260125_Chapter_1E_-_Dental_3342685_City_of_Tucson_07.01.2025_AZ_and_CA_members.pdf

“Cigna” is a registered service mark, and,” the “Tree of Life” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc.

June 18, 2025

Linda Kile City of Tucson P.O. Box 27210 Tucson, AZ 85726

Dear Linda, We wish to take this opportunity to thank your organization for renewing your coverage with Cigna Dental Health.

Here you will find your Cigna Dental Health Group Contract(s), Patient Charge Schedule(s) and Plan Booklet(s). These documents cover employees located in Arizona and California. You should retain the enclosed documents in your file.

Please note that your organization will be deemed to have accepted the terms of the Group Contract unless you advise us to the contrary within twenty (20) days from the date of receipt.

You may also receive other policies or participation agreements from Cigna Health and Life Insurance Company to reflect dental health coverage in other states or additional out-of-network coverage that you may have purchased.

If you have any questions, please feel free to call Contracts Administration at 860.902.4177. Thank you again for selecting Cigna Dental Health.

Sincerely, Cheryl Terrell Account Installation Representative

CIGNA DENTAL HEALTH, INC.

Enclosures: Group Contract(s) Patient Charge Schedule(s) Plan Booklet(s) a52016 Cross-Out

Group Contract

City of Tucson and

Cigna Dental Health

Member Services 1.800.Cigna24 (Reaches all Regional locations)

Cigna Dental Health Plan of Arizona, Inc.

Regional Offices P.O. Box 453099 Sunrise, Florida 33345-3099

THIS IS A LEGAL CONTRACT BETWEEN THE ABOVE MENTIONED GROUP AND THE Cigna

DENTAL COMPANIES LISTED ABOVE. IT IS ISSUED IN CONSIDERATION OF THE PRE-

CONTRACT APPLICATION AND PAYMENT OF THE PREMIUMS/PREPAYMENT FEES AS THEY ARE

DUE. READ YOUR GROUP CONTRACT CAREFULLY.

85600 08.11.05

TABLE OF CONTENTS

Page

A. DEFINITIONS

B. THE DENTAL PLAN

C. PREMIUMS/PREPAYMENT FEES

D. GRACE PERIOD/REINSTATEMENT

E. EFFECTIVE DATE/TERM & RENEWAL

F. ELIGIBILITY

G. COMPLIANCE WITH THE FEDERAL OMNIBUS BUDGET RECONCILIATION ACT OF

H. ADMINISTRATION AND RECORDS

I. TERMINATION OF CONTRACT

J. NOTICE

K. ASSIGNMENT

L. AMENDMENTS TO CONTRACT

M. ENTIRE CONTRACT

N. GOVERNING LAW

O. INCONTESTABILITY

A. DEFINITIONS

Capitalized terms in this contract (the "Contract"), unless otherwise defined, shall have the meanings set forth below.

Cigna Dental: The Cigna Dental Health organization that provides dental benefits in your state as listed on the face page of this Contract.

Covered Persons: Subscribers and their Dependents who are enrolled in the Dental Plan.

Dental Plan: Managed dental care plan to be provided pursuant to this Contract.

Dependent: Those Covered Persons which are named as Dependents of a Subscriber, as further defined in the applicable Plan Booklet, Evidence of Coverage and/or Certificate of Coverage.

Evidence of Coverage: Subscriber's dental plan booklet or certificate of coverage which summarizes the dental plan and covered benefits. The Evidence of Coverage is attached hereto and made a part of this Contract as if fully set forth herein.

Group: Employer, labor union, association, or other organization named on the title page of this Contract.

Patient Charge Schedule: List of covered services and associated patient charges, which is attached hereto and incorporated herein by reference, and as it may be revised during the term of this Contract.

Pre-Contract: The Cigna Dental Pre-Contract Application which designates certain terms and conditions of coverage and which is attached hereto and made a part hereof by reference.

Premiums/Prepayment Fees: The fees/premiums stated in the Pre-Contract which the Group must remit to Cigna Dental for Covered Persons each calendar month during the term of this Contract.

Subscriber: Employee or member of the Group who is enrolled in the Dental Plan.

B. THE DENTAL PLAN

1. Cigna Dental shall provide dental benefits to Subscribers and Dependents in accordance with the terms of this Contract and as set out in the attached Pre-Contract, Evidence of Coverage, applicable State Riders, and Patient Charge Schedule.

2. The terms and conditions of the Evidence of Coverage including State Riders, applicable Patient Charge Schedule, and any amendments or revisions thereto, are incorporated into this Contract by reference and made a part hereof as if fully set forth herein. Each Subscriber shall receive an Evidence of Coverage outlining the terms, exclusions and limitations of the coverage provided hereunder. Any conflicts between the Group Contract and Evidence of Coverage shall be resolved according to the terms most favorable to the Subscriber.

3. The relationship between Cigna Dental Health and a Network Dentist is an independent contractor relationship. All contracts between Cigna Dental Health and Network Dentists state that under no circumstances shall any Covered Person be liable to any Network Dentist for any sums owed to the Network Dentist by Cigna Dental Health, notwithstanding any delay by Cigna Dental Health in paying the Network Dentist any such sums. Cigna Dental Health shall provide reasonable notice to the Group of any termination, breach of contract, or inability to perform of any Network Dentist if Cigna Dental Health determines that Covered Persons may be materially and adversely affected thereby.

