Maintainers 0% 0% Limited to 1 per consecutive 6 months after initial insertion. MINOR RESTORATIVE SERVICES Amalgam Restorations 20% 20% Multiple restorations on one surface will be treated as a single filling. DSCH.IPO,06.XX 35 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee; if any; which is greater than the Eligible Expense, Composite Resin Restorations - 20 `14 20 % Anterior Multiple restorations on one surface will be treated as a single filling. Gold Foil Restorations 20 % 20 % Multiple restorations on one surface will be treated as a single filling, ENDODONTICS Apexification 20 % 20 % Limited to 1 time per tooth per lifetime. Apicoectomy and Retrograde Filling 20 % 20 % Limited to 1 time per tooth per lifetime. Hemisection 20 % 20 % Limited to 1 time per tooth per lifetime, Root Canal Therapy 20 % 20 % Limited to 1 time per tooth per lifetime. Dentist who performed the original root canal should not be reimbursed for the retreatment for the first 12 months. Retreatment of Previous Root Canal 20 % 20 % Therapy Dentist who performed the original root canal should not be reimbursed for the retreatment for the first 12 months. DSCH.IPO.06.XX 36 BENEFIT DESCRIPTION & LIMITATION Root Resection/Amputation Limited to 1 time per tooth per lifetime. Therapeutic Pulpotomy Limited to 1 time per primary or secondary tooth per lifetime. Pulpal Therapy (resorbable filling) - Anterior or Posterior. Primary Tooth (excluding final restoration) Limited to 1 time per tooth per lifetime, Covered for anterior or Posterior teeth only. Pulp Caps - DirecUindirect - excluding final restoration Not Covered if utilized solely as a liner or base underneath a restoration. Pulpal Debridement, Primary and Permanent Teeth Limited to 1 time per tooth per lifetime. This procedure is not to be used when endodontic sentices are done on same date of service. PERIODONTICS Crown Lengthening Limited to 1 per quadrant or site per consecutive 36 months. NETWORK COPAYMENT is shown as a percentage of Eligible Expenses after applicable Deductible is satisfied. 20 % 20F% 20 % 20 % 20 20 % DSCH-lP0.06.XX 37 NON -NETWORK COPAYMENT is shown as a percentage of Eligible Expenses after applicable Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. 20 % 20 % 20 % 20 % 20 % 20 °o BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied, You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. Gingivectomy/Gingivoplasty 20% 20% Limited to 1 per quadrant or site per consecutive 36 months. Gingival Flap Procedure 20% 20% Limited to 1 per quadrant or site per consecutive 36 months. Osseous Graft 20 % 20% Limited to 1 per quadrant or site per consecutive 36 months. Osseous Surgery 20% 20% Limited to 1 per quadrant or site per consecutive 36 months. Guided Tissue Regeneration 20% 20% Limited to 1 per quadrant or site per consecutive 36 months. Soft Tissue Surgery 20% 20% Limited to I per quadrant or site per consecutive 36 months. Periodontal Maintenance 20% 20% Limited to 2 times per consecutive 12 months following active or adjunctive periodontal therapy, exclusive of gross debridement. Full Mouth Debridement 20 % 20% Limited to once per consecutive 36 months. DSCH.IPO.06.XX 38 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK GOPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. Provisional Splinting 20 % 20 % Cannot be used to restore vertical dimension or as part of full mouth rehabilitation, should not include use of laboratory based crowns and/or fixed partial dentures (bridges). Exclusion of laboratory based crowns or bridges for the purposes of provisional splinting. Scaling and Root Planing 20 % 20 % Limited to 1 time per quadrant per consecutive 24 months. Localized Delivery of Antimicrobial 20 % 20 % Agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report Limited to 3 sites per quadrant, or 12 sites total, for refractory pockets, or in conjunction with scaling or root planing, by report. ORALSURGERY Alveoloplasty 20 % 20 % Biopsy 20 % 20 % Limited to 1 biopsy per site per visit. Frenectomy/Frenuloplasty 20 % 20 % Surgical Incision 20 % 20 °Ili Limited to 1 per site eer visit. DSCH. I PU.06.XX 39 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. Removal of a Benign Cyst/Lesions 20% 20% Limited to 1 per site per visit. Removal of Torus 20% 20% Limited to 1 per site per visit. Root Removal, Surgical 20% 20% Limited to 1 time per tooth per lifetime. Simple Extractions 20% 20% Limited to 1 time per tooth per lifetime. Surgical Extraction of Erupted Teeth 20 % 20% or Roots Limited to 1 time per tooth per lifetime. Surgical Extraction of Impacted 20% 20% Teeth Limited to 1 time per tooth per lifetime. Surgical Access, Surgical Exposure, 20% 20% or Immobilization of Unerupted Teeth Limited to 1 time per tooth per lifetime. Primary Closure of a Sinus 20% 20% Perforation Limited to 1 per tooth per lifetime. DSCH.IPO,06,XX 40 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. Placement of Device to Facilitate 20 % 20 % Eruption of Impacted Tooth Limited to 1 time per tooth per lifetime. Transseptal Fiberotomy/Supra 20 % 20 % Crestal Fiberotomy, by report Limited to 1 time per tooth per lifetime. Vestibuloplasty 20 Rio 20 % Limited to 1 time per site per consecutive 60 months. Bone Replacement Graft for Ridge 20 % 20 % Preservation - per site Limited to 1 per site per lifetime. Not Covered if done in conjunction with other bone graft replacement procedures. Excision of Hyperplastic Tissue or 20 % 20 % Pericoronal Gingiva Limited to 1 per site per consecutive 36 months. Appliance Removal (not by dentist 20 % 20 % who placed appliance) includes removal of arch bar Limited to once per appliance per lifetime. Tooth Reimplantation and'or 20 % 20 % Transplantation Services Limited to 1 per site per lifetime. DSCH.IPO.06.XX 41 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. Oroantral Fistula Closure 20% 20% Limited to 1 per site per visit. ADJUNCTIVE SERVICES . . ......... Analgesia . 