5-EXHIBIT A - Current Plan Certificate.pdf

50534-0718 PPO Plus

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

P.O. BOX 40028

JACKSONVILLE, FLORIDA 32203

Florida Combined Life Insurance Company, Inc. (herein referred to as "FCL") has issued a group insurance contract to your employer, the contractholder. The contract is between the contractholder and FCL, and through which you are provided dental insurance coverage.

This is your certificate of coverage, as long as you are a certificateholder. While this insurance is in effect, FCL agrees to provide dental benefits as set forth in this certificate, subject to its terms, conditions, limitations, and exclusions.

This certificate is issued in consideration of the employee’s application for dental insurance coverage and the payment by the contractholder of the applicable premium rates. All periods of time under this certificate will begin and end at 12:01 a.m. at the contractholder’s address.

Any provision of this certificate which, on its effective date or anytime thereafter, is in conflict with the laws of the State of Florida, or Federal law, is hereby amended to conform to the minimum requirements of such laws.

Signed for the Florida Combined Life Insurance Company, Inc. at Jacksonville, Florida, on the certificateholder’s effective date.

Secretary President

GROUP DENTAL

BENEFITS CERTIFICATE

WARNING: LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE

USED. You should be aware that when you elect to utilize the services of a nonparticipating provider for a covered nonemergency service, benefit payments to the provider are not based upon the amount the provider charges. The basis of the payment will be determined according to your policy’s out-of-network reimbursement benefit. Nonparticipating providers may bill insureds for any difference in the amount. YOU MAY BE REQUIRED TO PAY MORE THAN THE COINSURANCE OR COPAYMENT AMOUNT. Participating providers have agreed to accept discounted payments for services with no additional billing to you other than coinsurance, copayment, and deductible amounts. You may obtain further information about the providers who have contracted with your insurance plan by consulting your insurer’s website or contacting your insurer or agent directly.

This Certificate Contains A Deductible Provision

FOR CUSTOMER SERVICE ASSISTANCE: 1-888-223-4892*

*This telephone number is available to Certificateholders to present inquiries or obtain information about coverage and to provide assistance in resolving complaints.

Florida Combined Life Insurance Company, Inc. and Blue Cross and Blue Shield of Florida, Inc., are Independent Licensees of the Blue Cross and Blue Shield Association.

50534-0718 Page 2 PPO Plus

If you, or someone you’re helping, has questions about BlueDental Choice Plus PPO Policy, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-888-223-4892.

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de BlueDental Choice Plus PPO Policy, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-888-223-4892.

Si oumenm oswa yon moun w ap ede gen kesyon konsènan BlueDental Choice Plus PPO Policy, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-888-223-4892.

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Se você, ou alguém a quem você está ajudando, tem perguntas sobre o BlueDental Choice Plus PPO Policy, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-888-223-4892.

如果您，或是您正在協助的對象，有關於 插入項目的名稱 BlueDental Choice Plus PPO Policy 方面的問題，您

有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 在此插入數字 1-888-223-4892。

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de BlueDental Choice Plus PPO Policy, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-888-223-4892.

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa BlueDental Choice Plus PPO Policy, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-888-223-4892.

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу BlueDental Choice Plus PPO Policy, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-888-223-4892.

نإ ناك ك يدل وأ ىد ل صخش ه دعاست ةلئسأ صوصخب ,BlueDental Choice Plus PPO Policy ، كي د لف قحلا ي ف لوصح ل ا ى لع ةدعاسملا ت ا م ولعملاو تاص ل ـب 1-888-223-4892. تم رمج للتدحث عم . فلكتة یاة ضلا ررو ي ة كتغلب نم نود

Se tu o qualcuno che stai aiutando avete domande su BlueDental Choice Plus PPO Policy, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-888-223-4892.

Falls Sie oder jemand, dem Sie helfen, Fragen zum BlueDental Choice Plus PPO Policy haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-888-223-4892 an.

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 BlueDental Choice Plus PPO Policy 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1- 888-223-4892 로 전화하십시오.

Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie BlueDental Choice Plus PPO Policy, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-888-223-4892.

જો તમે કે તમે મદદ કરી ર�ાં હો તેમને BlueDental Choice Plus PPO Policy િવશ ેપ્ર�ો હોય, તો તમને મદદ અને તમારી

ભાષામાં માિહતી કોઇ ખચ� વગર મેળવવાનો અિધકાર છે. દુભાિષયા માટે આ નંબર પર ફોન કરો, 1-888-223-4892.