C. PREMIUMS/PREPAYMENT FEES

In consideration of the services to be rendered and made available by Cigna Dental pursuant to this Contract, the Group shall remit to Cigna Dental the Premium/Prepayment Fee for the initial month of coverage on or before the first day of said month accompanied by a list of persons to be covered under the Dental Plan. On or before the twelfth (12th) day of each month during the term of this Contract, Cigna Dental will send the Group an alphabetized list of Subscribers and a statement of Premiums/Prepayment Fees due for that month of coverage. On or before the twenty-fifth (25th) day of each month during the term of this Contract, the Group shall remit the Premium/Prepayment Fee to Cigna Dental with an updated list indicating Covered Persons to be added to or deleted from the Dental Plan and any changes in type of coverage. Alternative payment mechanisms developed for the Group by Cigna Dental shall supersede the terms of this Paragraph.

Premiums/Prepayment Fees are guaranteed for an initial period of twelve

(12) months (unless otherwise extended in the Pre-Contract). However, Premiums/Prepayment Fees may be adjusted by Cigna Dental upon 30 days' notice to the Group if, in Cigna Dental's sole opinion, its liability is altered by any state or federal law.

D. GRACE PERIOD/REINSTATEMENT

1. Cigna Dental shall provide written notice of non-receipt of payment on or before the twelfth (12th) day of the month following the month for which Premiums/Prepayment Fees remain due and owing. Group shall have an additional thirty-one (31) days for the payment of any Premium/Prepayment Fee except the first. The Contract shall remain in full force and effect during this Grace Period. If the Premium/Prepayment Fees are not remitted by the end of the Grace Period, the Contract will terminate on the last day of the Grace Period. The Group will remain liable to Cigna Dental for any Premium/Prepayment Fees accrued during the Grace Period.

2. If proper payment is received by Cigna Dental on or before the expiration of the Grace Period, the Contract shall remain in full force and effect. If the Contract terminates due to non-payment of the required Premiums/Prepayment Fees, the Group may request that Cigna Dental reinstate the Contract. The Group must make this request and pay all past due and current Premiums/Prepayment Fees to Cigna Dental within fifteen (15) days after the expiration of the applicable Grace Period.

3. If Cigna Dental elects to reinstate this Contract, the coverage provided herein will resume as of the date of termination with no gap in coverage. If Cigna Dental elects not to reinstate the Contract, it will notify the Group of such decision in writing. In such event, any unearned Premium/Prepayment Fees submitted with the request for reinstatement will be returned to the Group.

4. Cigna Dental's reinstatement of the Contract or waiver of the right to terminate this Contract pursuant to this Section shall not constitute a waiver of any future right to terminate for nonpayment of Premium/Prepayment Fees.

E. EFFECTIVE DATE/TERM & RENEWAL

The Group's effective date of coverage under the Dental Plan (the "Effective Date") shall be the date listed on the Pre-Contract, for and in consideration of Cigna Dental's receipt of the Premium/Prepayment Fees.

The original term of this Contract shall extend from the Effective Date until the expiration of the initial Premium/Prepayment Fee Guarantee as set forth in the Pre-Contract (the "Expiration Date"). This Contract shall be automatically renewed on an annual basis effective the day following the Expiration Date (the "Renewal Date") unless otherwise terminated as provided herein. The Patient Charge Schedule shall be in effect for a minimum of one year.

The Premium/Prepayment Fee and Patient Charge Schedule shall be reviewed and may be adjusted on an annual basis at the anniversary of the Renewal Date upon sixty (60) days' notice from Cigna Dental.

F. ELIGIBILITY

1. The Group shall determine which of its employees, associates or members are eligible to enroll in the Dental Plan. The Group shall be responsible for providing eligibility information to Cigna Dental on a timely basis as provided in Section C hereinabove. Where the Group provides eligibility information of any kind, including but not limited to electronic data, tapes or software, the data must be accurate and accessible.

2. The Group will have at least one open enrollment period every eighteen (18) months. Such open enrollment periods are required for as long as the Contract exists unless Cigna Dental and the Group mutually agree to a shorter period of time. Subscribers and Dependents may be disenrolled only during the Group's open enrollment periods unless there has been a life status change such as divorce or termination.

3. In the event a Covered Person is eligible for benefits pursuant to the requirements of the Family and Medical Leave Act of 1993 or the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Group shall be responsible for collecting the Subscriber's portion of the Premium/Prepayment Fees, if any, for which the Subscriber would have been responsible if Subscriber had not taken the leave or become qualified for COBRA coverage.

G. COMPLIANCE WITH THE FEDERAL OMNIBUS BUDGET RECONCILIATION ACT OF 1993

The parties agree, as follows, to perform the terms of this Contract in accordance with the requirements of the Federal Omnibus Budget Reconciliation Act of 1993:

1. Cigna Dental shall not take into account that a Covered Person is eligible for or is provided medical assistance under 12 U.S.C. §1396a (section 1902 of the Social Security Act) in covering or providing benefits to or on behalf of said Covered Person under the Dental Plan.

