Attachment_B3__DPPO_Plan_Summary(6008297.1).pdf

Customer Service: 800.352.6132 (TTY users call 711) | www.deltadentalaz.com Contract Start Date: July 1, 2025

Document Creation Date: December 17, 2024

Delta Dental PPO plus Premier™ Summary of Benefits for Group# 6169-10001000, 10002000, 19901000 Tempe Union High School District #213

This Summary Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.*

Group – Tempe Union High School District #213

Benefit Year – January 1 through December 31

Deductible – $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $150 per family per Benefit Year. The Deductible does not apply to oral exams, preventive services, X-rays, periodontal maintenance, and orthodontic services.

Benefit Maximum Payment – $1,500 per person total per Benefit Year on all services, except periodontics (excluding periodontal maintenance) and orthodontic services. $1,000 per person total per lifetime on orthodontic services.

$1,000 per person total per lifetime on periodontics (excluding periodontal maintenance).

Child Age Limit – To age 26

Student Age Limit – To age 26

Covered Services – Delta Dental PPO™ Dentist

Delta Dental Premier® Dentist

Non-Participating Dentist

Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive

Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 100% 100%

Radiographs – X-rays 100% 100% 100% Periodontal Maintenance – cleanings following periodontal therapy 100% 100% 100%

Basic Services Emergency Palliative Treatment – to temporarily relieve pain 80% 80% 80%

Sealants – to prevent decay of permanent teeth 80% 80% 80% Minor Restorative Services – fillings 80% 80% 80% Extractions – removal of teeth 80% 80% 80% Other Basic Services – misc. services 80% 80% 80%

Major Services Crown Repair – to individual crowns 50% 50% 50% Endodontic Services – root canals 50% 50% 50% Periodontic Services – to treat gum disease 50% 50% 50% Other Oral Surgery – dental surgery other than extractions 50% 50% 50%

Major Restorative Services – crowns 50% 50% 50% Relines and Repairs – to bridges and dentures 50% 50% 50% Prosthodontic Services – bridges, implants, and dentures 50% 50% 50%

Orthodontic Services Orthodontic Services – braces 50% 50% 50%

Orthodontic Age Limit – Treatment for Dependent

Children must begin on or after age 8 and banded prior to age 17.

Treatment for Dependent

Children must begin on or after age 8 and banded prior to age 17.

Treatment for Dependent

Children must begin on or after age 8 and banded prior to age 17.

* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what the dentist charges and you are responsible for that difference.

Frequencies and Limitations

➢ Oral exams are payable twice per calendar year.

➢ Prophylaxes (cleanings) are payable twice per calendar year. Scaling (equivalent to one cleaning) is payable once in any two-year period. Full mouth debridement (equivalent to one cleaning) is payable once in any five-year period.

➢ People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment.

➢ Fluoride treatments are payable twice per calendar year for people age 17 and under.

➢ Sealants are payable once per tooth in any three-year period for bicuspids and first and second molars for people age 18 and under. The surface must be free from decay and restorations. Preventive resin restoration on molars is payable once per lifetime for people age 15 and under with moderate to high caries risk. Treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament is payable twice per tooth per calendar year for people age 18 and under.

➢ Bitewing X-rays are payable once per calendar year. Full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any five-year period.

➢ Six periapical X-rays are payable per calendar year.

➢ Space maintainers, including distal shoe space maintainers, and recement or rebond of space maintainers are payable once per area in any three-year period for people age 13 and under.

➢ Endodontic treatment is payable once per tooth per lifetime. Endodontic retreatment is payable once per tooth in any three-year period.

➢ Root planing and scaling is payable once per quadrant in any two-year period. Only two quadrants of root planing and scaling can be performed on the same day.

➢ Full and partial dentures are payable once in any seven-year period.

➢ Bridges are payable once in any seven-year period.

➢ Crowns over implants are payable once per tooth in any seven-year period. Services related to crowns over implants are payable.

➢ Implants are payable once per tooth in any seven-year period. Implant-related services are payable.

Prefabricated and custom fabricated abutments are payable once in any seven-year period.

➢ Silver amalgam and, for front teeth only, composite resin restorations are payable once per surface in any two-year period. Composite resin restorations are optioned treatment on posterior teeth.

➢ Porcelain and resin facings on crowns are optioned treatment.