หากคุณ หรือคนท่ีคุณกาลงัช่วยเหลือมีคาถามเก่ียวกบั BlueDental Choice Plus PPO Policy คุณมีสิทธิท่ีจะไดรั้บความช่วยเหลือและขอ้มูลในภาษาของคุณไดโ้ดยไม่มีค่าใชจ้่าย พูดคุยกบัล่าม โทร 1-888-223-4892

50534-0718 Page 3 PPO Plus

1557 NON-DISCRIMINATION NOTICE

Florida Combined Life Insurance Company, Inc. (FCL) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity or sexual orientation. FCL does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity or sexual orientation.

FCL:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact 1-888-223-4892

If you believe that FCL has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity or sexual orientation, you can file a grievance with:

Civil Rights Coordinator 17500 Chenal Parkway Little Rock, AR 72223 1-800-260-0331 Email civilrightscoordinator@fclife.com.

You can file a grievance in person or by mail, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201

1–800–368–1019, 800–537–7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

50534-0718 Page 4 PPO Plus

TABLE OF CONTENTS

PAGE

SECTION I DEFINITIONS

SECTION II GENERAL PROVISIONS

General Contract Provisions Representations on Group Applications Identification Cards Extension of Benefits Upon Contract Termination Non-Duplication of Coverage Under Government Programs or Extension of Benefits Change in Provider Networks Claims Processing Notice of Claim Claim Forms Proof of Loss Payment, Contest or Denial of Claims Payment of Claims Contested Claims Denied Claims Appeal of an Adverse Determination Additional Claims Processing Provisions Release of Information/Cooperation Physical Examination Legal Actions Fraud, Misrepresentation or Omission in Applying for Benefits Explanation of Benefits Form

SECTION III ELIGIBILITY

Certificateholder Eligibility Class Dependent Eligibility Class Extension of Eligibility for Certain Dependent Children

SECTION IV ENROLLMENT AND EFFECTIVE DATE OF COVERAGE

Initial Enrollment/Electing Coverage Effective Date of an Individual’s Coverage Following Enrollment Changes in Coverage/Effective Date Marital Status Newborn Children Adopted/Foster Children Deleting Dependents From Coverage Other Provisions Regarding Enrollment and Effective Date of Coverage Rehired Employees Premium Payments Prior Coverage Under an Extension of Benefits Replacement Provision Prior Coverage Waiting Period Credit Prior Coverage Deductible Credit

SECTION V THE DATE ON WHICH INSURANCE TERMINATES

Termination of Certificateholder Coverage Termination of Dependent Coverage

SECTION VI YOUR OBLIGATIONS

Individual Deductible Limit Family Deductible Limit Coinsurance Predetermination of Benefits

SECTION VII PROVIDER ALTERNATIVES

Participating Dentist Non-Participating Dentist Selection of a Dentist

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SECTION VIII BENEFITS

Preventive Basic Major

Enhanced Dental Benefits

SECTION IX LIMITATIONS AND EXCLUSIONS

Limitations Exclusions

SECTION X COORDINATION OF BENEFITS

SECTION XI SUBROGATION

SECTION XII COBRA CONTINUATION OF COVERAGE

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SECTION I

DEFINITIONS

Adverse Benefit Determination - means any denial, reduction or termination of coverage, benefits, or payment (in whole or in part) under the certificate with respect to a claim.

Allowance Or Allowable Expense - means the maximum amount on which FCL will base payment for dental benefits covered under the contract or the maximum amount established by a third party contracted by FCL to provide dental benefits through their network. The allowance for participating dentists is determined and established solely by FCL or the contracted third party and is subject to change at any time without notice to or consent of the contractholder or any insured. The allowance for non-participating dentists is based on usual and customary charges.

Annual Open Enrollment Period - means a specified period of time during which individuals can apply for coverage. This period occurs prior to the effective date of the contract; and thereafter, annually for a specified period of time, established by us, which occurs prior to the contract anniversary date.

The annual open enrollment period is shown on the contractholder’s application for insurance.

Certificateholder - means the employee, or other individual, who meets and continues to meet the applicable eligibility requirements and is covered under this certificate, other than as a dependent.

Coinsurance - means the sharing of expenses for covered dental benefits between FCL and the insured. After the insured’s deductible is met, FCL will pay a percentage of the allowance, as shown on the Schedule of Benefits. The insured is responsible for the remaining percentage of the allowance, if any, and for all non-covered services.

For services received from a non-participating dentist, the insured is also responsible for the difference between the FCL allowance and the actual dentist charges, if any.

Contract - means this certificate, the contract issued to the contractholder, the application for coverage signed by the contractholder, the applications completed by the contractholder's employees, the identification card issued to the insured and any attached endorsements, amendments or riders.