2. If a Subscriber who is eligible for family coverage under the Dental Plan is required by a court or administrative order to provide dental coverage for his or her child:

(a) Cigna Dental Health and the Group:

(i) Shall not deny enrollment of the child in the Dental Plan on any of the following grounds:

a) The child was born out of wedlock,

b) The child is not claimed as a dependent on the

Subscriber's federal income tax return, or

c) The child does not reside with the Subscriber or in the Dental Plan's service area.

(ii) Shall allow the Subscriber to enroll the child in the Dental Plan under family coverage, without regard to any enrollment season restrictions, provided that the child is otherwise eligible for Dental Plan coverage.

(iii) Shall enroll the child in the Dental Plan under the family coverage upon application of the child's other parent or the Department of Human Resources in connection with its administration of the Medical Assistance or Child Support Enforcement Program if the Subscriber fails to enroll the child.

(iv) Except as otherwise provided herein, shall not terminate the child's Dental Plan coverage unless Cigna Dental and the Group are provided satisfactory written evidence that:

a) The court or administrative order is no longer in effect, or

b) The child is or will be enrolled in comparable dental coverage through another dental plan, which coverage will take effect no later than the effective date of termination.

(b) The Group shall withhold from Subscriber's compensation the

Subscriber's share, if any, of Premiums for Dental Plan coverage and shall pay the appropriate Premiums to Cigna Dental pursuant to the terms of this Contract.

(c) If the Subscriber is not the child's custodial parent, Cigna

Dental and the Group shall:

(i) Provide such information to the custodial parent as may be necessary for the child to obtain benefits under the Dental Plan.

(ii) Permit the custodial parent or dentist (with custodial parent's approval) to submit claims for Covered Services without the approval of the non-custodial parent.

(iii) Make payments, pursuant to this Contract, on the claims submitted under clause (b) of this paragraph directly to the custodial parent, the dentist, or the Department of Human Resources.

(d) Cigna Dental shall not impose on any State agency that has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered under the Dental Plan requirements that are different from requirement applicable to an agent or assignee of any other individual covered under the Dental Plan.

3. If a Subscriber who is eligible for family coverage under the

Dental Plan is required by a court or administration order to provide dental coverage for his or her child who does not reside in the Dental Plan's service area, the following alternatives for coverage are available:

(a) If the Group offers its employees a choice between the Dental

Plan or indemnity dental coverage, the family shall be covered under the Dental Plan and the child shall be treated at the Subscriber's Dental Office in the Dental Plan's service area, except as provided herein for emergencies and specialty referrals; or the family shall be covered under the indemnity dental coverage.

(b) If the Group does not offer its employees any indemnity dental coverage and an affiliate of Cigna Dental has a network of dentists in the service area within which the child resides, the child shall be covered under a contract between the Group and the affiliate of Cigna Dental and the Subscriber shall be covered under a contract between the Group and Cigna Dental.

(c) If the Group does not offer its employees any indemnity dental coverage and an affiliate of Cigna Dental does not have a network in the service area within which the child resides, the family shall be covered by an indemnity dental policy which the Group shall obtain or the family shall be covered under the Dental Plan and the child shall be treated at the Subscriber's Dental Office in the Dental Plan's service area, except as provided herein for emergencies and specialty referrals.

(d) Except as otherwise restricted by federal law, the Subscriber shall be permitted to change his or her dental coverage election (between the Dental Plan and indemnity dental coverage) without regard to any enrollment reason restrictions.

4. A child who is less than 18 years of age and is placed for adoption with a Subscriber shall be entitled to benefits under the same terms and conditions that apply to the Subscriber's natural, Dependent children, irrespective of whether the adoption has become final. Cigna Dental shall not restrict Dental Plan coverage of any dependent child adopted by or placed for adoption with a Subscriber solely on the basis of any pre-existing condition of the child at the time that the child would otherwise become eligible for coverage under the Dental Plan if the adoption or placement for adoption occurs while the Subscriber is eligible for coverage under the Dental Plan. As used in this paragraph, "placement for adoption" means the assumption and retention by a Subscriber of a legal obligation for total or partial support of a child in anticipation of the adoption of the child. The child's placement with Subscriber terminates upon the termination of such legal obligations.

5. A subscriber's foster child shall be treated the same as a newborn child and shall be eligible for coverage on the same basis, under the terms of this Contract, upon placement in Subscriber's home.

As used in this paragraph, "Foster child" means a minor over whom a Subscriber has been appointed (1) guardian by a court of competent jurisdiction in the state or (2) the primary or sole custodian by order of a court of competent jurisdiction. As used in this paragraph, "placement in the Subscriber's home" means physically residing with a Subscriber who has been appointed guardian or custodian as long as that Subscriber has assumed the legal obligation for total or partial support of the foster child with the intent that the foster child reside with the Subscriber on a more than temporary or short-term basis.

H. ADMINISTRATION AND RECORDS

1. The Group shall cooperate with Cigna Dental with respect to soliciting and enrolling persons eligible to enroll in the Dental Plan and in obtaining authorized payroll withholding from Subscribers to the extent that the applicable Premium/Prepayment Fees exceed the Group's contribution, if any, on Subscriber's behalf.

2. The Group shall provide to Cigna Dental enrollment information, including copies of all signed enrollment and change forms. Cigna Dental shall be permitted to inspect the Group's records which have a bearing on coverage of Covered Persons hereunder, including but not limited to records pertaining to eligibility, enrollment, payment of Premiums/Prepayment Fees and administration of benefits hereunder, and shall be permitted to make copies thereof at any reasonable time upon reasonable prior notice to the Group.

