City of Burleson Dental Passive PPO Plan

Effective: January 1, 2024 Group Number: 906435

Summary Plan Description

CITY OF BURLESON DENTAL PASSIVE PPO PLAN

i TABLE OF CONTENTS

TABLE OF CONTENTS

SECTION 1 - WELCOME

How To Use This SPD

Network and Non-Network Benefits

Dental Services Covered Under the Plan

Important Information Regarding Medicare

Identification ("ID") Card

Contact the Plan Administrator

SECTION 2 - INTRODUCTION

Eligibility

Cost of Coverage

How to Enroll

When Coverage Begins

Changing Your Coverage

SECTION 3 - HOW THE PLAN WORKS

Network and Non-Network Benefits

Eligible Expenses

Annual Deductible

Annual Maximum Benefit

Lifetime Maximum Benefit for Orthodontic Services

Coinsurance

SECTION 4 - PLAN HIGHLIGHTS

SECTION 5 - EXCLUSIONS: WHAT THE DENTAL PLAN WILL NOT COVER

SECTION 6 - CLAIMS PROCEDURES

Network Benefits

Non-Network Benefits

If Your Dentist Does Not File Your Claim

Explanation of Benefits (EOB)

Claim Denials and Appeals

SECTION 7 - SUBROGATION AND REIMBURSEMENT

ii TABLE OF CONTENTS

Right of Recovery

SECTION 8 - WHEN COVERAGE ENDS

Extended Coverage

Coverage for a Disabled Child

Continuing Coverage Through COBRA

When COBRA Ends

Uniformed Services Employment and Reemployment Rights Act

SECTION 9 - COORDINATION OF BENEFITS

Coordination of Benefits Applicability

Definitions

Order of Benefit Determination Rules

Effect on the Benefits of This Coverage Plan

Right to Receive and Release Needed Information

Payments Made

Right of Recovery

SECTION 10 - OTHER IMPORTANT INFORMATION

Qualified Medical Child Support Orders (QMCSOs)

Your Relationship with UnitedHealthcare Dental and City of Burleson

Relationship with Dentists

Your Relationship with Dentists

Interpretation of Benefits

Information and Records

Incentives to Dentists

Incentives to You

Workers' Compensation Not Affected

Future of the Plan

Plan Document

SECTION 11 - GLOSSARY

SECTION 12 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA

ATTACHMENT I – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS

iii TABLE OF CONTENTS

ATTACHMENT II – GETTING HELP IN OTHER LANGUAGES OR FORMATS

1 SECTION 1 - WELCOME

SECTION 1 - WELCOME

Quick Reference Box

■ Member services and claim inquiries; (866) 844-4864.

■ Claims submittal address: Dental Claims, P.O. Box 30567, Salt Lake City, UT 84130- 0567; and

■ Online assistance: www.myuhcdental.com.

This Summary Plan Description describes the terms and conditions of Coverage under City of Burleson Welfare Benefit Plan ("Plan"). Read this document carefully so that you will have a clear understanding of your Coverage under the Plan. If you have any questions regarding your Coverage or procedures for obtaining Dental Services, you may call the toll-free number shown on your ID card or contact the Plan Administrator. City of Burleson is utilizing the services of UnitedHealthcare Dental in the administration of Coverage under the Plan.

Coverage is subject to the terms, conditions, exclusions, and limitations of the Plan. As a Summary Plan Description ("SPD"), this document describes the provisions of Coverage under the Plan but does not constitute the entire Plan. You may examine the entire Plan at the office of the Plan Sponsor during regular business hours.

For Dental Services rendered after the effective date of the Plan, this SPD replaces and supersedes any SPD which may have been previously issued to you by the Plan Sponsor.

Any subsequent SPDs issued to you by the Plan Sponsor will in turn supersede this SPD.

How To Use This SPD

This SPD should be read and re-read in its entirety. Many of the provisions of this SPD are interrelated; therefore, reading just one or two provisions may not give you an accurate understanding of your Coverage.

Your SPD may be modified by the attachment of Amendments. Please read the provision described in these documents to determine the way in which provisions in this SPD may have been changed.

Many words used in this SPD have special meanings. These words will appear capitalized and are defined for you in Section 11, Glossary. By reviewing these definitions, you will have a clearer understanding of your SPD.

From time to time, the Plan may be amended. When that happens, a new SPD or Amendment pages for this SPD will be sent to you. Your SPD should be kept in a safe place for your future reference.