20% 20% Covered when Necessary in conjunction with Covered Dental Services. if required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically Necessary. Covered for patients over age of 6 if it is clinically Necessary. Desensitizing Medicament 20% 20% General Anesthesia 20% 20% Covered when Necessary in conjunction with Covered Dental Services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically Necessary. Covered for patients over age of 6 if it is clinically Necessary. Local Anesthesia 20% 20% Not Covered in conjunction with operative or surgical procedure, intravenous Sedation and Analgesia 20 9/6 20% Covered when Necessary in conjunction with Covered Dental Services. DSCH,IPO.06,XX 42 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically Necessary. Covered for patients over age of 6 if it is clinically Necessary. Therapeutic Drug Injection, by 20 % 20% report/Other Drugs and/or Medicaments, by report Limited to 1 per visit. Limited to 1 guard every consecutive 36months and only covered if prescribed to control habitual grinding. Occlusal Guard Reline and Repair 20 % 20% Limited to relining and repair performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months. Occlusion Analysis - Mounted Case 20% 20% Limited to I time per consecutive 60 Palliative Treatment 20% 20% Covered as a separate benefit only if no other services, other than exam and radiographs, were done on the same tooth during the visit, provided by dentists or physician other than practitioner providing DSCH]PO.08,XX 43 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied, You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense. treatment.) Not Covered if done with exams or professional visit. MAJOR RESTORATIVE SERVICES Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. Coping 50% 50% Limited to 1 per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Not Period. Period. Covered if done at the same time as a crown on same tooth. Crowns - Retainers"Abutments 50% 50% Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months, Not Period. Period. Covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes. Crowns - Restorations 50% 50% Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months, Covered Period, Period, only when a filling cannot restore the tooth. Not Covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes. Temporary Crowns - Restorations 50% 50% Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Covered Period, Period, only when a filling cannot restore the tooth. Not Covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes. ... .. ...... DSCH.lP0.06.XX 44 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense, Inlays/Onlays - Retainers!Abutments 50% 50% Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Not Period. Period. Covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes, Inlays/Onlays - Restorations 50% 50% Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Covered Period, Period, only when a filling cannot restore the tooth. Not Covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes, Pontics 50% 50% Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Period. Period. Retainer -Cast Metal for Resin 50 % 50% Bonded Fixed Prosthesis Subject to a 12 month Waiting Subject to a 12 month Waiting Limited to 1 time per tooth per Period. Period. consecutive 60 months. Pin Retention 50% 50% Limited to 2 pins per tooth, not Subject to a 12 month Waiting Subject to a 12 month Waiting Covered in addition to cast Period. Period. restoration. Post and Cores 50% 50% Covered only for teeth that have had Subject to a 12 month Waiting Subject to a 12 month Waiting root canal therapy, Period, Period, DSCH.IPO.06.XX 45 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee. if any,. which is greater than the Eligible Expense. Re -Cement Inlays/Onlays, Crowns, 50 % 50 % Bridges and Post and Core Subject to a 12 month Waiting Subject to a 12 month Waiting Limited to those performed more Period. Period. than 12 months after the initial insertion. Sedative Filling 50 % 50 % Covered as a separate benefit only if Subject to a 12 month Waiting Subject to a 12 month Waiting no other service, other than x-rays Period. Period. and exam, were performed on the same tooth during the visit. Stainless Steel Crowns 50 % 50 % Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Covered Period. Period. only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown - primary tooth, are limited to primary