Attachment F

Summary of Benefits and Coverage - Dental

Your Dental Care Benefits Program

Current Dental Terminology© American Dental Association

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve

Company, an Independent Licensee of the Blue Cross and Blue Shield Association

City of Leander Account #434679

Group #434682 4346820004.0126

CERTIFICATE OF COVERAGE

DEN-CB-COC-LG-2025-TX

Blue Cross and Blue Shield of Texas (herein called “BCBSTX” or “Carrier”)

Hereby certifies that it has issued a Group Dental Benefits Contract (herein called the “Plan”). Subject to the provisions of the Plan, each Employee (Subscriber) to whom a Blue Cross and Blue Shield of Texas

Identification Card is issued, together with their eligible Dependents for whom application is initially made and accepted, shall have coverage under the Plan, beginning on the Effective Date shown on the Identification

Card, if the Employer makes timely payment of total premium due to the Carrier. Issuance of this Benefit

Booklet by BCBSTX does not waive the eligibility and Effective Date provisions stated in the Plan.

James Springfield

President of Blue Cross and Blue Shield of Texas

The Dental Schedule of Coverage enclosed with this Benefit Booklet indicates benefit percentages, Deductibles, maximums, and other benefit and payment issues that apply to the Plan.

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A

POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR

EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE

WORKERS’ COMPENSATION SYSTEM.

TOLL FREE NOTICE 05‐2025

Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation

To get information or file a complaint with your insurance company or HMO: Call:

Blue Cross and Blue Shield of Texas Toll-Free: 1-800-521-2227 Email: BCBSTXComplaints@bcbstx.com Mail: P. O. Box 660044, Dallas, TX 75266-0044

The Texas Department of Insurance

To get help with an insurance question or file a complaint with the state: Call with a question: 1-800-252-3439

File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: Consumer Protection, MC: CO-CP, Texas Department of Insurance, PO Box 12030, Austin, TX 78711-2030

¿Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamación o con su prima de seguro, llame primero a su compañía de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas

Department of Insurance, por su nombre en inglés) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, también debe presentar una queja a través del proceso de quejas o de apelaciones de su compañía de seguros o HMO. Si no lo hace, podría perder su derecho para apelar.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation

Para obtener información o para presentar una queja ante su compañía de seguros o HMO: Llame a: Blue Cross and Blue Shield of Texas Teléfono gratuito: 1-800-521-2227

Correo electrónico: BCBSTXComplaints@bcbstx.com Dirección postal: P. O. Box 660044, Dallas, TX 75266-0044

El Departamento de Seguros de Texas

Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: www.tdi.texas.gov

Correo electrónico: ConsumerProtection@tdi.texas.gov Dirección postal: Consumer Protection, MC: CO-CP, Texas Department of Insurance, PO Box 12030, Austin, TX 78711-2030 mailto:BCBSTXComplaints@bcbstx.com http://www.tdi.texas.gov/ mailto:ConsumerProtection@tdi.texas.gov mailto:BCBSTXComplaints@bcbstx.com http://www.tdi.texas.gov/ mailto:ConsumerProtection@tdi.texas.gov

DEN-CB-SOC-LG-2025-TX

Dental Schedule of Coverage

The Deductibles, Coinsurance Amount, and Annual Maximum below are subject to change as permitted by applicable law.

BlueCare DentalSM

Covered Services Contracting Dentist Non-Contracting Dentist

Diagnostic Evaluations

(Deductible waived)

100% 100%

Preventive Services

(Deductible waived)

100% 100%

Diagnostic Radiographs

(Deductible waived)

100% 100%

Miscellaneous Preventive Services (Deductible waived)

100% 100%

Basic Restorative Services 50% 50%

Non-Surgical Extractions 50% 50%

Non-Surgical Periodontal Services 50% 50%

Adjunctive Services 50% 50%

Endodontic Services 50% 50%

Oral Surgery Services 50% 50%

Surgical Periodontal Services 50% 50%

Major Restorative Services 20% 20%

Prosthodontic Services 20% 20%

Miscellaneous Restorative and Prosthodontic Services

20% 20%

Implants 20% 20%

Orthodontia

Not Covered Not Covered

Deductible

Three-Month Deductible Carryover applies

$50 Individual / $150 Family

$50 Individual / $150 Family

Annual Maximum $750 $750

All benefits are based upon the Allowable Amount, which is the amount determined by BCBSTX as the maximum amount eligible for payment of benefits. A Contracting Dentist cannot balance bill for charges in excess of the Allowable Amount. Benefits for covered services provided by a Non-Contracting Dentist will be based upon the same Allowable Amount, and it is likely that the

Non-Contracting Dentist will balance bill for amounts above this, resulting in higher out-of-pocket expenses.

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TABLE OF CONTENTS

Page No.