Contract Anniversary Date - means the same day and month as the contract effective date for each year the contract stays in force.

Contractholder - means your employer who has contracted with FCL to provide dental benefits to its employees. The contractholder will also act on behalf of any subsidiary, division or affiliate specified in the contractholder’s application for insurance. Every action taken by the contractholder will be binding on them.

Deductible - means the amount of charges, up to the allowable expenses, an insured must pay each Plan Year before our reimbursement for dental benefits begins. To calculate the amount to be applied towards satisfying the deductible, only allowable expenses are applied. For Example:

if your deductible amount = $50.00 and the charges = $30.00 and the allowable expense = $25.00 then the amount applied towards your deductible = $25.00

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Dental Benefits - means those medically necessary covered services and supplies as set forth in this certificate and any rider or endorsement attached to it.

Dental Services Waiting Period - if shown in the Schedule of Benefits, means the period of time an insured must wait before benefits are payable for specific dental services.

Dentist - means a duly licensed doctor of Dental Surgery (D.D.S.), or doctor of dental medicine (D.M.D.), doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is legally qualified to practice medicine or dentistry and perform surgery at the time and place the service is rendered, and acting within the scope of his or her license.

Dependent - means your legal spouse and/or natural, newborn, adopted, foster, or step child(ren), or a child for whom you have been court-appointed as legal guardian or legal custodian. A child may be considered a dependent until the end of the calendar year in which the child reaches the age specified in the Schedule of Benefits. The definition of Dependent and all references to dependent and legal spouse include a domestic partner who has met all the eligibility requirements of a domestic partnership, unless domestic partners are excluded in the Schedule of Benefits. The definition of dependent also includes the dependents of a domestic partner unless excluded in the Schedule of Benefits.

A dependent cannot be: (1) insured as a dependent and an employee; (2) insured under more than one insured employee; or (3) in full-time military service.

The age limit that applies to dependent children will not apply to any insured child who: (1) remains dependent on you for support and maintenance; and (2) is incapable of self-sustaining employment due to physical handicap or mental retardation.

The symptoms or causes of physical handicap or mental retardation must have existed prior to the limiting age and while the child was covered under this contract.

If a claim is denied because the child has reached the limiting age, it is your responsibility to provide proof that the child meets the contract’s requirements for extended eligibility. We may, at any time, require proof satisfactory to us that a child continues to meet such requirements. This extended eligibility provision does not modify any eligibility requirement other than the limiting age requirement.

Employee - means a person who is directly employed by the contractholder on a permanent basis and normally works at least the number of hours each week as specified on the contractholder’s application.

Experimental or Investigational - means services or supplies that are determined by FCL to be experimental or investigational. A drug, a device, a procedure or treatment will be determined to be experimental or investigational if:

a. there are insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or

b. approval is required by the FDA and has not been granted for marketing; or

c. a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or

d. the written protocol or protocols used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental, investigational or for research purposes.

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Insured - means the certificateholder or any eligible dependent covered under this certificate.

Eligibility requirements for certificateholders and eligible dependents are specified in the Eligibility For Coverage and Enrollment and Effective Date of Coverage sections of this certificate.

Medicare - means any coverage under Title XVIII of the Federal Social Security Act. If this Act is amended, this term will mean any coverage provided under the amended Act.

Medically Necessary - means any services, care, or supplies received while covered, which are determined by FCL, to be: 1) consistent with the symptom, diagnosis, and treatment of the insured's condition; 2) in accordance with standards of good dental or medical practice; 3) approved by the appropriate dental or medical body or board for the condition in question; 4) not primarily for the comfort or convenience of the insured, or dentist; 5) the most appropriate, efficient, and economical dental or medical supply, service, or level of care which can be safely provided; and

6) not cosmetic in nature. FCL will make final determination as to which services are medically necessary based upon review by our consulting dentists.

NOTE: The fact that a dentist may prescribe, order, recommend, furnish or approve a service or supply does not, of itself, make it medically necessary or a covered service; nor does it make the charge an allowable expense under this certificate, even though it is not specifically listed as an exclusion.

Non-Participating Dentist - means a dentist who HAS NOT signed an agreement with FCL or an agreement with a third party contracted by FCL to provide dental benefits through their network, to accept the allowance as payment in full for his or her services.

Participating Dentist - means a dentist who HAS signed an agreement with FCL or an agreement of a third party contracted by FCL to provide covered dental benefits through their network. If an insured receives covered services or supplies from a participating dentist, payment of dental benefits will be made directly to the participating dentist. These dentists will file claims on the insured’s behalf.