anterior teeth. FIXED PROSTHETICS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously limited to 1 time consecutive 60 months from initial or supplemental submitted for payment under the plan is per placement. Fixed Partial Dentures (Bridges) 50 % 50 % Limited to 1 time per tooth per Subject to a 12 month Waiting Subject to a 12 month Waiting consecutive 60 months. Period. Period. REMOVABLE PROSTHETICS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously limited to 1 time consecutive 60 months from initial or supplemental submitted for payment under the plan is per placement. Full Dentures 50 % 50 % Limited to 1 per consecutive 60 Subject to a 12 month Waiting Subject to a 12 month Waiting months. No additional allowances Period. Period. for precision or semi -precision attachments. DSCH.IPO.06.XX 46 BENEFIT DESCRIPTION & NETWORK COPAYMENT is NON -NETWORK COPAYMENT is LIMITATION shown as a percentage of Eligible shown as a percentage of Eligible Expenses after applicable Expenses after applicable Deductible is satisfied. Deductible is satisfied. You must also pay the amount of the Dentist's fee; if any, which is greater than the Eligible Expense. Partial Dentures 50 % 50 % Limited to 1 per consecutive 60 Subject to a 12 month Waiting Subject to a 12 month Waiting months. No additional allowances Period. Period. for precision or semi -precision attachments. Relining and Rebasing Dentures 50 `Yo 50 % Limited to relining/rebasing Subject to a 12 month Waiting Subject to a 12 month Waiting performed more than 6 months after Period. Period. the initial insertion, Limited to 1 time per consecutive 12 months. Tissue Conditioning - Maxillary or 50 % 50 % Mandibular Subject to a 12 month Waiting Subject to a 12 month Waiting Limited to 1 time per consecutive 12 Period. Period. months. Repairs or Adjustments to Full 50 % 50 % Dentures. Partial Dentures. Bridges or Crowns Subject to a 12 month Waiting Subject to a 12 month Waiting Period. Period. Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months. DSCH.IPO.06.XX 47 EXHIBIT IV Group Policy United HealthCare Insurance Company 450 Columbus Boulevard Hartford, Connecticut 06115-0450 1-800-445-9090 This Group Policy ("Policy") is entered into by and between United HealthCare Insurance Company ("Company"), and the "Enrolling Group," as described in Exhibit 1. Upon receipt of the Enrolling Group's application and payment of the required Policy Charges, this Policy is deemed executed. The Company agrees with the Enrolling Group to provide Coverage for Dental Services set forth herein, subject to the terms, conditions, exclusions, and limitations of this Policy. The Enrolling Group's application is made a part of this Policy. This Policy replaces and supersedes any previous agreements relating to the Coverage of Dental Services between the Enrolling Group and the Company. The terms and conditions of this Policy will in turn be superseded by those of any subsequent agreements relating to the Coverage of Dental Services between the Enrolling Group and the Company. The Company will not be deemed or construed as an employer for any purpose with respect to the administration or provision of benefits under the Enrolling Group's benefit plan. The Company will not be responsible for fulfilling any duties or obligations of an employer with respect to the Enrolling Group's benefit plan. This Policy will become effective at 12:01 a.m. at the Enrolling Group's address on the date specified in Exhibit 1, and will be continued in force by the timely payment of the required Policy Charges when due, subject to termination of this Policy as provided herein. When the Policy is terminated, as provided for in Article 5, this Policy and all Coverage under this Policy will end at 12:00 midnight on the date of termination. This Policy is delivered in and governed by the laws of the State of XXXX. Issued By: United HealthCare Insurance Company President DPOL.06.XX (11/15/2006) Article 1: Definitions The terms used in this Policy have the same meaning given those terms in the Certificate of Coverage ("Certificate'); unless otherwise specifically defined in this Policy. Article 2: Dental Services Subscribers and their Enrolled Dependents are entitled to Coverage for Dental Services subject to the terms, conditions, limitations and exclusions set forth in the Certificate(s) and Schedules ) of Covered Dental Services, included in this Policy. The Certificate(s) and Schedule(s) of Covered Dental Services describe the Covered Dental Services including any optional Riders and Amendments, required Copayments, and the terms, conditions, limitations and exclusions related to Coverage. Article 3: Premium Rates and Policy Charge 3.1 Premiums Monthly Premiums payable by or on behalf of Covered Persons are specified on Exhibit 2 to the Policy entitled "Premiums". The Company reserves the right to change the schedule of rates for Premiums as described in Exhibit 1. 3.2 Computation of Policy Charge Each Policy Charge will be calculated based on the number of Subscribers in each Coverage classification the Company shows in its records at the time of calculation, at the Premiums then in effect. The Policy Charge is calculated as described in Exhibit 1. 