Network and Non-Network Benefits

This SPD describes both Network and Non-Network benefit levels available under the Plan.

2 SECTION 1 - WELCOME

Network Benefits - These benefits apply when you choose to obtain Dental Services from a Network Dentist. Section 3, How the Plan Works describes the procedures for obtaining Covered Dental Services as Network Benefits.

Non-Network Benefits - These benefits apply when you decide to obtain Dental Services from non-Network Dentists. Section 3, How the Plan Works describes the procedures for obtaining Coverage of Dental Services as Non-Network Benefits. When you obtain Dental Services from Non-Network Dentists, you must file a claim to be reimbursed for Eligible Expenses. For information on the Plan's reimbursement policy guidelines used to determine Eligible Expenses, you should contact UnitedHealthcare Dental at the telephone number on your ID card.

Generally, when you receive Covered Dental Services from a Network Dentist, you pay less than you would if you receive the same care from a non-Network Dentist. Your level of Benefits will be the same if you visit a Network Dentist or non-Network Dentist. Because the total amount of Eligible Expenses may be less when you use a Network Dentist, the portion you pay will be less. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network Dentist.

Dental Services Covered Under the Plan

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 should always verify the participation status of a Dentist prior to seeking services. From time to time, the participation status of a Dentist may change. You can verify the participation status by calling UnitedHealthcare Dental. If necessary, UnitedHealthcare Dental can provide assistance in referring you to Network Dentists. If you use a Dentist that is not a participating Dentist, you will be required to pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Only Necessary Dental Services are Covered under the Plan. 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 Plan.

Important Information Regarding Medicare

Coverage under the Plan 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 Plan. If you are eligible for or enrolled in Medicare, please read the following information carefully.

If you are eligible for Medicare and do not enroll for and maintain coverage under both Medicare Part A and Part B and if the Plan Sponsor is the secondary payer as described in the Section 9, Coordination of Benefits, the Plan Sponsor will pay benefits under the Plan as if you were covered under both Medicare Part A and Part B and you will incur a larger out of pocket cost for Dental Services.

3 SECTION 1 - WELCOME

If, in addition to being enrolled for Coverage under the Plan, 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 Dentists. When the Plan Sponsor is the secondary payer, the Plan will pay any benefits available to you under the Plan as if you had followed all rules of the Medicare Advantage plan. If this Plan 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.

Identification ("ID") Card

You must show your ID card every time you request Dental Services. If you do not show your card, the Dentists have no way of knowing that you are Covered under a Plan issued by the Plan Sponsor.

Contact the Plan Administrator

Whenever you have a question or concern regarding Dental Services or any required procedure, please contact the Plan Administrator or call the telephone number stated on your ID card.

4 SECTION 2 - INTRODUCTION

SECTION 2 - INTRODUCTION

What this section includes:

■ Who's eligible for coverage under the Plan;

■ The factors that impact your cost for coverage;

■ Instructions and timeframes for enrolling yourself and your eligible Dependents;

■ When coverage begins; and

■ When you can make coverage changes under the Plan.

Eligibility

You are eligible to enroll in the Plan if you are:

■ A regular full-time employee who is scheduled to work at least 30 hours per week.

■ A regular part-time employee in a position designated as benefit eligible and are scheduled to work at least 20 hours per week.

■ A person who retires while covered under the Plan.

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:

■ your Spouse, as defined in Section 11, Glossary;

■ your or your Spouse's unmarried child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal guardian; or

■ an unmarried child of any age who is or becomes disabled and dependent upon you; or

To be eligible for coverage under the Plan, a Dependent must reside within the United States.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. If you and your Spouse are both covered under the Plan, you may each be enrolled as a Participant or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Plan, only one parent may enroll your child as a Dependent.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 10, Other Important Information.

Cost of Coverage

You and City of Burleson share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll.

5 SECTION 2 - INTRODUCTION

Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld -and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.

Your contributions are subject to review and City of Burleson reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling Human Resources.

How to Enroll

To enroll, call Human Resources within 14 days of the date of hire, unless you elect to waive coverage. If you do not enroll within 14 days, you may need to wait until the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your dental election. Any changes you make during Open Enrollment will become effective the following January 1.

Important If you wish to change your benefit elections following your marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact Human Resources within 30 days of the event. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections.

When Coverage Begins

Once Human Resources receives your properly completed enrollment, coverage will become effective on the date of hire. Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the first of the month following the date Human Resources receives notice of your marriage, provided you notify Human Resources within 30 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the family status change, provided you notify Human Resources within 30 days of the birth, adoption, or placement.