Certificate of Coverage

Important Notice

Dental Schedule of Coverage .............................................................................................Enclosure

INTRODUCTION

WHO GETS BENEFITS

HOW THE PLAN WORKS

CLAIM FILING AND APPEALS PROCEDURES

ELIGIBLE DENTAL EXPENSES, PAYMENT OBLIGATIONS, AND BENEFITS

COVERED DENTAL SERVICES

DENTAL LIMITATIONS AND EXCLUSIONS

DEFINITIONS

GENERAL PROVISIONS

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INTRODUCTION

This Plan is offered by your Employer as one of the benefits of your employment. The benefits provided are intended to assist you with many of your dental care expenses for Dentally Necessary services and supplies. Coverage under this Plan is provided regardless of your race, color, national origin, disability, age, sex, gender identity or sexual orientation. There are provisions throughout this Benefit Booklet that affects your dental care coverage. It is important that you read the Benefit Booklet carefully so you will be aware of the benefits and requirements of this Plan.

The defined terms in this Benefit Booklet are capitalized and shown in the appropriate provision in the Benefit

Booklet or in the DEFINITIONS section of the Benefit Booklet. Whenever these terms are used, the meaning is consistent with the definition given. Terms in italics may be section headings describing provisions or they may be defined terms.

The terms “you” and “your” as used in this Benefit Booklet refer to the Employee.

Benefits available under the Plan are explained in the COVERED DENTAL SERVICES section. The benefits available to you are indicated on the Dental Schedule of Coverage in this Benefit Booklet.

You are covered only for those benefit categories of services selected by your Employer and shown on your Dental Schedule of Coverage.

The benefit percentage to be applied to each category of service is shown on your Dental Schedule of Coverage.

Important Contact Information

Resource Contact Information Accessible Hours

Dental Customer Service Helpline

1-800-521-2227

Monday – Friday 8:00 a.m. – 6:00 p.m.

(hours are subject to change)

Website www.bcbstx.com 24 hours a day 7 days a week

Dental Customer Service Helpline

Dental Customer Service Representatives can:

• Give you information about Contracting Dentists;

• Distribute claim forms;

• Answer your questions on claims;

• Assist you in identifying a Contracting Dentist (but will not recommend specific Dentists);

• Provide information on the features of the Plan.

BCBSTX Website

Visit the BCBSTX website at www.bcbstx.com for information about BCBSTX, access to forms referenced in this Benefit Booklet, and much more.

http://www.bcbstx.com/

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WHO GETS BENEFITS

Eligibility

The Eligibility Date is the date a person becomes eligible to be covered under the Plan. A person becomes eligible to be covered when the person becomes an Eligible Employee or a Dependent under the Plan. The

Eligibility Date is:

• The date the Employee, including any Dependents to be covered, completes the Waiting Period, if any, for coverage;

• For a new Dependent of an Employee already having coverage under the Plan, the date the Employee acquired the Dependent (date of marriage, birth, Court Order, placement of a foster child, adoption, or suit for adoption).

Any person eligible under this Contract and covered by the Employer’s previous dental care Plan on the date prior to the Contract Date, including any person who has continued group coverage under applicable federal or state law is eligible on the Contract Date. Otherwise, you are eligible for coverage under the Plan when you satisfy the definition of an Eligible Employee.

If you are a retired Employee and your Employer provides coverage for retired Employees, you may continue your coverage under the Plan, but only if you were covered under the Employer’s dental care plan as an

Employee on the date of retirement.

Dependent Eligibility

If you apply for coverage, you may include your Dependents. Eligible Dependents are:

1. Your spouse;

2. A child under the limiting age shown in the definition of Dependent;

3. A child of any age who is medically certified as Disabled and dependent on you;

4. A grandchild who is your Dependent for federal income tax purposes at the time application for coverage of the grandchild is made;

5. Any other child included as an eligible Dependent under the Contract. A detailed description of

Dependent is in the DEFINITIONS section of this Benefit Booklet.

An Employee must be covered first in order to cover their eligible Dependents. No Dependent shall be covered hereunder prior to the Employee’s Effective Date.

Applying For Coverage

You may apply for coverage for yourself and your eligible Dependents by submitting an Enrollment Application/Change form to your Employer or BCBSTX.

No eligibility rules or variations in premium will be imposed based on your health status, dental condition, claims experience, receipt of health care, dental history, genetic information, evidence of insurability, disability, or any other health status related factor. Coverage under this Plan is provided regardless of your race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or benefits of this Plan that are based on clinically indicated, reasonable dental management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination.

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Effective Dates of Coverage

The Effective Date is the date the coverage for a Participant actually begins. The Effective Date is shown on your Identification Card.

It is important that your application for coverage under the Plan is received timely by the Carrier. If you apply for coverage and pay any required premium for yourself and your eligible Dependents and if you:

1. Are eligible on the Contract Date and the application is received by the Carrier prior to or within 31 days following such date, your coverage will become effective on the Contract Date;

2. Enroll for coverage for yourself or your Dependents during an Open Enrollment Period, coverage shall become effective on the Contract Anniversary Date, provided your application is received timely by the Carrier.

In no event will your Dependent’s coverage become effective prior to your Effective Date.