➢ Crowns, onlays, and substructures are payable once per tooth in any seven-year period.

➢ Oral surgery is not payable except for extraction of coronal remnants and erupted tooth or exposed root

(excluding bone removal), exposure of unerupted tooth, and placement of device to facilitate eruption of impacted tooth.

➢ Fabrication of athletic mouthguard is payable once in any two-year period for people age 17 and under. Deep sedation and intravaneous moderate sedation are not payable.

Special Health Care Needs

Members diagnosed with “special health care needs” (as defined below) that significantly impair the Member’s ability to obtain routine covered dental services, may be eligible for additional services, including:

• Additional visits, consultations and/or exams

• Up to four total dental cleanings per benefit year

• Treatment delivery modifications, which may include limited anesthesia, when necessary for dental staff to provide oral health care

“Special health care needs” are any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition requiring medical management, health care intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity.

Special health care needs may include:

• Intellectual and neurodevelopmental disabilities

• Environmental or congenital injuries leading to disability

• Chromosomal abnormalities

• Syndromes or sequences with craniofacial or airway abnormalities

• Other sequences that require special dental care needs

• Any other syndrome, sequence, or abnormality which is not otherwise specified but has a significant deleterious effect in activities of daily living and/or requires significant modification at home and/or in care settings

Special health care needs does not include anxiety, depression, or a fear of dentists or dental treatment (odontophobia).

In evaluating whether you qualify for this special health care needs benefit, your dentist will determine whether they need to change or add new equipment, increase procedure time, and/or change or require additional therapeutic regimes and/or techniques in order to treat you. In making the assessment, your dentist may ask you for documentation evidencing your special health care need. Your dentist will submit the required paperwork to us, and we will determine if you qualify for this benefit. There is no age limit on the special health care need benefit.

Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a treatment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon treatment plan, Delta Dental will make an initial payment to you or your Participating Dentist upon insertion of the appliances or initial banding, equal to 50% of Delta Dental's stated Copayment on the Maximum Payment for Orthodontic Services as set forth in this Summary of Benefits. Provided Member has current eligibility on the date of service 12 months from the date the appliances or initial banding were placed, Delta Dental will make an additional payment equal to the balance of Delta Dental's stated Copayment on the Maximum Payment for Orthodontic Services. Maximum Payment for Orthodontic Services equals the lesser of Delta Dental's total Copayment for Orthodontic Services, the Maximum Payment per person total per lifetime on orthodontic services or the fee charged by your provider for orthodontic services.

Eligible People – As defined by the Employer Group. The Subscriber pays the full cost of this plan.

Enrollees and dependents choosing this Dental Plan are required to remain enrolled for a minimum of 12 months. Should a Subscriber or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Subscriber is enrolled (except under COBRA) and must be enrolled in the same plan as the Subscriber. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125.

Dual Spouse – If you and your Spouse are both eligible to enroll in this Dental Plan as Subscribers, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Subscribers under this Dental Plan.

Coverage ends at the end of the month that the Subscriber and/or Dependent is no longer eligible.

Delta Dental of Arizona

14850 N. Scottsdale Rd., Ste. 400 Scottsdale, AZ 85254

An Arizona dental and optometric service corporation

Fully Insured Group Dental Certificate

Welcome!

Your dental program is administered by Arizona Dental Insurance Service, Inc., an Arizona nonprofit dental and optometric service corporation doing business as Delta Dental of Arizona. Good oral health is a vital part of good general health, and your Delta Dental program is designed to promote regular dental visits. We encourage you to take advantage of this program by calling your Dentist today for an appointment.

This Certificate, along with your Summary of Benefits, describes the specific benefits of your Group’s dental contract with Delta Dental. If you have any questions about this Dental Plan, please call our Customer Service department at 800.352.6132 or access our website at www.deltadentalaz.com.

You can easily verify your own Benefit, Claims and eligibility information online 24 hours a day, seven days a week by visiting www.deltadentalaz.com/member and selecting the link for our Member Portal. The Member Portal will also allow you to print claim forms and ID cards, opt-in to paperless Explanation of Benefits statements (EOBs), search our Dentist directories, and read oral health tips.

We look forward to serving you!