Plan Year - with respect to the dental benefits of this contract, means the 12-month period specified on the contractholder’s application and on the Schedule of Benefits.

Plan Year Maximum – means the total amount FCL will pay in a Plan Year for Covered Services.

This total amount is listed in the Schedule of Benefits. 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.

Predetermination - means the pretreatment review by FCL of a treatment plan to determine the eligibility of the insured and the amount payable under the contract.

Treatment Plan - means the dentist’s written report of a series of procedures and estimated charges recommended for the treatment of dental disease, defect or injury, which is prepared for an insured as a result of an examination made by such dentist.

Usual and Customary Charges - means an amount measured by comparing it with charges normally made for similar services and supplies to individuals of similar conditions in the locality where the service is performed. Payment under this contract for covered services provided by a non-participating dentist is based on usual and customary charges.

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Waiting Period - means the length of time an individual must be employed by the contractholder before he or she is eligible for coverage under the contract. This period, if any, is specified on the contractholder’s application.

We, Us, And Our - means Florida Combined Life Insurance Company, Inc. (FCL).

You And Your - means the certificateholder who is in a class eligible for employee insurance.

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SECTION II

GENERAL PROVISIONS

General Contract Provisions

Representations on Group Applications

FCL relies on the information provided by an individual on the application to determine whether he or she is eligible for and entitled to coverage under the contract. All statements made on the application are representations and not warranties, except in the case of fraud.

No statement made by the insured shall be used to deny or reduce benefits unless contained in the application or other written statement signed by the insured, and a copy has been given to the insured.

Identification Cards

The identification card issued to you in no way creates, or serves to verify, eligibility or coverage under the contract. Identification cards are the property of FCL and must be destroyed or returned to FCL immediately following termination of coverage.

Extension of Benefits Upon Contract Termination

If an insured is receiving covered dental treatment as of the termination date of the contract, FCL will provide a limited extension of the dental care benefits provided by the contract, if:

a. a course of treatment or dental procedures were recommended in writing and commenced while the insured was covered under the contract; and

b. the dental procedures were for other than routine examinations, prophylaxis, x-rays, sealants, or orthodontic services; and

c. the dental procedures were performed within ninety (90) days after the insured’s coverage terminated under the contract, and the termination did not occur as a result of your voluntary termination of coverage.

This extension of benefits is for covered services necessary to complete the dental treatment only.

This extension of benefits will automatically terminate on the earlier of: (a) the date, ninety (90) days after the contract terminates; or (b) the date the insured becomes covered under a succeeding insurance, health maintenance organization or self-insured plan providing coverage or services for similar dental procedures.

Non-Duplication Of Coverage Under Government Programs or Extension of Benefits

The dental benefits under this certificate shall not duplicate any dental benefits to which the insured is entitled to or eligible for under government programs (e.g., Medicare, Medicaid, Champus, Veterans Administration) to the extent allowed by law, or under any extension of dental benefits of coverage under a prior plan or program which may be provided or required by law.

Change In Provider Networks

FCL's provider networks included the provider network of a third party contracted by FCL to provide dental benefits through their network are subject to change at any time without the consent of or notice to the contractholder or any insured. It is the insured's responsibility to determine whether a dental care provider is participating in FCL's provider network(s) at the time the service or supply is rendered.

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Claims Processing

Participating dentists have agreed to file claims for services and supplies with FCL on the insured's behalf.

If the insured obtains dental benefits from a dental care provider who does not file the claim on the insured's behalf, it is the insured's responsibility to file the claim with FCL.

Notice of Claim

Written notice of claim must be given to us:

1. within twenty (20) days after the date a loss covered by the group contract occurs; or

2. as soon thereafter as reasonably possible.

The notice may be given to us at our home office or to one of our authorized representatives. Notice should include the insured’s name and group contract number.

Claim Forms

We will furnish claim forms for filing proof of loss within fifteen (15) days after we receive notice of the claim. If we do not do so, the insured can meet the proof of loss requirement by giving us this proof:

1. within the time limit for filing “Proof of Loss” stated below; and

2. covering the occurrence, nature, and extent of the loss.

Proof of Loss

Proof of loss: If the policy provides for periodic payment for a continuing loss, written proof of loss must be given to the insurer within ninety (90) days after the end of each period for which the insurer is liable. For any other loss, written proof must be given within ninety (90) days after such loss. If it was not reasonably possible to give written proof in the time required, the insurer shall not reduce or deny the claim for this reason if the proof is filed as soon as reasonably possible. In any event, the proof required must be given no later than 1 year from the time specified unless the claimant was legally incapacitated.