3.3 Adjustments to the Policy Charge Retroactive adjustments may be made for any additions or terminations of Subscribers or changes in Coverage classification not reflected in the Company's records at the time the Policy Charge is calculated by the Company. However, no retroactive credit will be granted for any change occurring more than 60 days prior to the date the Company received notification of the change from the Enrolling Group, nor will retroactive credit be granted for any calendar month in which a Subscriber has received Dental Services. The Enrolling Group will notify the Company in writing within 30 days of the effective date of enrollments, terminations or other changes; provided, however, that the Enrolling Group will notify the Company in writing each month of any changes in the Coverage classification of any Subscriber. In the event there is any increase in premium tax, guarantee or uninsured fund assessment or other governmental charges relating to or calculated in regard to Premium such increase will be automatically added to the Premium. 3.4 Payment of the Policy Charge The Policy Charge is payable in advance by the Enrolling Group to the Company as described in Exhibit 1. The first Policy Charge is due and payable on the effective date of the Policy. Subsequent Policy Charges are due and payable no later than the first day of each period thereafter that the Policy is in effect. A late payment charge will be assessed for any Policy Charge not received by the due date. A service charge will be assessed for any non -sufficient -fund check received in payment of the Policy Charge. All Policy Charge payments will be accompanied by supporting documentation which states the names of the Covered Persons for whom payment is made. The Enrolling Group will reimburse the Company for attorney's fees and any other costs related to collecting delinquent Policy Charges. DPOL06.XX (11/15/2006) 2 3.5 Grace Period A Grace Period of 31 days will be granted for the payment of any Policy Charge, during which time the Policy will continue in force. In no event will the Grace Period extend beyond the date the Policy terminates. This Policy will automatically terminate retroactive to the last paid date of Coverage if the Grace Period expires and any Policy Charge remains unpaid, or if the Company receives written notice of termination from the Enrolling Group during the Grace Period. Article 4: Enrollment and Eligibility 4.1 Initial Eligibility Period Eligible Persons and their Dependents may enroll for Coverage under the Policy during the Initial Eligibility Period, The Initial Eligibility Period is the period of time agreed to by the Enrolling Group and the Company. 4.2 Open Enrollment If specified in the Certificate(s) , the Enrolling Group will provide an Open Enrollment Period as specified in the Certificate(s), during which Eligible Persons may enroll for Coverage under the Policy. 4.3 Eligibility Conditions The eligibility conditions stated in the application are in addition to those specified in Section 2 of the Certificate(s). 4.4 Effective Date of Coverage Coverage for properly enrolled Eligible Persons and their Dependents will begin on the date stated in Exhibit 1. , Article 5: Policy Termination 5.1 Conditions for Termination of This Entire Policy This Policy and all Coverage under this Policy will automatically terminate on the earliest of the dates specified below: A. At the Company's option, retroactive to the last paid date of Coverage, if the Grace Period expires and any Policy Charge remains unpaid. B. On the date specified by the Enrolling Group, after at least 31 days prior written notice to the Company that this Policy will be terminated. C. On the date specified by the Company, in written notice to the Enrolling Group that this Policy will be terminated, due to the Enrolling Group's violation of participation and contribution rules. D. On the date specified by the Company in written notice to the Enrolling Group that this Policy will be terminated because the Enrolling Group provided the Company with false information material to the execution of this Policy or to the provision of Coverage under this Policy. The Company has the right to rescind this Policy back to the effective date. E. On the date specified by the Company, after at least 90 days prior written notice to the Enrolling Group that this Policy will be terminated because the Company will no longer renew or issue this type of dental benefit plan within the applicable market. F. On the date specified by the Company, after at least 180 days prior written notice to the applicable state authority and to the Enrolling Group that this Policy will be terminated because the Company will no longer renew or issue any employer dental benefit plan within the applicable market. 