Late Applications

If you apply for coverage for yourself or for yourself and any Dependents and your application is not received within 31 days from your Eligibility Date, you will not be eligible to apply for coverage until the next Open

Enrollment Period unless qualified for a Special Enrollment Period.

Special Enrollment Periods

Special enrollment periods have been designated during which you may apply for or request a change in coverage for yourself and/or your eligible Dependents. You must apply for coverage within 31 days from the date of a triggering event in order to qualify for the changes described in this Special Enrollment Period subsection, including the following:

1. Birth, Adoption, or Party to a Suit for Adoption, Placement of a Foster Child or Court- Ordered

Dependent Coverage

The Effective Date of coverage will be the date of birth, adoption, or party to a suit for adoption or date of placement of a foster child. The Effective Date of coverage for Court-Ordered Dependent coverage will be determined by BCBSTX in accordance with the provisions of the Court Order.

2. Marriage

The Effective Date of coverage will be no later than the first day of the month following your marriage date.

BCBSTX must receive notification from you on an Enrollment Application/Change Form during the 31-day period after the event. If you wait until after this 31-day period, the coverage will become effective on the

Contract Anniversary Date following your Employer’s next Open Enrollment Period.

Enrollment Application/Change Form

Use this form to...

• Notify the Plan and BCBSTX of a change to your name;

• Add Dependents (other than a newborn child where notification only is required);

• Drop Dependents;

• Cancel all or a portion of your coverage;

• Notify BCBSTX of all changes in address for yourself and your Dependents.

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You may obtain this form from your Employer, by calling the BCBSTX Dental Customer Service Helpline telephone number shown in this Benefit Booklet or on your Identification Card, or by accessing the BCBSTX website. If a Dependent’s address and zip code are different from yours, be sure to indicate this information on the form. After you have completed the form, return it to your Employer.

Changes in Your Family

You should promptly notify the Carrier, as appropriate, in the event of a birth or follow the instructions below when events, such as but not limited to, the following take place:

• If you are adding a Dependent due to marriage or placement of a foster child, adoption, or a child being involved in a suit for which an adoption of a child is sought, or your Employer receives a Court Order to provide health or dental coverage for a Participant’s child or your spouse, you must submit an

Enrollment Application/Change Form and the coverage of the Dependent will become effective as described in this WHO GETS BENEFITS section.

• When you divorce, your child reaches the Dependent child age limit or a Participant in your family dies, coverage under the Plan terminates in accordance with the Termination of Coverage provisions.

Notify your Employer promptly if any of these events occur. Benefits for expenses incurred after termination are not available. If your Dependent’s coverage is terminated, premium refunds will not be made for any period before the date of notification. If benefits are paid prior to notification to BCBSTX, refunds will be requested.

Please refer to the Continuation of Group Coverage - Federal subsection in this Benefit Booklet for additional information.

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HOW THE PLAN WORKS

Allowable Amount

The Allowable Amount is the maximum amount of benefits BCBSTX will pay for Eligible Dental Expenses you incur under the Plan. The portion of the charges by your Dentist that exceeds the Allowable Amount of

BCBSTX will be your responsibility to pay to your Dentist, except when you have used a Contracting Dentist.

You will also be responsible for charges for services, supplies, and procedures limited or not covered under the Plan and any applicable Deductibles and Coinsurance Amounts.

Review the definition of Allowable Amount in the DEFINITIONS section of this Benefit Booklet to understand the guidelines used by BCBSTX.

Course of Treatment

Your Dentist may decide on a planned series of dental procedures which a dental exam shows you need. In cases where there is more than one professionally acceptable covered procedure or Course of Treatment, benefits will be covered for the least costly covered procedure or Course of Treatment, as determined by the

Plan. If the Participant requests or accepts the more costly service, the person is responsible for expenses that exceed the amount covered for the least costly service.

Current Dental Terminology (CDT)

The most recent edition of the manual published by the American Dental Association (ADA) entitled “Current Dental Terminology and Procedure Codes (CDT)” is used when classifying dental services.

The Allowable Amount for an Eligible Dental Expense will be based on the most inclusive procedure codes.

Freedom of Choice

Each time you need dental care, you can choose to:

See a Contracting Dentist See a Non-Contracting Dentist

• Your out-of-pocket cost will generally be the least amount because Contracting Dentists have contracted to accept a lower Allowable Amount as payment in full for Eligible

Dental Expenses;

• You are not required to file claim forms;

• You are not balance billed for costs exceeding the BCBSTX Allowable Amount for Contracting Dentists.

• Your out-of-pocket cost may be greater because Non-Contracting Dentists have not entered into a contract with BCBSTX to accept the maximum Allowable Amount as payment in full for Eligible Dental Expenses;

• You are required to file claim forms;

• You may be balanced billed by Non-

Contracting Dentists for costs exceeding the

BCBSTX Allowable Amount.

In each event as described above, you will be responsible for the following:

• Any applicable Deductibles;

• Coinsurance Amounts;

• Services that are limited or not covered under the Plan.