To file a claim, the insured must obtain an itemized statement from the dental care provider and attach it to a completed ADA claim form. The insured may obtain an ADA claim form by contacting us at our home office. The itemized statement must contain the following information: (a) the date the dental benefit was provided; (b) a description of the dental benefit; (c) the amount actually charged by the provider; (d) the provider's name and address; (e) the patient's name; and (f) the certificateholder's name.

Payment, Contest or Denial of Claims

We will pay, contest or deny a claim, or any part of a claim, within the timeframes described below.

Payment of Claims

Benefits not assigned will be paid to the insured. Loss-of-life benefits are payable in accordance with the beneficiary designation in effect at the time of payment. If none is then in effect, the benefits will be paid to the insured’s estate. Any other benefits unpaid at death may be paid, at the insurer’s option, either to the insured’s beneficiary or estate.

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We will use our best efforts to pay a claim or any part of a claim that establishes proof of loss and contains, as determined by us, all the information we need to pay the claim, as follows:

1. for an electronically filed claim, within twenty (20) days of our receipt; and

2. for a claim filed on a paper claim form, within forty (40) days of our receipt.

We may provide the claimant notice of payment within thirty (30) days of receipt.

If we are unable to determine if a claim or any part of a claim is payable because additional information is needed, we may contest the claim as set forth below.

Contested Claims

If a claim is contested or additional information is needed, we will use our best efforts to provide notice that the claim or any part of the claim is contested, within the following timeframes:

2. for a claim filed on a paper claim form, within thirty (30) days of our receipt.

This notice will identify:

1. the contested portion or portions of the claim;

2. the reason(s) for the contest;

3. the date we reasonably expect to notify the claimant of the decision; and

4. the additional information needed.

If we request additional information, we must receive it within forty-five (45) days of the request.

Upon receipt of the requested information, we will use our best efforts to complete the processing of the claim within fifteen (15) days of receipt. If we do not receive the requested information, the claim will be processed based on the information we possess at the time, and it may be denied.

Denied Claims

If a claim is denied, we will use our best efforts to provide notice that the claim or any part of the claim is denied, within the following timeframes:

2. for a claim filed on a paper claim form, within thirty (30) days of our receipt.

This notice will identify:

1. the denied portion or portions of the claim; and

2. reason(s) for the denial.

It is the claimant’s responsibility to provide all information determined by us as necessary to process a claim. If we do not receive the necessary information, the claim or any part of the claim may be denied.

Any claim that is denied is an adverse benefit determination. A claimant has the right to appeal an adverse benefit determination for a claim as specified in “Appeal of an Adverse Benefit Determination.”

Time of Payment of Claims: After receiving written proof of loss, FCL will pay monthly all benefits then due for covered dental benefits. Benefits for any other loss covered by this policy will be paid as soon as the insurer received proper written proof.

FCL will use its best efforts to pay or deny all claims within the following timeframes:

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1. for an electronically filed claim, within ninety (90) days of our receipt;

2. for a claim filed on a paper claim form, within one hundred twenty (120) days after our receipt.

Processing of the claim will be considered complete on the date notice of the claim decision is deposited in the mail by FCL or otherwise electronically transmitted.

Any claims payment not made within the applicable timeframe shall bear simple interest at the rate specified by law.

FCL will investigate any allegation of improper billing by a provider, upon written notice from an insured. If we determine that the insured was billed for a service that was not actually performed, any payment amount will be adjusted, and if applicable, a refund will be requested.

In such a case, if payment to the provider is reduced due solely to the notice from the insured, FCL will pay the insured twenty (20) percent of the amount of the reduction, up to $500.

Appeal of an Adverse Determination

The insured, or a representative designated by the insured in writing, has the right to appeal an adverse benefit determination. The insured’s written appeal must be filed with FCL within 180 days of the original adverse benefit determination.

We will review the insured’s appeal under the following guidelines:

1. we must receive the appeal orally or in writing;

2. the insured may request to review pertinent documents, such as any internal rule, guideline, protocol, or similar criterion relied upon to make the determination, and submit issues or comments in writing;

3. if the adverse benefit determination is based on the lack of medical necessity of a specific service or experimental, investigational or other similar limitations or exclusions, the insured may request at no charge, an explanation of the scientific or clinical judgment relied upon, if any, for the determination, that applies the terms of the certificate to the insured’s circumstances;

4. during the review process, the services in question will be reviewed without regard to the decision reached in the initial determination;

5. we may consult with appropriate dentists, as necessary; and

6. any independent medical or dental consultant who reviews an insured’s adverse benefit determination on FCL’s behalf will be identified upon request.