3. Cigna Dental shall keep administrative records of all Covered Persons, but shall not be liable for any obligation dependent upon information from the Group prior to the receipt of such information in a form satisfactory to Cigna Dental. Incorrect information furnished by the Group may be corrected if Cigna Dental shall not have acted in reliance upon such information to its prejudice.

4. Cigna Dental is entitled to receive from each dentist who renders service to a Covered Person hereunder all information reasonably necessary to fulfill the terms of this Contract. Covered Persons, by their enrollment in the Dental Plan, authorize each dentist who renders service to the Covered Person to disclose to Cigna Dental all facts pertaining to such service and to render to Cigna Dental reports and/or copies of records pertaining to such service for Cigna Dental administrative or quality management purposes.

I. TERMINATION OF CONTRACT

In addition to termination for nonpayment of Premium/Prepayment Fees as set out in Section D hereinabove, either the Group or Cigna Dental may terminate this Contract for any reason, including low participation, effective as of any Renewal Date by providing a minimum of sixty (60) days' prior written notice to the other party.

In the event of termination of this Contract by either Cigna Dental or the Group, the Group shall provide a notice of termination to each Covered Person. Upon the request of Cigna Dental, Group agrees to provide Cigna Dental proof of such notice and the date of such notice.

In the event of termination of this Contract, Cigna Dental shall within thirty (30) days return to the Group the pro rata portion of Premium/Prepayment Fees, if any, which correspond to any unexpired period for which payment has been received, if any, less amounts due to Cigna Dental.

Cigna Dental will pay covered claims incurred by Covered Persons prior to termination. This subsection shall not apply to termination by Cigna Dental made as a result of fraud or deception in the use of services or facilities, or knowingly permitting such fraud or deception by another.

J. NOTICE

Any notice required by this Contract shall be in writing and mailed with postage fully prepaid and addressed to the Group at the address listed on the Pre-Contract and to Cigna Dental at:

Attn: Contracts Administration

The Group shall disseminate to Covered Persons any notice from Cigna

Dental of material matters no later than thirty (30) days after receipt thereof.

K. ASSIGNMENT

Group shall not assign this Contract or its rights hereunder nor delegate its duties hereunder without the prior written consent of Cigna Dental.

L. AMENDMENTS TO CONTRACT

Except as otherwise provided herein, Cigna Dental may amend this Contract by giving the Group sixty (60) days' prior written notice of the proposed amendment. Failure of the Group to object in writing to any such proposed amendment within such notice period shall constitute the Group's acceptance of the amendment as of its effective date. Except as otherwise provided herein, changes in the Premium/Prepayment Fees or Patient Charge Schedule shall be effective as of the Renewal Date following proper notice.

In the event that federal, state, or municipal laws or regulations should change, alter or modify the present services, levels of premiums to Cigna Dental, standards of eligibility of Covered Persons, or any operations of Cigna Dental such that the terms, benefits and conditions of this Contract must be modified accordingly, Cigna Dental shall have the right to amend this Contract upon 30 days' written notice to the Group.

Except as otherwise provided herein, this Contract may be amended only in writing as approved by both the Group and Cigna Dental. Only a duly authorized officer of Cigna Dental has the authority to amend this Contract.

M. ENTIRE CONTRACT

This Contract, including the attached Plan Booklet/Evidence of Coverage/Certificate of Coverage, State Riders, Patient Charge Schedule, Pre- Contract Application, and any amendments thereto, represents the entire agreement between the parties with respect to the subject matter.

Having executed the Pre-Contract, the Group shall be deemed to have accepted the terms of this Contract unless written notice is given to Cigna Dental within twenty (20) days of receipt hereof. The invalidity or unenforceability of any Section or sub-Section of this Contract shall not affect the validity or enforceability of the remaining Sections or sub- Sections hereof.

N. GOVERNING LAW

This Contract shall be construed for all purposes as a legal document and shall be interpreted and enforced in accordance with laws of the state in which the Subscriber receives services under the Dental Plan and with pertinent federal laws and regulations. Any provision required to be in the Contract by relevant state statute or regulation shall bind Cigna Dental whether or not contained herein. In the event this Contract contains any provisions not in conformity with relevant and applicable state or federal laws, the Contract shall not be rendered invalid but shall be construed and applied as if it were in full compliance with the applicable law.

O. INCONTESTABILITY

In the absence of fraud, all statements contained in a written application made by a Subscriber are considered representations and not warranties. Coverage can be voided: (a) during the first two years for material misrepresentations contained in a written enrollment form; and,

(b) after the first two years, for fraudulent misstatement contained in a written enrollment form.

CIGNA DENTAL HEALTH PLAN OF ARIZONA, INC.

BY:

TITLE: President

DATE: July 1, 2025

08/11/05

Group Contract

City of Tucson and Cigna Dental Health of California, Inc.

Member Services 1.800.Cigna24

400 North Brand Boulevard, Suite 400

Glendale, California 91203

THIS IS A LEGAL CONTRACT BETWEEN THE ABOVE MENTIONED GROUP AND CIGNA

DENTAL HEALTH OF CALIFORNIA, INC. IT IS ISSUED IN CONSIDERATION OF THE

PRE-CONTRACT APPLICATION AND PAYMENT OF THE PREPAYMENT FEES AS THEY ARE

DUE. READ YOUR GROUP CONTRACT CAREFULLY.