Changing Your Coverage

You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan:

■ your marriage, divorce, legal separation or annulment;

■ the birth, adoption or legal guardianship of a child;

6 SECTION 2 - INTRODUCTION

■ a change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan;

■ loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis;

■ the death of a Dependent;

■ your Dependent child no longer qualifying as an eligible Dependent;

■ a change in your or your Spouse's position or work schedule that impacts eligibility for health coverage;

■ contributions were no longer paid by the employer (This is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer);

■ you or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent;

■ benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent;

■ you or your eligible Dependent incurs a claim that would exceed a lifetime limit on all benefits under the elected health care option through City of Burleson;

■ a strike or lockout involving you or your Spouse; or

■ a court or administrative order.

If you wish to change your elections, you must contact Human Resources within 30 days of the change in family status. Otherwise, you will need to wait until the next annual Open Enrollment.

While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.

Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all dental Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.

7 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 - HOW THE PLAN WORKS

What this section includes:

■ Network and Non-Network Benefits;

■ Eligible Expenses

■ Annual Deductible;

■ Annual Maximum Benefit;

■ Lifetime Maximum Benefit for Orthodontic Services; and

■ Coinsurance.

Network and Non-Network Benefits

As a participant in this Plan, you have the freedom to choose the Dentist you prefer each time you need to receive Covered Dental Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the Network level of Benefits under this Plan when you receive Covered Dental Services from Dentists who have contracted to provide those services.

Generally, when you receive Covered Dental Services from a Network Dentist, you pay less than you would if you receive the same care from a non-Network Dentist. Your level of Benefits will be the same if you visit a Network Dentist or non-Network Dentist. Because the total amount of Eligible Expenses may be less when you use a Network Dentist, the portion you pay will be less. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network Dentist.

If you choose to seek care outside the Network, the Plan generally pays Benefits at a lower level. You are required to pay the amount that exceeds the Eligible Expense. The amount in excess of the Eligible Expense could be significant, and this amount does not apply to the Out-of-Pocket Maximum. You may want to ask the non-Network Dentist about their billed charges before you receive care. Emergency services received at a non-Network Dentist are covered at the Network level.

Looking for a Network Dentist?

In addition to other helpful information, www.myuhcdental.com contains a directory of Network health care professionals and facilities. While Network status may change from time to time, www.myuhcdental.com has the most current source of Network information. Use www.myuhcdental.com to search for Dentists available under your Plan.

Network Dentists

You may request a directory of Network Dentists free of charge. Keep in mind, a Dentist's Network status may change at any time. To verify a Dentist's current status or request a

8 SECTION 3 - HOW THE PLAN WORKS

Dentist directory, you can call the toll-free number on your ID card or log onto www.myuhcdental.com.

Network Dentists are independent practitioners and are not employees of the Plan or the Claims Administrator.

Eligible Expenses

Eligible Expenses are charges for Covered Dental Services that are provided while the Plan is in effect, determined according to the definition in Section 11, Glossary. For certain Covered Dental Services, the Plan will not pay these expenses until you have met your Annual Deductible. City of Burleson has delegated to UnitedHealthcare Dental the initial discretion and authority to decide whether a treatment or supply is a Covered Dental Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

Don't Forget Your ID Card Remember to show your ID card every time you receive dental services from a Dentist. If you do not show your ID card, a Dentist has no way of knowing that you are enrolled under the Plan.

Annual Deductible

The Annual Deductible is the amount of Eligible Expenses you must pay each calendar year for Covered Dental Services before you are eligible to begin receiving Benefits. There is a combined Annual Deductible for Network and Non-Network Benefits for this Plan. The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

Annual Maximum Benefit

The Annual Maximum Benefit is the maximum amount the Plan will pay each calendar year for Covered Dental Services. There is a combined Annual Maximum Benefit for Network Benefits and Non-Network Benefits.

Lifetime Maximum Benefit for Orthodontic Services

The Lifetime Maximum Benefit is the most the Plan will pay for orthodontic services during the entire period you are enrolled in this Plan and any other dental plans offered by City of Burleson. There is a combined Network and non-Network Lifetime Maximum Benefit for this Plan.

Coinsurance

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying.

Coinsurance is a fixed percentage that applies to certain Covered Dental Services after you meet the Annual Deductible.