If your Dentist is not a Contracting Dentist, you may be responsible for filing your claim, as described in the

CLAIM FILING AND APPEALS PROCEDURES portion of this Benefit Booklet. You may also be responsible for payment in full at the time services are rendered.

To find a Contracting Dentist, you may look up a dental Provider in the Dental Directory, log on to the Blue

Cross and Blue Shield of Texas website at www.bcbstx.com and search for a Dentist using Provider Finder, HOW THE PLAN WORKS

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or call the Dental Customer Service Helpline number located in this Benefit Booklet or on your Identification

Card.

How Benefits are Calculated

Your benefits are based on a percentage of the Dentist’s Allowable Amount. To determine your benefits, subtract the Deductible (if applicable and not previously satisfied) from your Eligible Dental Expenses, then, multiply the difference by the Coinsurance Amount percentage applicable to the benefit category of services shown on your Dental Schedule of Coverage. The resulting total is the amount of benefits available.

The remaining unpaid amounts, including any excess portion above the Allowable Amount, except when you have used a Contracting Dentist, any Deductible, and your Coinsurance Amount will be your responsibility to pay to your Dentist.

When using a Non-Contracting Dentist, your out–of-pocket cost may be greater because Non-Contracting

Dentists have not entered into a contract with BCBSTX to accept the maximum Allowable Amount as payment in full for Eligible Dental Expenses. You may be balanced billed by Non-Contracting Dentists for costs exceeding the BCBSTX Allowable Amount.

Identification Card

The Identification Card tells Providers that you are entitled to benefits under your Employer’s dental care plan with BCBSTX. The card offers a convenient way of providing important information specific to your coverage including, but not limited to, the following:

• Your Subscriber identification number. This unique identification number is preceded by a three character alpha prefix that identifies Blue Cross and Blue Shield of Texas as your Carrier.

• Your group number. This is the number assigned to identify your Employer’s dental care Plan with

BCBSTX.

• Important telephone numbers.

Always remember to carry your Identification Card with you and present it to your Dentist when receiving dental care services or supplies. Do not let anyone who is not named in your coverage use your Identification

Card to receive benefits.

Please remember that any time a change in your family takes place it may be necessary for a new Identification

Card to be issued to you (refer to the WHO GETS BENEFITS section for instructions when changes are made). Upon receipt of the change in information, the Carrier will provide a new Identification Card.

Predetermination of Benefits

If a Course of Treatment for non-emergency services can reasonably be expected to involve Eligible Dental

Expenses in excess of $300, a description of the procedures to be performed and an estimate of the Dentist’s charge should be filed with and predetermined by BCBSTX prior to the commencement of treatment.

BCBSTX may request copies of existing radiographic images, photographs, models, and any other records used by the Dentist in developing the Course of Treatment. BCBSTX will review the reports and materials, taking into consideration alternative Courses of Treatment. BCBSTX will notify you and the Dentist of the benefits to be provided under the Plan. Predetermination gives you and your Dentist the opportunity to know the extent of the benefits available. Benefit payments may be reduced based on any claims paid after a predetermination estimate is provided.

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CLAIM FILING AND APPEALS PROCEDURES

Filing of Claims Required

Notice of Claim

You must give written notice to BCBSTX within 20 days, or as soon as reasonably possible, after any

Participant receives services for which benefits are provided under the Plan. Failure to give notice within this time will not invalidate or reduce any claim if you show that it was not reasonably possible to give notice and that notice was given as soon as it was reasonably possible.

Claim Forms

When BCBSTX receives notice of claim, it will furnish to you, or to your Employer for delivery to you, or to the Dentist, the dental claim forms that are usually furnished by it for filing Proof of Loss. If the forms are not furnished within 15 days after receipt of notice by BCBSTX, you have complied with the requirements of the

Plan for Proof of Loss by submitting, within the time fixed under the Plan for filing Proof of Loss, written proof covering the occurrence, the character, and the extent of the loss for which claim is made.

BCBSTX must receive claims prepared and submitted in the proper manner and form, in the time required, and with the information requested before it can consider any claim for payment of benefits.

Who Files Claims

Provider-filed claims

Contracting Dentists will usually submit your claims directly to BCBSTX for services provided to you or any of your covered Dependents. At the time services are provided, inquire if they will file claim forms for you.

To assist Dentists in filing your claims, you should carry your Identification Card with you.

Participant-filed claims

If your Dentist does not submit your claims, you will need to submit them to BCBSTX using a Participant-filed claim form provided by BCBSTX. You can obtain a Dental Claim Form from the BCBSTX website.

Follow the instructions on the reverse side of the form to complete the claim. Remember to file each

Participant’s expenses separately because any Deductibles, maximum benefits, and other provisions are applied to each Participant separately. Include itemized bills from the Dentist printed on their letterhead and show the:

• services performed;

• dates of service;

• charges; and

• name of the Participant involved.