85600.CA 2/20/04

Page

A. DEFINITIONS

B. THE DENTAL PLAN

C. PREPAYMENT FEES

D GRACE PERIOD/REINSTATEMENT

E. EFFECTIVE DATE/TERM & RENEWAL

F. ELIGIBILITY

G. COMPLIANCE WITH THE FEDERAL OMNIBUS BUDGET RECONCILIATION ACT OF

1993. 4

H. ADMINISTRATION AND RECORDS

I. TERMINATION OF CONTRACT

J. NOTICE

K. ASSIGNMENT

L. AMENDMENTS TO CONTRACT

M. ENTIRE CONTRACT

N. GOVERNING LAW

O. INCONTESTABILITY

A. DEFINITIONS

Capitalized terms in this contract (the "Contract"), unless otherwise defined, shall have the meanings set forth below.

Cigna Dental: Cigna Dental Health of California, Inc.

Combined Evidence of Coverage and Disclosure Form: Subscriber's dental plan booklet which summarizes the Dental Plan and Covered Services.

Covered Persons: Subscribers and their Dependents who are enrolled in the Dental Plan.

Covered Services: The dental procedures listed on the applicable Patient Charge Schedule to be provided by Cigna Dental in consideration for the payment of the Prepayment Fees.

Dental Plan: The plan of managed dental care benefits to be provided pursuant to this Contract.

Dependent: Those Covered Persons which are named as Dependents of a Subscriber, as further defined in the Combined Evidence of Coverage and Disclosure Form.

Group: Employer, labor union, association, or other organization named on the title page of this Contract.

Patient Charge Schedule: List of Covered Services and associated copayments, which is attached to the Combined Evidence of Coverage and Disclosure Form.

Pre-Contract: The Cigna Dental Pre-Contract Application which designates certain Group-specific terms and conditions of coverage.

Prepayment Fees: The premium or fees stated in the Pre-Contract which the Group must pay to Cigna Dental for Covered Persons each calendar month during the term of this Contract.

Subscriber: Employee or member of the Group who is enrolled in the

B. THE DENTAL PLAN

1. Cigna Dental shall provide Covered Services to Subscribers and Dependents in accordance with the terms of this Contract and as set out in the attached Pre-Contract, Combined Evidence of Coverage and Disclosure Form, and Patient Charge Schedule.

2. The terms and conditions of the Pre-Contract, Combined Evidence of Coverage and Disclosure Form including the applicable Patient Charge Schedule, and any amendments or revisions thereto, are incorporated into this Contract by reference and made a part hereof as if fully set forth herein.

Each Subscriber shall receive a Combined Evidence of Coverage and Disclosure Form outlining the terms and conditions, exclusions and limitations of the coverage provided hereunder. Any conflicts between the Group Contract and Combined Evidence of Coverage and Disclosure Form shall be resolved according to the terms most favorable to the Subscriber.

3. The relationship between Cigna Dental and its Network Dentists is an independent contractor relationship. All contracts between Cigna Dental and Network Dentists state that under no circumstances shall any Covered Person be liable to any Network Dentist for any sums owed to the Network Dentist by Cigna Dental, notwithstanding any delay by Cigna Dental in paying the Network Dentist any such sums. Cigna Dental shall provide reasonable notice to the Group of any termination, breach of contract, or inability to perform of any Network Dentist if Cigna Dental determines that Covered Persons may be materially and adversely affected thereby.

C. PREPAYMENT FEES

In consideration of the services to be rendered and made available by Cigna Dental pursuant to this Contract, the Group shall remit to Cigna Dental the Prepayment Fee for the initial month of coverage on or before the first day of said month accompanied by a list of persons to be covered under the Dental Plan. On or before the twelfth (12th) day of each month during the term of this Contract, Cigna Dental will send the Group an alphabetized list of Subscribers and a statement of Prepayment Fees due for that month of coverage. On or before the twenty-fifth (25th) day of each month during the term of this Contract, the Group shall remit the Prepayment Fee to Cigna Dental with an updated list indicating Covered Persons to be added to or deleted from the Dental Plan and any changes in type of coverage.

Alternative payment mechanisms developed for the Group by Cigna Dental shall supersede the terms of this Paragraph.

Prepayment Fees are guaranteed for an initial period of twelve (12) months (unless otherwise extended in the Pre-Contract). However, Prepayment Fees may be adjusted by Cigna Dental upon 30 days' notice to the Group if, in Cigna Dental's sole opinion, its liability is altered by any state or federal law. Additionally, Cigna Dental reserves any and all rights to change the Prepayment Fees or applicable Copayments during the term of the Group Contract if Cigna Dental determines Group’s information relied upon by Cigna Dental in setting the Prepayment Fees materially changes or is determined by Cigna Dental to be inaccurate.

D. GRACE PERIOD/REINSTATEMENT

1. Cigna Dental shall provide written notice of non-receipt of payment and intent to terminate the Contract on or before the twelfth (12th) day of the month following the month for which Prepayment Fees remain due and owing.