We will use our best efforts to review an insured’s appeal of an adverse benefit determination and notify the insured of our review decision within sixty (60) days of our receipt.

An insured, or a provider acting on behalf of the insured, who has had a claim denied as not medically necessary, has the right to appeal the claim denial. The appeal may be directed to an independently contracted licensed dentist by FCL who is responsible for medical necessity reviews.

The appeal may be by telephone and the dentist will respond to the insured within a reasonable time, not to exceed fifteen (15) business days.

A federal law, known as the Employee Retirement Income Security Act of 1974 (ERISA), as amended, may apply to a certificateholder’s group plan. If ERISA applies to the certificateholder’s plan, the certificateholder or his or her covered dependents are entitled, after exhaustion of the appeal procedures provided for under the plan, to pursue civil action under Section 502(a) of ERISA in connection with an adverse benefit determination or any other legal or equitable remedy otherwise available.

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Additional Claims Processing Provisions

Release of Information/Cooperation

In order to process claims under the contract, we may need information, including medical information, from the dental care provider who rendered the service or supply. Insureds shall cooperate with FCL in its effort to obtain such information by, among other ways, signing any release of information form as requested by us. An insured’s failure to fully cooperate with us will result in a denial of the pending claim and we will not be liable for such claim.

Physical Examination

We, at our expense, have the right to have the insured examined by a dental care provider of our choice as often as is reasonably necessary while a claim is pending. Failure by an insured to fully cooperate with such examination shall result in a denial of the pending claim and we will not be liable for such claim.

Legal Actions

No claimant may sue for payment of a claim:

1. within sixty (60) days after the date proof of loss is sent as required; or

2. if, from the time proof of loss is required to be given, the applicable statute of limitations has expired.

Fraud, Misrepresentation or Omission in Applying for Benefits

FCL relies on the information provided on the itemized statement and the claim form when processing a claim. All information must be accurate, truthful and complete. Any fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect information may result in denial of the claim.

Explanation of Benefits Form

All claims decisions, including denial and claims review decisions, will be given to the insured in writing in an explanation of benefits form. This form may indicate:

a. the reason(s) the claim was denied;

b. a reference to the certificate provision upon which the denial is based;

c. a description of additional material or information necessary to make the claim payable and why such material or information is necessary; and

d. an explanation of the steps to be taken if an insured wants a claim denial decision reviewed.

IF YOU HAVE ANY QUESTIONS ON YOUR SUBMISSION OF

CLAIMS OR BENEFITS

CALL 1-888-223-4892

OR

WRITE TO

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

P.O. BOX 69436

Harrisburg, PA 17106-9436

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SECTION III

ELIGIBILITY

Only the following individuals are eligible to apply for coverage under the contract. FCL may require acceptable proof that an individual meets and continues to meet the eligibility requirements.

Certificateholder Eligibility Class

If you are an employee of the contractholder and you meet each of the following requirements, you are eligible to apply for coverage under the contract:

1. you must be in an eligible class as shown on the contractholder’s application;

2. you must work at least the number of hours each week which is specified on the contractholder’s application; and

3. you must have completed any applicable waiting period set forth on the contractholder’s application.

Dependent Eligibility Class

The following individuals are eligible to apply for dependent coverage under this certificate:

1. your legal spouse; and

2. a child under the limiting age who is your natural, newborn, adopted, foster, or step child(ren), or a child for whom you have been court appointed as legal guardian or legal custodian.

Extension of Eligibility For Certain Dependent Children

The limiting age for dependent children may be extended for a handicapped child as specified in the definition of “Dependent.”

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SECTION IV

ENROLLMENT AND EFFECTIVE DATE OF COVERAGE

Initial Enrollment/Electing Coverage

Employees who are eligible to apply for coverage under the contract may do so by completing an application and forwarding it to the contractholder.

Effective Date Of An Individual’s Coverage Following Enrollment

Coverage for an individual who meets the eligibility requirements prior to the effective date of the contract will begin on such effective date provided we receive the application during the first annual open enrollment period. The first annual open enrollment period must occur prior to the contract effective date.

Coverage for an individual who first meets the eligibility requirements after the effective date of the contract (e.g., newly hired employees and their dependents), will begin on the date specified on the application, provided we receive the application within the thirty-one (31)-day period after the individual first meets the eligibility requirements.

Any individual who does not apply within the thirty-one (31)-day period after he or she first meets the eligibility requirements, must wait until the next annual open enrollment period to apply. We must receive the application during the annual open enrollment period. Insurance will take effect on the next contract anniversary date.