9 SECTION 4 - PLAN HIGHLIGHTS

SECTION 4 - PLAN HIGHLIGHTS

The table below provides an overview of the Plan's Annual Deductible, Annual Maximum Benefit and Lifetime Maximum Benefits.

Plan Features Network Non-Network

Annual Deductible

■ Individual $50

■ Family $150

Annual Maximum Benefit $2,000

Temporomandibular Joint Dysfunction Annual Maximum Benefit

$500

Lifetime Maximum Benefit for Orthodontic Services

$1,500 per Covered Person, per lifetime

10 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

DIAGNOSTIC SERVICES

Bacteriologic Cultures 100% 100%

Viral Cultures 100% 100%

Intraoral Bite-Wing Radiographs

Limited to 2 series of films per calendar year.

100% 100%

Panorex Radiographs

Limited to one time per consecutive 60 months.

100% 100%

Oral/Facial Photographic Images

Limited to 1 time per consecutive 36 months.

100% 100%

Diagnostic Casts

Limited to 1 time per consecutive 24 months.

100% 100%

Extraoral Radiographs

Limited to 2 films per calendar year.

100% 100%

Intraoral - Complete Series (including bitewings)

Limited to 1 time per consecutive 60 months. Vertical bitewings cannot be billed in conjunction with a complete series.

100% 100%

Individual Periapical Radiographs

11 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Pulp Vitality Tests

Limited to 1 charge per visit, regardless of how many teeth are tested.

100% 100%

Intraoral Occlusal Film 100% 100%

Periodic Oral Evaluation

Limited to 2 times per calendar year. Not Covered if done in conjunction with other exams.

100% 100%

Comprehensive Oral Evaluation

Limited to 2 times per calendar year. Not Covered if done in conjunction with other exams.

100% 100%

Limited or Detailed Oral Evaluation

Limited to 2 times per calendar year. Only 1 exam is Covered per date of service.

100% 100%

Comprehensive Periodontal Evaluation

- new or established patient

Limited to 2 times per calendar year.

100% 100%

Adjunctive Pre-Diagnostic Test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

Limited to 1 time per consecutive 12 months.

12 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the

PREVENTIVE SERVICES

Dental Prophylaxis Cleanings

Limited to 2 times per calendar year.

100% 100%

Fluoride Treatments - child

Limited to Covered Persons under the age of 19 years, not to exceed $200 per calendar year.

100% 100%

Sealants

Limited to Covered Persons under the age of 19 years, not to exceed $200 per calendar year.

100% 100%

Space Maintainers

Limited to Covered Persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation.

100% 100%

Re-Cement Space Maintainers

Limited to 1 per consecutive 6 months after initial insertion.

MINOR RESTORATIVE SERVICES

Amalgam Restorations Fillings

Multiple restorations on one surface will be treated as a single filling.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

13 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Composite Resin Restorations Fillings

Composite Resin Restorations - Anterior

Multiple restorations on one surface will be treated as a single filling.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Gold Foil Restorations

Multiple restorations on one surface will be treated as a single filling.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Stainless Steel Crowns

Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

Prefabricated esthetic coated stainless steel crown - primary tooth, are limited to primary anterior teeth.

80% after you meet the Annual Deductible

80% after you meet the Annual

ENDODONTICS

Apexification

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Apicoectomy and Retrograde filling

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Hemisection

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Root Canal Therapy

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.

80% after you meet the Annual Deductible

80% after you meet

14 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Retreatment of Previous Root Canal Therapy

Dentist who performed the original root canal should not be reimbursed for the retreatment for the first 12 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Root Resection/Amputation

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Therapeutic Pulpotomy

Limited to 1 time per primary or secondary tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

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.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Pulp Caps - Direct/Indirect – excluding final restoration

Not covered if utilized solely as a liner or base underneath a restoration.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Pulpal Debridement, Primary and Permanent Teeth

Limited to 1 time per tooth per lifetime.

This procedure is not to be used when endodontic services are done on same date of service.

80% after you meet the Annual Deductible

80% after you meet

15 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the

PERIODONTICS

Crown Lengthening

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Gingivectomy/Gingivoplasty

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Gingival Flap Procedure

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Osseous Graft

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Osseous Surgery

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Guided Tissue Regeneration

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Soft Tissue Surgery

Limited to 1 per quadrant or site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Periodontal Maintenance

Limited to 2 times per calendar year following active or adjunctive periodontal therapy, exclusive of gross debridement.