Group shall have an additional thirty-one (31) days for the payment of any Prepayment Fee except the initial Prepayment Fee. The Contract shall remain in full force and effect during this Grace Period. If the Prepayment Fees are not remitted by the end of the Grace Period, the Contract will terminate on the last day of the Grace Period. The Group will remain liable to Cigna Dental for any Prepayment Fees accrued during the Grace Period.

2. If proper payment is received by Cigna Dental on or before the expiration of the Grace Period, the Contract shall remain in full force and effect. If the Contract terminates due to non-payment of the required Prepayment Fees, the Group may request that Cigna Dental reinstate the Contract. The Group must make this request and pay all past due and current Prepayment Fees to Cigna Dental within fifteen (15) days after the expiration of the applicable Grace Period.

3. If Cigna Dental elects to reinstate this Contract, the coverage provided herein will resume as of the date of termination with no gap in coverage. If Cigna Dental elects not to reinstate the Contract, it will notify the Group of such decision in writing. In such event, any unearned Prepayment Fees submitted with the request for reinstatement will be returned to the Group.

4. Cigna Dental's reinstatement of the Contract or waiver of the right to terminate this Contract pursuant to this Section shall not constitute a waiver of any future right to terminate for nonpayment of Prepayment Fees.

E. EFFECTIVE DATE/TERM & RENEWAL

The Group's effective date of coverage under the Dental Plan (the "Effective Date") shall be the date listed on the Pre-Contract, for and in consideration of Cigna Dental's receipt of the Prepayment Fees.

The original term of this Contract shall extend from the Effective Date until the expiration of the initial Prepayment Fee Guarantee as set forth in the Pre-Contract (the "Expiration Date"). This Contract shall be automatically renewed on an annual basis effective the day following the Expiration Date (the "Renewal Date") unless otherwise terminated as provided herein. The Patient Charge Schedule shall be in effect for a minimum of one year, except as otherwise provided in Section C.

The Prepayment Fee and Patient Charge Schedule shall be reviewed and may be adjusted on an annual basis at the anniversary of the Renewal Date upon sixty (60) days' notice from Cigna Dental.

F. ELIGIBILITY

1. The Group shall determine which of its employees, associates or members are eligible to enroll in the Dental Plan. The Group shall be responsible for providing eligibility information to Cigna Dental on a timely basis as provided in Section C hereinabove. Where the Group provides eligibility information of any kind, including but not limited to electronic data, tapes or software, the data must be accurate and accessible.

2. The Group will have at least one open enrollment period every eighteen (18) months. Such open enrollment periods are required for as long as the Contract exists unless Cigna Dental and the Group mutually agree to a shorter period of time. Subscribers and Dependents may be disenrolled only during the Group's open enrollment periods unless there has been a life status change such as divorce or termination.

3. In the event a Covered Person is eligible for benefits pursuant to the requirements of the Family and Medical Leave Act of 1993 or the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Group shall be responsible for collecting the Subscriber's portion of the Prepayment Fees, if any, for which the Subscriber would have been responsible if Subscriber had not taken the leave or become qualified for COBRA coverage.

G. COMPLIANCE WITH THE FEDERAL OMNIBUS BUDGET RECONCILIATION ACT OF 1993

The parties agree, as follows, to perform the terms of this Contract in accordance with the requirements of the Federal Omnibus Budget Reconciliation Act of 1993:

1. Cigna Dental shall not take into account that a Covered Person is eligible for or is provided medical assistance under 12 U.S.C. §1396a (section 1902 of the Social Security Act) in covering or providing benefits to or on behalf of said Covered Person under the Dental Plan.

2. If a Subscriber who is eligible for family coverage under the Dental Plan is required by a court or administrative order to provide dental coverage for his or her child:

(a) Cigna Dental and the Group:

(i) Shall not deny enrollment of the child in the Dental Plan on any of the following grounds:

a) The child was born out of wedlock,

b) The child is not claimed as a dependent on the Subscriber's federal income tax return, or

c) The child does not reside with the Subscriber or in the Dental Plan's service area.

(ii) Shall allow the Subscriber to enroll the child in the Dental Plan under family coverage, without regard to any enrollment season restrictions, provided that the child is otherwise eligible for Dental Plan coverage.

(iii) Shall enroll the child in the Dental Plan under the family coverage upon application of the child's other parent or the Department of Human Resources in connection with its administration of the Medical Assistance or Child Support Enforcement Program if the Subscriber fails to enroll the child.

(iv) Except as otherwise provided herein, shall not terminate the child's Dental Plan coverage unless Cigna Dental and the Group are provided satisfactory written evidence that:

a) The court or administrative order is no longer in effect, or

b) The child is or will be enrolled in comparable dental coverage through another dental plan, which coverage will take effect no later than the effective date of termination.

(b) The Group shall withhold from Subscriber's compensation the

Subscriber's share, if any, of Premiums for Dental Plan coverage and shall pay the appropriate Prepayment Fees to Cigna Dental pursuant to the terms of this Contract.

(c) If the Subscriber is not the child's custodial parent, Cigna

Dental and the Group shall:

(i) Provide such information to the custodial parent as may be necessary for the child to obtain benefits under the

(ii) Permit the custodial parent or dentist (with custodial parent's approval) to submit claims for Covered Services without the approval of the non-custodial parent.

(iii) Make payments, pursuant to this Contract, on the claims submitted under clause (b) of this paragraph directly to the custodial parent, the dentist, or the Department of Human Resources.