Changes In Coverage/Effective Date

Marital Status If you wish to add dependents to your coverage, due to a change in marital status, such change will take effect on the first billing date after we approve the change request. We must receive requests to add dependents to your coverage within thirty (30) days after the date of the marriage.

Newborn Children

Coverage for a newborn child will take effect from the moment of birth. If we receive a change request within sixty (60) days after the date of birth, premium will not be charged for the first thirty (30) days of coverage. If we do not receive a change request within sixty (60) days after the date of birth, we may charge an additional premium from the date of birth.

Coverage for a newborn child born to a covered dependent, other than your dependent spouse, will automatically terminate eighteen (18) months after the birth of the newborn child.

Newborn coverage also includes coverage for the transportation of a newborn child to and from the nearest available facility appropriately staffed and equipped to treat his or her condition. The attending physician must certify that the transportation is necessary to protect the health and safety of the child. Not more than $1,000 will be paid for this transportation.

Adopted/Foster Children Coverage for an adopted or foster child, other than an adopted newborn child, who has been placed in accordance with Florida law, will begin on the date the child is placed in your home, provided we receive a change request within sixty (60) days after the date the child was placed.

FCL will require proof of adoption or foster care. If a change request is received by FCL within this sixty (60)-day period, premium will not be charged for the first thirty (30) days of coverage.

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Coverage for an adopted newborn child will begin the earlier of:

a. the moment of birth, provided that you have entered into a written agreement to adopt such child prior to the birth of the child; or

b. the date the adopted newborn child is placed in your home in accordance with Florida law, with no premium charged for the first thirty (30) days of coverage, if we receive a change request within sixty (60) days of the date of birth or placement of the adopted newborn child.

If we do not receive a change request within sixty (60) days of the date of placement of an adopted or foster child or birth of a newborn, we may charge an additional premium from the date of placement or birth.

If the adopted newborn child is not ultimately placed in your home, there will be no coverage for such newborn child under this certificate. It is your responsibility to notify FCL within ten (10) calendar days if the adopted newborn child is not placed in your home.

If a final decree of adoption is not issued, coverage will not be continued for the proposed adopted child under this certificate. Proof of final adoption must be submitted to FCL. It is your responsibility to notify FCL if the adoption does not take place. We will terminate the coverage of the child on the first billing date following our receipt of your written notice.

If your status as a foster parent of a covered child is terminated, coverage will not be continued for that foster child under this certificate. It is your responsibility to notify FCL that the foster child is no longer in your care. We will terminate the coverage of the child on the first billing date following our receipt of your written notice.

Deleting Dependents From Coverage

If you wish to delete an eligible dependent from coverage, a change request should be submitted to us. Coverage for such dependent will terminate on the first billing date following our receipt of the change request.

Other Provisions Regarding Enrollment and Effective Date of Coverage

Rehired Employees

If you are rehired as an employee of the contractholder, you are considered a newly hired employee under this contract. The provisions of this certificate which apply to newly hired employees and their eligible dependents apply to you and your eligible dependents.

Premium Payments When a new employee or dependent is added to coverage under this certificate, the coverage will take effect, as set forth in this section, provided we receive the required additional premium payment within thirty (30) days of the date we notify the contractholder of such amount. In no event will an individual be covered under this certificate if FCL does not receive the required premium payment within this time period.

Prior Coverage under an Extension of Benefits

The contractholder's prior carrier may be required to provide certain benefits to the insured under an extension of benefits provision. In no event will FCL pay any claims for dental benefits which are paid under any provision in the prior carrier's plan for extension of benefits after plan termination.

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Replacement Provision

The following applies to any person who: (a) was covered under the contractholder’s prior dental plan on the date it terminated; and (b) is in a class eligible for coverage under this contract on its effective date. However, this contract must take effect immediately following termination of the prior plan.

Prior Coverage Waiting Period Credit

If an insured covered by this provision must satisfy any waiting period under this contract, he or she will be given credit for any part of the waiting period that was satisfied under the contractholder’s prior dental plan.

Prior Coverage Deductible Credit

A deductible credit will be given to all insureds covered by this contract for expenses that were applied toward the deductible of the contractholder’s prior dental plan during the ninety (90) days prior to the effective date of this contract, but only to the extent those charges are allowable expenses under this contract and are subject to a similar deductible. Prior coverage credit only applies at the initial enrollment of the group. You and/or the contractholder are responsible for providing FCL with the information necessary to apply this prior coverage credit.

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SECTION V

THE DATE ON WHICH INSURANCE TERMINATES

Termination of Certificateholder Coverage

Your coverage under this certificate will automatically terminate on the earliest of:

1. the date the contract terminates;

2. the date you fail to meet any eligibility requirement;

3. the date specified by the contractholder that your coverage terminates;

4. the date the first premium is not paid after the Contractholders thirty-one (31) day grace period ends.

