2-EXHIBIT F - Current Schedule of Benefits.pdf

SCHEDULE OF BENEFITS

CONTRACTHOLDER: MARION COUNTY EMPLOYEES

CONTRACT NUMBER: 177L22

CERTIFICATE EFFECTIVE DATE: 2024-10-01

PLAN YEAR: October 1st through September 30th

Insureds covered under this contract have the right to obtain care from the dental provider of their choice.

Florida Combined Life Insurance Company., Inc. (FCL) has an agreement with certain dental providers, called Participating Dentists, to accept the lesser of the actual charge or the FCL allowance as payment in full for covered services. Benefits are payable for Participating and Non-Participating Dentists as shown in this Schedule of Benefits. See the Provider Alternatives provision for further details.

Eligibility and Deductibles

Dependent Child(ren) to Age 30/30 Domestic Partner Not Eligible Dependent Child(ren) of Domestic Partner Not Eligible

Participating Dentists Non-Participating Dentists Deductible for Preventive Services None None Individual Deductible Per Insured, Per Plan Year for Basic and Major Services

$50 $50

Family Deductible Per Plan Year for Basic and Major Services

$150 $150

Coinsurance payable by FCL for covered services

Preventive Basic Major

100% 80% 50%

0.9 0.6 0.4

Maximums and Waiting Periods

Plan Year Maximum *** $1,000

Waiting Period for Major Services Initial Enrollment* Subsequent Enrollment**

None None

Waiting Period for Replacement of Missing Teeth

None

* Insureds who enroll on the original effective date ** Insureds who enroll after the original effective date *** If there is a different Plan Year Maximum for Participating Dentists and Non-Participating Dentists this does not mean there are two independent amounts of benefits for Covered Services, but rather, that once the Plan Year Maximum for Non-Participating Dentists has been paid by FCL no further Non-Participating Dentist benefits will be available, and the only available benefits will be the difference in the Plan Year Maximum for Participating Dentists and Non-Participating Dentists for Covered Services received by a Participating Dentist.

50743-0718 Choice, Choice Plus 51+

~TOD~

The following services are covered as follows:

Sealants Preventive Benefit Full Mounth/Panoramic X-rays Preventive Benefit Space Maintainers Basic Benefit Bitewing X-rays Preventive Benefit Non-Surgical Periodontics Services Major Benefit Surgical Periodontics Services Major Benefit Endodontic Services Major Benefit Prophylaxis (cleaning) Two times per plan year Oral Examination Two times per plan year Periodontal Maintenance Including Prophylaxis Two times per plan year

Riders Orthodontia Services Child to Age 19 Waiting Period for Orthodontia Services Initial Enrollment* None Subsequent Enrollment** None Orthodontia Lifetime Maximum**** Per Insured $1,000 $1,000 Orthodontia Coinsurance Payable by FCL 50% 50%

**** If there is a different Orthodontia Lifetime Maximum for Participating Dentists and Non-Participating Dentists this does not mean there are two independent amounts of benefits for Covered Services, but rather, that once the Orthodontia Lifetime Maximum for Non-Participating Dentists has been paid by FCL no further Non-Participating Dentist benefits will be available, and the only available benefits will be the difference in the Orthodontia Lifetime Maximum for Participating Dentists and Non-Participating Dentists for Covered Services received by a Participating Dentist.

Maximum Rollover Benefit Included

50743-0718 Choice, Choice Plus 51+

50393-899 (Rev. 2/13) Page 1 Ortho Rider

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

P.O. BOX 40028

JACKSONVILLE, FLORIDA 32203

GROUP DENTAL BENEFITS

ORTHODONTIA RIDER

This rider is a part of the certificate to which it is attached. The effective date of this rider is the later of the certificate’s effective date or the date of the amendment adding this rider to the certificate.

Unless amended by this rider, certificate definitions, terms and provisions will apply to this rider.