(d) Cigna Dental shall not impose on any State agency that has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered under the Dental Plan requirements that are different from requirement applicable to an agent or assignee of any other individual covered under the Dental Plan.

3. If a Subscriber who is eligible for family coverage under the

Dental Plan is required by a court or administration order to provide dental coverage for his or her child who does not reside in the Dental Plan's service area, the following alternatives for coverage are available:

(a) If the Group offers its employees a choice between the Dental

Plan or indemnity dental coverage, the family shall be covered under the Dental Plan and the child shall be treated at the Subscriber's Dental Office in the Dental Plan's service area, except as provided herein for emergencies and specialty referrals; or the family shall be covered under the indemnity dental coverage.

(b) If the Group does not offer its employees any indemnity dental coverage and an affiliate of Cigna Dental has a network of dentists in the service area within which the child resides, the child shall be covered under a contract between the Group and the affiliate of Cigna Dental and the Subscriber shall be covered under a contract between the Group and Cigna Dental.

(c) If the Group does not offer its employees any indemnity dental coverage and an affiliate of Cigna Dental does not have a network in the service area within which the child resides, the family shall be covered by an indemnity dental policy which the Group shall obtain or the family shall be covered under the Dental Plan and the child shall be treated at the Subscriber's Dental Office in the Dental Plan's service area, except as provided herein for emergencies and specialty referrals.

(d) Except as otherwise restricted by federal law, the Subscriber shall be permitted to change his or her dental coverage election (between the Dental Plan and indemnity dental coverage) without regard to any enrollment reason restrictions.

4. A child who is less than 18 years of age and is placed for adoption with a Subscriber shall be entitled to benefits under the same terms and conditions that apply to the Subscriber's natural, Dependent children, irrespective of whether the adoption has become final. Cigna Dental shall not restrict Dental Plan coverage of any dependent child adopted by or placed for adoption with a Subscriber solely on the basis of any pre-existing condition of the child at the time that the child would otherwise become eligible for coverage under the Dental Plan if the adoption or placement for adoption occurs while the Subscriber is eligible for coverage under the Dental Plan. As used in this paragraph, "placement for adoption" means the assumption and retention by a Subscriber of a legal obligation for total or partial support of a child in anticipation of the adoption of the child. The child's placement with Subscriber terminates upon the termination of such legal obligations.

5. A subscriber's foster child shall be treated the same as a newborn child and shall be eligible for coverage on the same basis, under the terms of this Contract, upon placement in Subscriber's home.

As used in this paragraph, "Foster child" means a minor over whom a Subscriber has been appointed (1) guardian by a court of competent jurisdiction in the state or (2) the primary or sole custodian by order of a court of competent jurisdiction. As used in this paragraph, "placement in the Subscriber's home" means physically residing with a Subscriber who has been appointed guardian or custodian as long as that Subscriber has assumed the legal obligation for total or partial support of the foster child with the intent that the foster child reside with the Subscriber on a more than temporary or short-term basis.

H. ADMINISTRATION AND RECORDS

1. The Group shall cooperate with Cigna Dental with respect to soliciting and enrolling persons eligible to enroll in the Dental Plan and in obtaining authorized payroll withholding from Subscribers to the extent that the applicable Prepayment Fees exceed the Group's contribution, if any, on Subscriber's behalf.

2. The Group shall provide to Cigna Dental enrollment information, including copies of all signed enrollment and change forms. Cigna Dental shall be permitted to inspect the Group's records which have a bearing on coverage of Covered Persons hereunder, including but not limited to records pertaining to eligibility, enrollment, payment of Prepayment Fees and administration of benefits hereunder, and shall be permitted to make copies thereof at any reasonable time upon reasonable prior notice to the Group.

3. Cigna Dental shall keep administrative records of all Covered Persons, but shall not be liable for any obligation dependent upon information from the Group prior to the receipt of such information in a form satisfactory to Cigna Dental. Incorrect information furnished by the Group may be corrected if Cigna Dental shall not have acted in reliance upon such information to its prejudice.

4. Cigna Dental is entitled to receive from each dentist who renders service to a Covered Person hereunder all information reasonably necessary to fulfill the terms of this Contract. Covered Persons, by their enrollment in the Dental Plan, authorize each dentist who renders service to the Covered

Person to disclose to Cigna Dental all facts pertaining to such service and to render to Cigna Dental reports and/or copies of records pertaining to such service for Cigna Dental administrative or quality management purposes.

I. TERMINATION OF CONTRACT

The Group may terminate this Contract for any reason, effective as of any Renewal Date by providing a minimum of sixty (60) days’ prior written notice to the other party. In addition to termination for nonpayment of Premium/Prepayment Fees as set out in Section D hereinabove, Cigna Dental may terminate this Contract for the following reasons:

1. For fraud or other intentional misrepresentation of material fact by the Group;

2. Low participation (i.e. less than ten enrollees);

3. If Cigna Dental ceases to provide or arrange for the provision of dental services for new dental plans in the state; provided, however, that notice of the decision to cease new or existing dental plans shall be provided as required by law at least 180 days prior to discontinuation of coverage; or

4. If Cigna Dental withdraws a group dental plan from the market;

provided, however, that notice of withdrawal shall be provided as required by law at least 90 days prior to the discontinuation and that any other dental plan offered is made available to the Group.