5.2 Payment and Reimbursement Upon Termination Upon any termination of this Policy, the Enrolling Group will be and will remain liable to the Company for the payment of any and all Premiums which are unpaid at the time of termination, including a pro rata fee for any period this Policy was in force during the Grace Period, if any, preceding the termination. D POL.06.XX (11 /15/2006) 3 Article 6: General Provisions 6.1 Entire Policy The Policy, including the Certificate(s), Schedule(s) of Covered Dental Services, the application of the Enrolling Group, any individual Subscriber applications, Amendments and Riders will constitute the entire Policy between parties. All statements made by the Enrolling Group or by a Subscriber will, in the absence of fraud, be deemed representations and not warranties. 6.2 Time Limit on Certain Defenses No statement made by the Enrolling Group, except a fraudulent statement, will be used to void this Policy after it has been in force for a period of 2 years. 6.3 Amendments and Alterations Amendments to the Policy are effective upon 31 days written notice to the Enrolling Group. Riders are effective on the date specified by the Company. No change will be made to this Policy unless made by an Amendment or a Rider which is signed by an executive officer of the Company. No agent has authority to change this Policy or to waive any of its provisions. 6.4 Relationship Between Parties The relationships between the Company and providers and relationships between the Company and Enrolling Groups, are solely contractual relationships between independent contractors. Providers and Enrolling Groups are not agents or employees of the Company, nor is the Company or any employee of the Company an agent or employee of providers or Enrolling Groups. The relationship between a provider and any Covered Person is that of provider and patient. The provider is solely responsible for the services provided by it to any Covered Person. The relationship between any Enrolling Group and any Covered Person is that of employer and employee, Dependent, or other Coverage classification as defined in this Policy. The Enrolling Group is solely responsible for enrollment and Coverage classification changes (including termination of a Covered Person's Coverage through the Company) and for the timely payment of the Policy Charge. 6.5 Records The Enrolling Group will furnish the Company with all information and proofs which the Company may reasonably require with regard to any matters pertaining to this Policy. The Company may at any reasonable time inspect all documents furnished to the Enrolling Group by an individual in connection with the Coverage, and the Enrolling Group's payroll, and any other records pertinent to the Coverage under this Policy. By accepting Benefits under this Policy, each Covered Person authorizes and directs any person or institution that has provided services to them, to furnish the Company or it's designees any and all information and records or copies of records relating to the services provided to the Covered Person. The Company has the right to request this information at any reasonable time. This applies to all Covered Persons, including Enrolled Dependents whether or not they have signed the Subscriber's enrollment form. The Company agrees that such information and records will be considered confidential. The Company has the right to release any and all records concerning dental services which are necessary to implement and administer the terms of this Policy, for appropriate medical review or quality assessment, or as the Company is required by law or regulation. During and after the term of the Policy, the Company and its related entities may use and transfer the information gathered under the Policy for research and analytic purposes. 6.6 Administrative Services The services necessary to administer this Policy and the Coverage provided under it will be provided in accordance with the Company's or its designee's standard administrative procedures. If the Enrolling Group requests that such administrative services be provided in a manner other than in accordance with these standard procedures, including requests for non-standard reports, the Enrolling Group will pay for such services or reports at the Company's or its designee's then -current charges for such services or reports. DPOL.06.XX (11/15/2006) 4 6.7 ERISA When this Policy is purchased by the Enrolling Group to provide benefits under a welfare plan governed by the Employee Retirement Income Security Act 29 U.S.C., 1001 et seq., the Company will not be named as and will not be the Plan Administrator or the named fiduciary of the welfare plan, as those terms are used in ERISA. 6.8 Examination of Covered Persons In the event of a question or dispute concerning Coverage for Dental Services, the Company may reasonably require that a Covered Person be examined at the Company's expense by a Dentist acceptable to the Company. 6.9 Clerical Error Clerical error will not deprive any individual of Coverage under this Policy or create a right to benefits. Failure to report the termination of Coverage will not continue such Coverage beyond the date it is scheduled to terminate according to the terms of this Policy. Upon discovery of a clerical error, any necessary appropriate adjustment in Premiums will be made. However, no such adjustment in Premiums or Coverage will be granted by the Company to the Enrolling Group for more than 60 days of Coverage prior to the date the Company received notification of such clerical error. 