1. For purposes of this rider, the following definition is added to the certificate:

Orthodontia - means the branch of dentistry concerned with the interception and treatment of improper alignment of biting or chewing surfaces (malocclusion) of the teeth and their surrounding structures.

2. For purposes of this rider, the following certificate provisions are amended:

A. “Benefits” is amended as follows:

(i) The following is added to the first paragraph:

The Orthodontia Lifetime Maximum benefit payable per person is shown on the Schedule of Benefits. If your employer offers more than one FCL dental plan and you change from one FCL dental plan to another FCL dental plan, the Lifetime Maximum benefit does not start over. This applies regardless of the number of times you change FCL dental plans offered by your employer. The Orthodontia Lifetime Maximum benefit is based on the higher benefit of any FCL dental plan offered by your employer, under which you have been enrolled.

(ii) The following is added under “Basic” benefits:

Cephalometric x-rays, but only in connection with orthodontic diagnosis, and only once in any thirty-six (36) consecutive month period.

(iii) The following provision is added:

Orthodontic Services

The following is a list of covered services for orthodontic services for the correction of an existing malocclusion and its attendant sequelae through the correction of malposed teeth.

1. diagnosis, including radiographs and study models;

2. active treatment, including necessary appliances; and

3. retention treatment following active treatment.

B. “Limitations and Exclusions” is amended as follows:

(i) The following is added under “Limitations”:

50393-899 (Rev. 2/13) Page 2 Ortho Rider

Orthodontia services will be limited to the Lifetime Orthodontia Maximum shown on the Schedule of Benefits.

Benefits for covered orthodontia services will be payable in equal monthly amounts during the period covered by the approved treatment plan and while coverage is in effect, not to exceed thirty-six (36) months.

If the treatment plan for covered orthodontia services is completed in less time than specified in the approved treatment plan, we will make payment in the amount of the remainder of the FCL liability, after we receive notice from the dentist.

Functional/myofunctional therapy is covered only when provided by a dentist in conjunction with orthodontic appliance therapy.

Benefit payment for orthodontic services will be limited to thirty-six (36) consecutive months’ active treatment or eighteen (18) consecutive months’ retention treatment. These limits will include the number of months of such treatment received prior to commencement of this coverage.

(ii) “Exclusions” is amended as follows:

(a) Item 5. is deleted and replaced with the following:

5. Services rendered primarily for cosmetic purposes, except for orthodontic services rendered for correction of defects incurred through traumatic injuries which occurred while this rider is in force.

(b) Item 32. is deleted and replaced with the following:

32. Charges for the replacement and/or repair of any orthodontic appliance furnished under the treatment plan or for any duplicate orthodontic device or appliance.

This rider terminates on the earliest of:

1. the date on which any event specified in section V, “The Date on Which Insurance

Terminates,” occurs;

2. the date the contractholder notifies us to terminate this rider; or

3. the date you elect to terminate the coverage provided by this rider.

The certificate to which this rider is attached is not changed, other than as herein stated.

Signed for the Florida Combined Life Insurance Company, Inc., at Jacksonville, Florida, on the effective date of this rider.

President

50659-0718 Rollover Benefit Plan Year

Plan Year Maximum Rollover Benefit Certificate Rider

The Group Dental Benefits Contract and Certificate to which this rider is attached is changed, for purposes of this rider, by adding the following new benefit:

Plan Year Maximum Rollover Benefit

A Rollover Benefit is a portion of a member’s un-used Plan Year Maximum that may be carried over to the next Plan Year, thereby increasing the next Plan Year Maximum amount, provided the following conditions are met:

1. the member is an active member of the plan on the last day of the plan year;

2. the member submits at least one (1) claim for a covered service during a Plan Year;

3. the member’s total claims paid during a Plan Year do not exceed the Yearly Threshold Amount, as stated in the table below; and

4. the Accumulated Rollover Maximum has not been reached.