80% after you meet the Annual Deductible

80% after you meet

16 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Full Mouth Debridement

Limited to once per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Provisional Splinting

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.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Scaling and Root Planning

Limited to 1 time per quadrant per consecutive 24 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Localized Delivery of Antimicrobial

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.

80% after you meet the Annual Deductible

80% after you meet the Annual

ORAL SURGERY

Alveoloplasty 80% after you meet

Deductible

80% after you meet the Annual Deductible

Biopsy

Limited to 1 biopsy per site per visit.

80% after you meet the Annual Deductible

80% after you meet

17 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Frenectomy/Frenuloplasty 80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Surgical Incision

Limited to 1 per site per visit.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Removal of a Benign Cyst/Lesions

Limited to 1 per site per visit.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Removal of Torus

Limited to 1 per site per visit.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Root Removal

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Simple Extraction

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Surgical Extraction of Erupted Teeth or Roots

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Surgical Extraction of Impacted Teeth

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Surgical Access, Surgical Exposure, or Immobilization of Unerupted Teeth

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Primary Closure of a Sinus Perforation

Limited to 1 per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet

18 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*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 Eruption of Impacted Tooth

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Transseptal Fiberotomy/Supra Crestal Fiberotomy, by report

Limited to 1 time per tooth per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Vestibuloplasty

Limited to 1 time per site per consecutive 60 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Bone Replacement Graft for Ridge Preservation - per site

Limited to 1 per site per lifetime Not Covered if done in conjunction with other bone graft replacement procedures.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Excision of Hyperplastic Tissue or Pericoronal Gingiva

Limited to 1 per site per consecutive 36 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Appliance Removal (not by dentist who placed appliance) includes removal of arch bar

Limited to once per appliance per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Tooth Reimplantation and/or Transplantation Services

Limited to 1 per site per lifetime.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Oroantral Fistula Closure

Limited to 1 per site per visit.

80% after you meet the Annual Deductible

80% after you meet

19 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the

ADJUNCTIVE SERVICES

Analgesia

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.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Desensitizing Medicament 80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

General Anesthesia

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.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Local Anesthesia

Not Covered in conjunction with operative or surgical procedure.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Intravenous Sedation and Analgesia

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.

80% after you meet the Annual Deductible

80% after you meet

20 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Therapeutic Drug Injection, by report/Other Drugs and/or Medicaments, by report

Limited to 1 per visit.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Occlusal Adjustment 80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Occlusal Guards

Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Occlusal Guard Reline and Repair

Limited to relining and repair performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Occlusion Analysis - Mounted Case

Limited to 1 time per consecutive 60 months.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Palliative Treatment

Covered as a separate benefit only if no other services, other than exam and radiographs, were done on the same tooth during the visit.

80% after you meet the Annual Deductible

80% after you meet the Annual Deductible

Consultation (diagnostic service provided by dentists or physician other than practitioner providing treatment.)

Not Covered if done with exams or professional visit.

80% after you meet the Annual Deductible

80% after you meet

21 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

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

Limited to 1 per tooth per consecutive 60 months. Not Covered if done at the same time as a crown on same tooth.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Crowns – Retainers/Abutments

Limited to 1 time per tooth per consecutive 60 months. Covered 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.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Crowns - Restorations

Limited to 1 time per tooth per 5 years.

Covered 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.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Gold Restorations

Limited to 1 time per tooth per consecutive 60 months. Covered 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.

50% after you meet the Annual Deductible

50% after you meet

22 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Temporary Crowns - Restorations

Limited to 1 time per tooth per consecutive 60 months. Covered 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.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Inlays/Onlays – Retainers/Abutments

Limited to 1 time per tooth per 60 consecutive months. Covered 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.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Inlays/Onlays - Restorations

Limited to 1 time per tooth per 5 years.

Covered 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.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Pontics

Limited to 1 time per tooth per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Retainer-Cast Metal for Resin Bonded Fixed Prosthesis

Limited to 1 time per tooth per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Pin Retention

Limited to 2 pins per tooth; not covered in addition to cast restoration.

50% after you meet the Annual Deductible

50% after you meet

23 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Post and Cores

Covered only for teeth that have had root canal therapy.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Re-cement Bridges

Re-Cement Inlays/Onlays, Crowns, Bridges and Post and Core

Limited to those performed more than 12 months after the initial insertion.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Sedative Filling

Covered as a separate benefit only if no other service, other than x-rays and exam, were done on the same tooth during the visit.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

FIXED PROSTHETICS

Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or

Fixed Partial Dentures (Bridges)

Limited to 1 time per tooth per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

REMOVABLE PROSTHETICS

Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or

Full Dentures

Limited to 1 per 5 years. No additional allowances for precision or semi-precision attachments.