6.10 Workers' Compensation Not Affected The Coverage provided under this Policy does not substitute for and does not affect any requirements for coverage by workers' compensation insurance. 6.11 Conformity with Statutes Any provision of this Policy which, on its effective date, is in conflict with the requirements of applicable state or federal statutes or regulations is hereby amended to conform to the minimum requirements of such statutes and regulations. 6.12 Waiver/Estoppel Nothing in the Policy, Cedificate(s) or Schedule(s) of Covered Dental Services is considered to be waived by any party unless the party claiming the waiver receives the waiver in writing. A waiver of one provision does not constitute a waiver of any other. A failure of either party to enforce at any time any of the provisions of the Policy, Certificate(s) or Schedule(s) of Covered Dental Services, or to exercise any option which is herein provided, will in no way be construed to be a waiver of such provision of the Policy, Certificate(s) or Schedule(s) of Covered Dental Services. 6.13 Headings The headings, titles and any table of contents contained in the Policy, Certificate(s) or Schedule(s) of Covered Dental Services are for reference purposes only and will not in any way affect the meaning or interpretation of the Policy, Certificate(s) or Schedule(s) of Covered Dental Services. 6.14 Unenforceable Provisions If any provision of the Policy, Certificate(s) or Schedule(s) of Covered Dental Services is held to be illegal or unenforceable by a court of competent jurisdiction, the remaining provisions will remain in effect and the illegal or unenforceable provision will be modified so as to conform to the original intent of the Policy, Certificate(s) or Schedule(s) of Covered Dental Services to the greatest extent legally permissible. 6.15 Notice Written notice given by the Company to an authorized representative of the Enrolling Group is deemed notice to all affected Subscribers and their Enrolled Dependents in the administration of this Policy, including termination of this Policy. The Enrolling Group is responsible for giving notice to Covered Persons. Any notice sent to the Company under this Policy and any notice sent to the Enrolling Group will be addressed as described in Exhibit 1. DPOL.06.XX (11/15/2006) 5 6.16 Continuation Coverage The Company agrees to provide Coverage under the Policy for those Covered Persons who are eligible to continue Coverage under federal or state law, as described in the Certificate(s). The Company will not provide any administrative duties with respect to the Enrolling Group's compliance with federal or state law. All duties of the plan sponsor or plan administrator, including but not limited to notification of COBRA and state law continuation rights, and billing and collection of Premium, remain the sole responsibility of the Enrolling Group. 6.17 Subscriber's Individual Certificate(s) The Company will issue Certificate(s), Schedule(s) of Covered Dental Services and any attachments to the Enrolling Group for delivery to each covered Subscriber. The Certificate(s), Schedule(s) of Covered Dental Services and any attachments will show all the benefits and provisions of the Policy. DPO L.06.XX (11 /15/2006 ) Exhibit 1 to Dental Group Policy 1. Parties. The parties to this Policy are United HealthCare Insurance Company ("Company") and AL DT P1211 ("Enrolling Group"). 2. Effective Date. The effective date of this Policy is November 1, 2006. 3. Premiums. The Company reserves the right to change the schedule of rates for Premiums, after 30 days prior written notice on the first anniversary of the Effective Date of the Policy specified in the application or on any monthly due date thereafter, or on any date the provisions of the Policy are amended. The Company also reserves the right to change the schedule of rates for Premiums, retroactive to the Effective Date, if a material misrepresentation has resulted in a lower schedule of rates. 4. Computation of Policy Charge. A full month's Premium will be charged for any Covered Person who is Covered under this Policy for any portion of a calendar month. 5. Payment of the Policy Charge. The Policy Charge is payable in advance by the Enrolling Group to the Company on a monthly basis. 6. Minimum Participation Requirement. The minimum participation requirement is 2 Eligible Persons enrolled for Coverage under the Policy. 7. Notice. Any notice sent to the Company under this Policy will be addressed to: United Healthcare Insurance Company 450 Columbus Blvd. Hartford, CT 06115-0450 Any notice sent to Enrolling Group under this Policy will be addressed to: AL DT P1211 2929 7TH AVENUE S BIRMINGHAM, AL 352330000 VR003N7059BW Enrolling Group Number DPOL.06.XX (11 /15/2006) 8 Exhibit 2 to Dental Group Policy Premiums Monthly Premiums payable by or on behalf of Covered Persons are specified in the Cost Summary. DPOL.06.XX (11 /15/2006) 10 Exhibit 3 to Dental Group Policy Policy Contents All of the Dental Services and provisions in the Certificate(s), Schedule(s) of Covered Dental Services, Amendments and Riders, issued for the Enrolling Group are included and made part of this Policy. D POL.06.XX (11 /15/2006) 12