Plan’s Annual Maximum* Benefit

Amount

Yearly Threshold Amount

Available Rollover Amount to use next year/beyond.

Accumulated Rollover

Maximum $500 - $749 $200 $150 $500 $750 - $999 $300 $200 $500

$1,000 - $1,249 $500 $350 $1,000 $1,250 - $1,499 $600 $450 $1,250 $1,500 - $1,999 $700 $500 $1,250 $2,000 - $2,499 $800 $600 $1,500 $2,500 - $2,999 $900 $700 $1,500 $3,000 or more $1,000 $750 $1,500

*If a Plan’s Annual Maximum is different for Participating and Non-Participating Dentists, (Example: $1500 Participating Dentist/$1000 Non-Participating Dentist) the Participating Dentist Annual Maximum, as shown on the Schedule of Benefits, will determine the Plan’s Annual Maximum Benefit Amount.

Beginning with the second (2nd) plan year of coverage under the Certificate, a member’s Plan Year Maximum, as shown on the Schedule of Benefits, may be increased by the amount shown on the table above if all the above listed conditions are met. If coverage under this Rider is first provided during a partial Plan Year, the Rollover Benefit will be calculated as if coverage was provided for a full Plan Year.

Here’s an example of how the Rollover Benefit works.

Plan Year One (1) Two (2) Three (3) Four (4)

Plan Year Maximum* shown on the schedule of benefits

$1,000 $1,000 $1,000 $1,000

Accumulated Rollover Amount credit from prior year $0 $350 $700 $700 Adjusted Plan Year Maximum $1,000 $1,350 $1,700 $1,700

Covered Service received Yes Yes No Total Claims Paid during Plan Year $275 $480 $350

Rollover Amount $350 $350 $0 Accumulated Rollover Amount $350 $700 $700

The Rollover Amount can be accumulated from one Plan Year to the next, up to the Accumulated Rollover Maximum, unless:

1. the member’s total claims paid during a Plan Year exceed the Yearly Threshold Amount (in this instance, there will be no additional Rollover Amount for that Plan Year), or

2. no claims for covered services are incurred during a Plan Year (in this instance, there will be no additional Rollover Amount for that Plan Year).

50659-0718 Rollover Benefit Plan Year

If total claims paid during any one Plan Year exceed the Plan Year Maximum shown on the schedule of benefits, the excess amount will be deducted from the Accumulated Rollover Amount available for that Plan Year. No additional Rollover Amount will be earned for that Plan Year and the Accumulated Rollover Amount available for the next Plan Year will be reduced by the amount deducted for the excess claim amount.

To properly calculate the Rollover Amount, claims should be submitted in a timely manner, as described in the Certificate.

Rollover Amounts are not available for the following expenses related to a member’s dental services:

1. deductibles;

2. coinsurance;

3. co-payments;

4. balance billed amounts; or

5. orthodontic benefits.

When Your Plan Year Maximum Rollover Benefit Ends

You will lose your right to any annual rollover benefit (or accumulated rollover maximum benefit) when you lose eligibility for coverage in your group’s dental plan. The accumulated rollover benefit can be used only while you are enrolled in your group’s dental plan and while your group continues to offer the Plan Year Maximum Rollover Benefit. This means that if you change from one group’s dental plan to another group’s dental plan, or if your group dental plan is terminated, you lose your right to any rollover benefit that has not been used.

Nothing herein contained shall be held to vary, alter, waive or extend any of the provisions, conditions, limitations, exceptions, or other terms of the Certificate to which this rider is attached other than as herein stated.

If you have any questions about this coverage, need claims assistance, or need assistance in resolving complaints, please call us at 1-888-223-4892.

Signed for the Florida Combined Life Insurance Company, Inc., at Jacksonville, Florida, on the later of: (1) the effective date of the Policy and Certificate; or (2) the date of a Policy Amendment adding this Rider.

President