Termination of Dependent Coverage

Your covered dependent’s coverage under this certificate will automatically terminate on the earliest of:

1. the date the contract terminates;

2. the date your coverage terminates;

3. the date the dependent fails to meet any eligibility requirement;

4. the date specified by the contractholder that dependent coverage terminates;

5. the date the first premium is not paid after the Contractholders thirty-one (31) day period ends.

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SECTION VI

YOUR OBLIGATIONS

Individual Deductible Limit The individual deductible per person, per plan year, which is shown on the Schedule of Benefits, must be met by an insured before covered benefits are payable.

Family Deductible Limit The family deductible per plan year, if applicable, is shown on the Schedule of Benefits. Once your family has met the family deductible per plan year, no further deductibles must be met during the rest of that plan year. The maximum amount that any one insured can contribute toward satisfaction of the family deductible per plan year is the individual deductible amount.

Coinsurance After the insured satisfies the deductible, allowable expenses for dental benefits will be paid at the percentage shown on the Schedule of Benefits. The insured’s choice of dentist will determine the amount he or she is responsible for.

For services received from a non-participating dentist, the insured is also responsible for the difference between the FCL allowance for non-participating dentists and the actual dentist charges, if any.

Predetermination of Benefits If treatment can reasonably be expected to involve allowable expenses of more than $500, a description of the procedures to be performed and an estimate of the dentist’s charges (treatment plan) may be filed with FCL for approval prior to the start of treatment.

The main purpose of a predetermination of benefits is to inform the insured and the dentist of the amount of FCL’s financial liability, prior to services being performed.

Requests for a predetermination of benefits should be submitted within thirty (30) days of the date of the initial diagnosis or exam. The insured must submit, for our review, x-rays, a complete treatment plan, and in some cases, more substantiating material such as a study model. All predetermination of benefits will be subject to the plan year maximum.

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SECTION VII

PROVIDER ALTERNATIVES

The insured has the choice of two provider alternatives which will affect how coverage is provided for dental benefits. The following describes the arrangement used to make payment under the contract.

Participating Dentist

These are dentists who have a signed agreement currently in effect with FCL or a third party contracted by FCL to provide benefits through their network, to participate in our dental plan.

Participating dentists have agreed to accept the lesser of the actual charge or the FCL allowance of the allowance established by a third party contracted by FCL to provide dental benefits through their network as payment in full for covered services. The insured is not responsible for charges in excess of the allowance. The insured is responsible for the deductible, coinsurance, and the payment of charges for non-covered services and charges in excess of any maximum benefit limitations. The participating dentist will file the claim on the insured’s behalf and payment will be made directly to the participating dentist. A list of participating dentists will be made available to you.

This list is subject to change without prior notice to, or approval of, the contractholder or certificateholder.

Non-Participating Dentist

These are dentists who do NOT have a signed agreement currently in effect with FCL to participate in our dental plan or with a third party contracted by FCL to provide dental benefits through their network. Non-participating dentists have not agreed to accept the FCL allowance or the allowance established by a third party contracted by FCL to provide dental benefits through their network, as payment in full. The insured is responsible for the difference between the FCL allowance or the allowance established by a third party contracted by FCL to provide dental benefits through their network, and the non-participating dentist charge, if any, the non-participating deductible and coinsurance shown on the Schedule of Benefits, and the payment of charges for non-covered services and charges in excess of any maximum benefit limitations.

Selection of a Dentist

FCL does not have the right to select a dentist for the insured. The insured must select his or her own dentist and nothing in this contract will interfere with the relationship between the insured and any such dentist selected. In any event, FCL shall not be liable for any action on the part of any dentist, or an agent or employee of the dentist.

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SECTION VIII

BENEFITS

The maximum benefit payable per plan year, per person is shown on the Schedule of Benefits. The following describes covered dental benefits. Note: Benefits with an asterisk (*) may be covered under a different Service Category or at a different frequency than listed below. Refer to the Schedule of Benefits for information on how these benefits are covered under this Certificate.

Payment for covered services provided by non-participating dentists will not exceed, usual and customary charges. See the “Limitations and Exclusions” section for other limits on services.

Preventive

1. *Two (2) routine oral examinations per plan year;

2. *Prophylaxis (cleaning, scaling and polishing of teeth), two (2) times per plan year;

3. Topical application of fluoride in conjunction with prophylaxis for dependent children under fourteen (14) years of age, two (2) times per plan year;

4. *Bitewing x-rays, once per plan year; and

5.