In the event of termination of this Contract by either Cigna Dental or the Group, the Group shall provide a notice of termination to each Covered Person at least fifteen (15) days in advance of the effective date of termination. Upon the request of Cigna Dental, Group agrees to provide Cigna Dental proof of such notice and the date of such notice.

In the event of termination of this Contract, Cigna Dental shall within thirty (30) days return to the Group the pro rata portion of Premium/Prepayment Fees, if any, which correspond to any unexpired period for which payment has been received, if any, less amounts due to Cigna Dental.

Cigna Dental will pay covered claims incurred by Covered Persons prior to termination. This subsection shall not apply to termination by Cigna Dental made as a result of fraud or deception in the use of services or facilities, or knowingly permitting such fraud or deception by another.

The Group, a Subscriber or a Dependent may request the Director of the California Department of Managed Health Care to review the termination of an enrollment under this Contract in accordance with California Health and Safety Code Section 1365(b).

J. NOTICE

Any notice required by this Contract shall be in writing and mailed with postage fully prepaid and addressed to the Group at the address listed on the Pre-Contract and to Cigna Dental at:

Attn: Contracts Administration

The Group shall disseminate to Covered Persons any notice from Cigna Dental of material matters no later than thirty (30) days after receipt thereof.

K. ASSIGNMENT

Group shall not assign this Contract or its rights hereunder nor delegate its duties hereunder without the prior written consent of Cigna Dental.

L. AMENDMENTS TO CONTRACT

Except as otherwise provided herein, Cigna Dental may amend this Contract by giving the Group sixty (60) days' prior written notice of the proposed amendment. Failure of the Group to object in writing to any such proposed amendment within such notice period shall constitute the Group's acceptance of the amendment as of its effective date. Except as otherwise provided herein, changes in the Prepayment Fees or Patient Charge Schedule shall be effective as of the Renewal Date following proper notice.

In the event that federal, state, or municipal laws or regulations should change, alter or modify the present services, levels of premiums to Cigna Dental, standards of eligibility of Covered Persons, or any operations of Cigna Dental such that the terms, benefits and conditions of this Contract must be modified accordingly, Cigna Dental shall have the right to amend this Contract upon 30 days' written notice to the Group.

Except as otherwise provided herein, this Contract may be amended only in writing as approved by both the Group and Cigna Dental. Only a duly authorized officer of Cigna Dental has the authority to amend this Contract.

M. ENTIRE CONTRACT

This Contract, including the Combined Evidence of Coverage and Disclosure Form, Patient Charge Schedule, Pre-Contract Application, and any amendments thereto, represents the entire agreement between the parties with respect to the subject matter. Having executed the Pre-Contract, the Group shall be deemed to have accepted the terms of this Contract unless written notice is given to Cigna Dental within twenty (20) days of receipt hereof.

The invalidity or unenforceability of any Section or sub-Section of this Contract shall not affect the validity or enforceability of the remaining Sections or sub-Sections hereof.

N. GOVERNING LAW

This Contract shall be construed for all purposes as a legal document and shall be interpreted and enforced in accordance with laws of the state in which the Subscriber receives services under the Dental Plan and with pertinent federal laws and regulations. Any provision required to be in the Contract by relevant state statute or regulation shall bind Cigna Dental whether or not contained herein. In the event this Contract contains any provisions not in conformity with relevant and applicable state or federal laws, the Contract shall not be rendered invalid but shall be construed and applied as if it were in full compliance with the applicable law.

O. INCONTESTABILITY

In the absence of fraud, all statements contained in a written application made by a Subscriber are considered representations and not warranties. Coverage can be voided: (a) during the first two years for material misrepresentations contained in a written enrollment form; and, (b) after the first two years, for fraudulent misstatement contained in a written enrollment form.

CIGNA DENTAL HEALTH OF CALIFORNIA, INC.

BY:

TITLE: President

DATE: July 1, 2025

02/20/04

EXHIBITS

W1SV9

CIGNA DENTAL CARE® PLAN

PATIENT CHARGE SCHEDULE

This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Important Highlights

› This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested that you check with your Network Dentist in advance of receiving services.

› The dollar amounts listed on the Patient Charge Schedule are only applicable to treatment performed by your selected Network General Dentist. If you receive care from a Network Specialty Dentist, you are responsible to pay for that care. You are entitled to pay at the Contract Fees negotiated rather than the Network Specialty Dentists’ usual fees.

Under this plan, referrals and preauthorization for payment are not necessary for care received at a Network Specialty Dentist. The plan will not make payments toward this treatment.

› Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees.

› Infection control and/or sterilization are considered to be incidental to and part of the charges for services provided and not separately chargeable.

› This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.

› Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.

92251.b 856679c 11/21 W1SV9

› All patient charges correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.

› Current Dental Terminology ("CDT") codes are established by the American Dental Association (ADA) Council on Dental Benefit Programs in accordance with authority granted by the federal government under the Health Insurance and Portability and Accountability Act of 1996 (HIPAA) as the national terminology for reporting dental services, and are recognized as the industry standard. The ADA publishes CDT as part of a reference manual and may periodically change CDT Codes or definitions.

Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the members’ benefit.

92251.b - 2 -

CIGNA DENTAL CARE PLAN

PATIENT CHARGE SCHEDULE (W1SV9)

Import…