VISIT THE BCBSTX WEBSITE FOR DENTAL CLAIM FORMS AND OTHER USEFUL INFORMATION

www.bcbstx.com

Where to Mail Completed Claim Forms

Dental Claims Division

P. O. Box 660247

Dallas, Texas 75266-0247

Who Receives Payment

Benefit payments will be made directly to the Dentists when they submit your claim to BCBSTX. Written agreements between BCBSTX and some Dentists may require payment directly to them. Any benefits payable

DEN-CB-CFAP-LG-2025-TX 16

to you, if unpaid at your death, will be paid to your beneficiary or to your estate, if no beneficiary is named.

Except as provided in the Assignment and Payment of Benefits section, rights and benefits under the

Plan are not assignable, either before or after services and supplies are provided.

Benefit Payments to a Managing Conservator

Benefits for services provided to your minor Dependent child may be paid to a third party if:

• the third party is named in a Court Order as managing or possessory conservator of the child; and

• BCBSTX has not already paid any portion of the claim.

In order for benefits to be payable to a managing or possessory conservator of a child, the conservator must submit to BCBSTX, with the claim form, proof of payment of the expenses and a certified copy of the Court

Order naming that person the managing or possessory conservator.

BCBSTX may deduct from its benefit payment any amounts it is owed by the recipient of the payment.

Payment to you or your Dentist, or deduction by BCBSTX from benefit payments of amounts owed to

BCBSTX, will be considered in satisfaction of its obligations to you under the Plan.

An Explanation of Benefits (EOB) for Dental Care summary is sent to you so you will know what has been paid.

When to Submit Claims

All claims for benefits under the Plan must be properly submitted within 90 days after the date you receive the services or supplies. Claims not submitted and received by BCBSTX within 90 days do not invalidate or reduce a claim if:

• it was not reasonably possible to provide the claim within that time;

• the written claim is provided as soon as reasonably possible; and

• unless the claimant does not have the legal capacity to provide it, the claim is provided not later than twelve (12) months after that date the claim is otherwise required.

Receipt of Claims by BCBSTX

A claim will be considered received by BCBSTX for processing upon actual delivery to the BCBSTX

Administrative Office in the proper manner and form and with all of the information required. If the claim is not complete, it may be denied or BCBSTX may contact either you or the Dentist for the additional information.

REVIEW OF CLAIM DETERMINATIONS

Claim Determinations

When BCBSTX receives a properly submitted claim, it has authority under the Plan to interpret and determine benefits in accordance with the Plan provisions. BCBSTX will render an initial decision to pay or deny a claim within 30 days of receipt of the claim. If BCBSTX requires further information in order to process the claim, we will request it within that 30-day period.

You have the right to seek and obtain a full and fair review by BCBSTX of any determination of a claim or any other determination made by BCBSTX of your benefits under the Plan.

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If a Claim Is Denied or Not Paid in Full

If the claim is denied in whole or in part, you will receive a written notice from BCBSTX with the following information, if applicable:

• The reasons for the determination;

• A reference to the benefit Plan provisions on which the determination is based;

• A description of additional information which may be necessary to perfect the claim and an explanation of why such material is necessary;

• Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, dental care Provider, claim amount (if applicable), and a statement describing denial codes with their meanings. Upon request, treatment codes with their meanings and the standards used are also available;

• An explanation of BCBSTX’s internal review/appeals and external review processes (and how to initiate a review/appeal or external review) and a statement of your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on internal review/appeal;

• The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits;

• Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;

• An explanation of the scientific or clinical judgment relied on in the determination as applied to claimant’s dental circumstances, if the denial was based on Dental Necessity, Experimental/Investigational treatment or similar exclusion, or a statement that such explanation will be provided free of charge upon request; and

• Contact information for applicable office of health insurance consumer assistance or ombudsman.

Timing of Required Notices and Extensions

Separate schedules apply to the timing of required notices and extensions, depending on the type of claim.

There are two types of claims as defined below.

• Pre-Service Claim is any request for benefits or a determination with respect to which the terms of the benefit Plan condition receipt of the benefit on approval of the benefit in advance of obtaining dental care.

• Post-Service Claim is notification in a form acceptable to BCBSTX that a service has been rendered or furnished to you. This notification must include full details of the service received, including your name, age, sex, identification number, the name and address of the Provider, an itemized statement of the service rendered or furnished, the date of service, the claim charge, and any other information which BCBSTX may request in connection with services rendered to you.

Pre-Service Claims

Type of Notice Timing

BCBSTX must notify you of the claim determination (whether adverse or not):

if We have received all information necessary to complete the review, within:

2 working days of or our receipt of the complete claim or 3 calendar days of the request, whichever is sooner, if the claim is approved; and 3 calendar days of the request, if the claim is denied.