50% after you meet the Annual Deductible

50% after you meet

24 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Partial Dentures

Limited to 1 per 5 years. No additional allowances for precision or semi-precision attachments.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Relining Dentures and Rebasing Dentures

Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Tissue Conditioning - Maxillary or Mandibular

Limited to 1 time per consecutive 12 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Repairs to Full Dentures, Partial Dentures, Bridges or Crowns

Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

TMD (commonly known as TMJ)

Services related to Temporomandibular Joint/Temporomandibular Disorder

Temporomandibular Joint Diagnostic

Limited to 1 film per joint, total of 2 films per consecutive 12 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Tomographic Survey

Limited to 1 film per joint, per consecutive 12 months.

50% after you meet the Annual Deductible

50% after you meet

25 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Manipulation Under Anesthesia

Limited to 1 per visit.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Occlusal Orthotic Device, by report

Limited to 1 time every consecutive 24 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Unspecified TMD Therapy, by report

Limited to 1 per visit. Cannot be billed in conjunction with other TMD procedures.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

IMPLANTS

Replacement of implants, implant crowns, implant prosthesis, and implant supporting structures (such as connectors) previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement.

Implant Placement

Limited to 1 time per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Implant Supported Prosthetics

Limited to 1 time per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Implant Maintenance Procedures, including removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis

Limited to 1 time per consecutive 12 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Repair Implant Supported Prosthesis, by report

Limited to repairs or adjustments performed more than 12 months after initial insertion. Limited to 1 per consecutive 6 months.

50% after you meet the Annual Deductible

50% after you meet

26 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Abutment Supported Crown (titanium) or Retainer Crown for FPD - titanium

Limited to 1 time per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Repair Implant Abutment, by report

Limited to repairs or adjustments performed more than 12 months after initial insertion. Limited to 1 per consecutive 6 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Implant Removal, by report

Limited to 1 time per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual Deductible

Radiographic/Surgical Implant Index, by report

Limited to 1 time per consecutive 60 months.

50% after you meet the Annual Deductible

50% after you meet the Annual

ORTHODONTICS

Orthodontic Services

Services or supplies furnished by a Dentist to a Dependent under age 19 in order to diagnose or correct misalignment of the teeth or the bite. The extended coverage provision does not apply to orthodontic services.

50% 50%

Appliance Therapy, Fixed or Removable

Limited to 1 time per consecutive 60 months. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.

50% 50%

27 SECTION 4 - PLAN HIGHLIGHTS

Benefit Description & Limitation

Percentage of Eligible Expenses Payable by the Plan:

Network Non-Network*

*You must also pay the amount of the Dentist's fee, if any, which is greater than the Eligible Expense.

Cephalometric Film

Limited to 1 per consecutive 12 months.

Can only be billed for orthodontics.

50% 50%

28 SECTION 5 - EXCLUSIONS

SECTION 5 - EXCLUSIONS: WHAT THE DENTAL PLAN WILL NOT COVER

Except as may be specifically provided in the Section entitled Plan Highlights through a rider to the Plan or through an Amendment to the SPD, the following are not Covered:

1. Dental Services that are not Necessary.

2. Hospitalization or other facility charges.

3. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

4. Reconstructive Surgery regardless of whether or not the surgery which 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.

5. Any Dental Procedure not directly associated with dental disease.

6. Any Dental Procedure not performed in a dental setting.

7. 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.

8. Any implant procedures performed which are not listed as Covered implant procedures in Section 4, Plan Highlights.

9. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

10. 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.

11. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

12. 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.

13. 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 Dental error. This

29 SECTION 5 - EXCLUSIONS

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.

14. 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 Plan 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.

15. Fixed or removable prosthodontic restoration procedures or implant services for complete oral rehabilitation or reconstruction.

16. Services other than those listed in Section 4, Plan Highlights for diagnosis and treatment of temporomandibular joint disorders (TMD).

17. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours’ notice.

18. Expenses for dental procedures begun prior to the Covered Person's eligibility with the Plan.

19. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

20. 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.

21. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

22. Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to Plan coverage unless the patient has been eligible under the Plan 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.

23. Replacement of missing natural…