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Post-Service Claims

Type of Notice or Extension Timing

If your claim is incomplete, BCBSTX must notify you within:

30 days

If you are notified that your claim is incomplete, you must then provide completed claim information to BCBSTX within:

45 days after receiving notice

BCBSTX must notify you of any adverse claim determination:

if the initial claim is complete, within: 30 days* after receiving the completed claim (if the initial claim is incomplete), within:

45 days

* This period may be extended one time by BCBSTX for up to 15 days, provided that BCBSTX both

(1) determines that such an extension is necessary due to matters beyond the control of the Plan and

(2) notifies you in writing, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which BCBSTX expects to render a decision.

Claim Appeal Procedures

Claim Appeal Procedures - Definitions An “Adverse Benefit Determination” means a denial, reduction, or a failure to provide or make payment

(in whole or in part) for, a benefit, including any such denial, reduction, or failure to provide in response to a claim, or Pre-Service Claim, or make payment for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental/Investigational or not Dentally Necessary or appropriate. If an ongoing Course of Treatment had been approved by BCBSTX and BCBSTX reduces such treatment (other than by amendment or termination of the Employer’s benefit Plan) before the end of the approved treatment period, that is also an

Adverse Benefit Determination.

How to Appeal an Adverse Benefit Determination

You have the right to seek and obtain a full and fair review of any determination of a claim, any determination of a request for preauthorization, or any other determination made by BCBSTX in accordance with the benefits and procedures detailed in your Plan. An appeal of an Adverse Benefit Determination may be filed by you or a person authorized to act on your behalf. In some circumstances, a dental care Provider may appeal on their own behalf. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative. To obtain an Authorized Representative Form, you or your representative may call BCBSTX at the number on the back of your

Identification Card. If you believe BCBSTX incorrectly denied all or part of your benefits, you may have your claim reviewed. BCBSTX will review its decision in accordance with the following procedure:

• Within 180 days after you receive notice of an Adverse Benefit Determination, you may call or write to BCBSTX to request a claim review. If the appeal is made orally, BCBSTX will acknowledge the request in writing and include a one-page appeal form sent to the appealing party. BCBSTX will need to know the reasons why you do not agree with the Adverse Benefit Determination. Send your request to:

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Dental Claim Review Section

Blue Cross and Blue Shield of Texas

• BCBSTX will honor telephone requests for information; however, such inquiries will not constitute a request for review. Any complaint concerning dissatisfaction or disagreement with an Adverse Benefit Determination constitutes an appeal.

• In support of your claim review, you have the option of presenting evidence and testimony to

BCBSTX. You and your authorized representative may ask to review your file and any relevant documents and may submit written issues, comments and additional dental information within 180 days after you receive notice of an Adverse Benefit Determination or at any time during the claim review process.

BCBSTX will provide you or your authorized representative with any new or additional evidence or rationale and any other information and documents used in the review of your claim without regard to whether such information was considered in the initial determination. No deference will be given to the initial Adverse

Benefit Determination. Such new or additional evidence or rationale will be provided to you or your authorized representative sufficiently in advance of the date a final decision on appeal is made in order to give you a chance to respond. If the initial benefit determination regarding the claim is based in whole or in part on a dental judgment, the appeal determination will be made by a Dentist associated or contracted with BCBSTX and/or by external advisors, but who were not involved in making the initial denial of your claim.

If you have any questions about the claims procedures or the review procedure, write to BCBSTX’s

Administrative Office or call the toll-free Customer Service Helpline number shown in this Benefit Booklet or on your Identification Card.

Timing of Appeal Determinations

BCBSTX will render a determination on an appeal of an Adverse Benefit Determination as soon as possible but not later than 30 days after the appeal has been received by BCBSTX.

If You Need Assistance

If you have any questions about the claims procedures or the review procedure, write or call BCBSTX

Headquarters at 1-800-521-2227. The BCBSTX Customer Service Helpline is accessible from 8:00 A.M. to 8:00 P.M., Monday through Friday.

Dental Claim Review Section

If you need assistance with the internal claims and appeals or the external review processes that are described below, you may call the number on the back of your Identification Card. In addition, for questions about your appeal rights or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-

EBSA (3272).

Notice of Appeal Determination

BCBSTX will notify the party filing the appeal, you, and, if a clinical appeal, any dental care Provider who recommended the services involved in the appeal, by a written notice of the determination.

The written notice to you or your authorized representative will include:

• The reasons for the determination;

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• A reference to the benefit Plan provisions on which the determination is based;

• Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, dental care Provider, claim amount (if applicable), and a statement describing denial codes with their meanings and the standards used. Upon request, treatment codes with their meanings are also available;

• An explanation of BCBSTX’s external review processes (and how to initiate an external review) and a statement of your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on external appeal;

• The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits;

• Any internal rule, guideline, protocol or other similar criterion relied on in the determination, and a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge on request;

• An explanation of the scientific or clinical judgment relied on in the determination, or a statement that such explanation will be provided free of charge upon request; and

• Contact information for applicable office of health insurance consumer assistance or ombudsman.

If BCBSTX denies your appeal, in whole or in part, or you do not receive a timely decision, you have the right to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. Your external review rights are described in the How to Appeal a Final Internal Adverse

Determination to an Independent Review Organization (IRO) section below.

How to Appeal a Final Internal Adverse Determination to an Independent Review Organization (IRO)

An “Adverse Determination” means a determination by BCBSTX or its designated utilization review organization that a dental care service that is a covered service has been reviewed and, based upon the information provided, is determined to be Experimental/Investigational, or does not meet BCBSTX’s requirements for Dental Necessity, or appropriateness and the requested service or payment for the service is therefore denied or reduced.

A “Final Internal Adverse Benefit Determination” means an Adverse Benefit Determination that has been upheld by BCBSTX at the completion of BCBSTX’s internal review/appeal process.

This procedure (not part of the complaint process) pertains only to appeals of Adverse Determinations.

Any party whose appeal of an Adverse Determination is denied by BCBSTX may seek review of the decision by an IRO. At the time the appeal is denied, BCBSTX will provide you, your designated representative or

Provider of record, information on how to appeal the denial, including the approved form, which you, your designated representative, or your Provider of record must complete.

• BCBSTX will submit dental records, names of Providers and any documentation pertinent to the decision of the IRO.

• BCBSTX will comply with the decision by the IRO.

• BCBSTX will pay for the independent review.

Upon request and free of charge, you or your designee may have reasonable access to, and copies of, all documents, records and other information relevant to the claim or appeal, including:

• information relied upon to make the decision;

• information submitted, considered or generated in the course of making the decision, whether or not it was relied upon to make the decision;

• descriptions of the administrative process and safeguards used to make the decision;

• records of any independent reviews conducted by BCBSTX;

• dental judgments, including whether a particular service is Experimental/Investigational or not

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Dentally Necessary or appropriate; and

• expert advice and consultation obtained by BCBSTX in connection with the denied claim, whether or not the advice was relied upon to make the decision.

The appeal process does not prohibit you from pursuing other appropriate remedies, including injunctive relief;

a declaratory judgment or other relief available under law. If your Plan is governed by the Employee

Retirement Income Security Act (ERISA), you have the right to bring civil action under 502(a) of ERISA.

For more information about the IRO process, call Texas Department of Insurance (TDI) on the IRO information line at (866) 554-4926, or in Austin call (512) 676-6000.

Actions Against BCBSTX

No lawsuit or action in law or equity may be brought by you or on your behalf prior to the expiration of 60 days after Proof of Loss has been filed in accordance with the requirement of the Plan and no such action will be brought at all unless brought within three years from the expiration of the time within which Proof of Loss is required by the Plan.

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ELIGIBLE DENTAL EXPENSES, PAYMENT OBLIGATIONS, AND

BENEFITS

Eligible Dental Expenses

The Plan provides coverage for services and supplies that are considered Dentally Necessary. The benefit percentage to be applied to each category of service is shown on the Dental Schedule of Coverage.

For benefits available for Eligible Dental Expenses, please refer to the Dental Schedule of Coverage in this

Benefit Booklet. Your benefits are calculated on a Calendar Year basis unless otherwise stated. At the end of a

Calendar Year, a new benefit period starts for each Participant.

Deductibles

The benefits of the Plan will be available after satisfaction of the applicable Deductibles as shown on your

Dental Schedule of Coverage. The Deductibles are explained as follows:

Calendar Year Deductible: The individual Deductible amount shown under “Deductible” on your Dental Schedule of Coverage must be satisfied by each Participant under your coverage each Calendar Year. This

Deductible, unless otherwise indicated, will be applied to all categories of services, before benefits are available under the Plan.

The following are exceptions to the Deductibles described above.

Your Dental Schedule of Coverage indicates “Three-Month Deductible Carryover applies”. This means that any Eligible Dental Expenses incurred during the last three months of a Calendar Year and applied toward satisfaction of the “Deductible” for that Plan Year may be applied toward satisfaction of that Deductible for the following Plan Year.

If you have several covered Dependents, all charges used to apply toward a “per individual” amount will be applied toward the “per family” amount shown on your Dental Schedule of Coverage. When that family

Deductible amount is reached, no further individual Deductibles will have to be satisfied for the remainder of that Calendar Year. No Participant will contribute more than the individual Deductible amount to the family Deductible amount.

Maximum Dental Benefits

Annual Maximum Benefit

The total amount of benefits available to any one Participant for all combined categories of services for a

Calendar Year shall not exceed the “Annual Maximum Benefit” amount shown on your Dental Schedule of

Coverage.

This Annual Maximum Benefit amount includes:

1. All payments made by BCBSTX under the benefit provisions of the Plan; and

2. Any benefits provided to a Participant under a dental care plan held by the Employer with BCBSTX immediately prior to the Participant’s Effective Date of coverage under this Plan.

ELIGIBLE DENTAL EXPENSES, PAYMENT OBLIGATIONS, AND

BENEFITS

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Changes in Benefits

Benefits for Eligible Dental Expenses incurred during a Course of Treatment that begins before the change will be those benefits in effect on the day the Course of Treatment was started.

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COVERED DENTAL SERVICES

The Plan will provide benefits for the following Eligible Dental Expenses, subject to the limitations and exclusions described in this Benefit Booklet, only if the category of service is shown on your Dental Schedule of Coverage. The benefit percentage applicable to each category of service is also shown on your Dental

Schedule of Coverage.

The Plan will provide coverage for the treatment of a Covered Dental Service in a non-office setting and anesthesia if you are unable to undergo the dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reasons as determined by your physician or Dentist providing the dental care.

You are covered only for those categories of services shown on the Dental Schedule of Coverage issued with this Benefit Booklet.

Diagnostic Evaluations

Diagnostic evaluations aid the Dentist in determining the nature or cause of a dental disease and include:

• Periodic oral evaluations for established patients.

• Problem focused exam, whether limited, detailed or extensive.

• Comprehensive oral evaluations for new or established patients.

• Comprehensive periodontal evaluations for new or established patients.

• Oral evaluations of children under three years of age, including counseling with primary caregiver.

Benefits for periodic, extensive, and detailed oral evaluations are limited to a combined maximum of two exam(s) every Calendar Year. Comprehensive oral evaluations are limited to one every 36 months when performed by the same Dentist.

Benefits will not be provided for comprehensive periodontal evaluations or problem-focused evaluations when

Eligible Dental Expenses are rendered on the same date as any other oral evaluation by the same Dentist.

Preventive Services

Preventive services are performed to prevent dental disease. Eligible Dental Expenses include:

• Prophylaxis – Professional cleaning and polishing of the teeth. Benefits are limited to two cleaning(s) every Calendar Year.

• Scaling in presence of generalized moderate or severe gingival inflammation. Benefits are limited to one per Calendar Year.

• Topical application of fluoride – Benefits for topical application of fluoride are available for

Participants under age 16 and are limited to two applications every Calendar Year.

Combination of prophylaxes, scaling in presence of generalized moderate or severe gingival inflammation, and periodontal maintenance treatments are limited to a combination of two every Calendar Year.

Diagnostic Radiographs

Diagnostic radiographic images are taken to diagnose a dental disease and include their interpretations. Eligible

Dental Expenses include:

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• Full-mouth (intraoral complete series) and panoramic films – Benefits are limited to a combined maximum of one every 60 months.

• Bitewing films – Benefits are limited to four horizontal images or eight vertical radiographic images once every Calendar Year.

• Bitewing films are not separately eligible when taken on the same date as full-mouth films.

• Periapical films, as necessary for diagnosis – Benefits are limited to six every Calendar Year.

Miscellaneous Preventive Services

Miscellaneous preventive services are other services performed to prevent dental disease and include:

• Sealants – Benefits for sealants are limited to one per permanent (first and second) molar per lifetime and are available for Participants under age 14.

• Space Maintainers – Benefits for space maintainers are limited to a lifetime maximum of one appliance per arch for Participants up to age 14.

Basic Restorative Services

Basic restorative services are restorations necessary to repair dental decay, including tooth preparation, all adhesives, bases, liners and polishing. Eligible Dental Expenses include:

• Amalgam restorations – Benefits are limited to one restorative service per tooth every 12 months.

• Resin-based composite restorations – Benefits are limited to one restorative service per tooth every 12 months.

Non-Surgical Extractions

Non-surgical extractions are non-surgical removal of tooth and tooth structures and include:

• Removal of retained coronal remnants – deciduous tooth.

• Removal of erupted tooth or exposed root.

Non-Surgical Periodontal Services

Non-surgical periodontal service is the non-surgical treatment of a dental disease in the supporting and surrounding tissues of the teeth (gums) and includes:

• Periodontal scaling and root planning – Benefits are limited to once per quadrant every 36 months.

• Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis limited to once per lifetime.

• Periodontal maintenance procedures – Benefits are limited to two every Calendar Year following active periodontal treatment.

Enhanced Benefits

Participants diagnosed and receiving active medical care for the following medical conditions as determined by the Plan may receive one or more of the following enhanced dental benefits in addition to standard coverage:

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Condition(s):

pregnancy, diabetes, cardiovascular disease, and prediabetics:

Benefit(s):

• An additional cleaning or

• Periodontal scaling and root planing (up to 2 quadrants) or

• An additional Periodontal maintenance

Enhanced benefits apply to the annual benefit maximum.

Adjunctive Services

Adjunctive general services include:

• Palliative treatment (emergency) of dental pain, when treatment is not performed in conjunction with a definitive treatment or service.

• Deep sedation/general anesthesia and intravenous/non-intravenous conscious sedation – By report only and when determined to be Medically Necessary by the Plan for Participants with documented medical or dental conditions. A person’s apprehension does not constitute a Medical Necessity.

Endodontic Services

Endodontics is the treatment of dental disease of the tooth pulp and includes:

• Therapeutic pulpotomy and pulpal debridement, when performed as a final endodontic procedure.

• Root canal therapy, including treatment plan, clinical procedures,…