TABLE OF CONTENTS

I. Delta Dental Certificate II. Definitions III. Enrolling in This Plan IV. Selecting a Dentist V. Accessing Your Benefits VI. How Payment is Made VII. Benefit Categories VIII. Exclusions and Limitations IX. Coordination of Benefits X. Claims Appeal Procedure XI. Termination of Coverage XII. Continuation of Coverage XIII. General Conditions

Please read this Certificate together with the Summary of Benefits. The Summary of Benefits lists the specific provisions of your group dental plan. If a statement in the Summary conflicts with a statement in this Certificate, the statement in the Summary applies to this Dental Plan and you should ignore the conflicting statement in this Certificate.

DDAZ-0465-rev0824 http://www.deltadentalaz.com/ http://www.deltadentalaz.com/member

Page 2 | DDAZ-0465-rev0824

I. Delta Dental Certificate

Delta Dental of Arizona, referred to herein as Delta Dental, issues this Certificate to you, the Subscriber. The Certificate and the Summary of Benefits is a description of your dental benefits coverage. It reflects and is subject to a contract between Delta Dental and the Group.

The Benefits provided under this Dental Plan may change if any state or federal laws change, or if there are changes to the Group contract. This Certificate takes the place of any prior certificate issued to you for this Dental Plan.

Delta Dental agrees to provide Benefits as described in this Certificate and the Summary of Benefits.

Note that regardless of dental or medical necessity, not all treatments and services recommended or performed by your dentist are covered benefits. Even if your dentist has prescribed, recommended or provided the service, it does not necessarily make the service eligible for benefits even if the service is not expressly excluded in this Certificate or the Summary of Benefits.

II. Definitions

Adverse Benefit Determination

Any denial, reduction or termination of the benefits for which you filed a Claim. Or a failure to provide or to make payment (in whole or in part) of the benefits you sought, including any such determination based on eligibility, application of any utilization review criteria, or a determination that the item or service for which benefits are otherwise provided was experimental or investigational, or was not medically necessary or appropriate.

Allowed Amount

The amount permitted under the applicable fee schedule for this Dental Plan, which was selected by your Group, and upon which Delta Dental will base its payment for a Covered Service.

Benefit Maximum Payment

The maximum dollar amount Delta Dental will pay in any Benefit Year or lifetime for Covered Services. The Benefit Maximum Payments apply to each Enrollee per Benefit Year. See the Summary of Benefits for the Benefit Maximum Payments applicable to this Dental Plan.

Benefit Waiting Period

A period of time during which covered dental services are not benefitted under this Dental Plan. Charges incurred for dental services that are not benefitted during a Benefit Waiting Period will not be applied toward the Deductible. Refer to the Summary of Benefits to see which procedures are subject to a Benefit Waiting Period, if any.

Benefit Year The period during which any benefit frequency limitation and/or annual Benefit Maximum will apply.

This will be the calendar year unless your Group elects a different period to serve as the Benefit Year. (See the Summary of Benefits for your Benefit Year.) If the Benefit Year is based upon a calendar year, the terms Benefit Year and Calendar Year may be used interchangeably.

Benefits

Payment for the Covered Services that have been selected under this Dental Plan.

Certificate

This document. Delta Dental will provide Benefits as described in this Certificate. Any changes in this Certificate will be based on changes to the Contract between Delta Dental and the Group.

Child(ren)

Your natural child(ren), stepchild(ren), adopted child(ren), child(ren) by virtue of legal guardianship, or child(ren) who residing with you during the waiting period for adoption or legal guardianship.

Refer to your Group’s rules for information on eligibility of Child(ren) as Dependents under this Dental Plan.

Claim

A request for payment for a Covered Service. Claims are not conditioned upon your seeking advance approval, certification, or authorization to receive payment for any Covered Service.

Coinsurance

The percentage of the charge that you must pay for Covered Services. Also known as “Co-Pay %.”

Completion Date

The date that treatment is complete. Some procedures may require more than one appointment before they can be completed. Treatment is complete:

♦ For dentures and partial dentures, on the delivery dates;

♦ For crowns and bridgework, on the permanent cementation date;

♦ For root canals and periodontal treatment, on the date of the final procedure that completes treatment.

Covered Services

The unique dental services selected for coverage as described in the Summary of Benefits and subject to the terms of this Certificate.

Deductible

The amount a Subscriber and/or Dependent(s) must pay toward Covered Services before Delta Dental begins paying for services under this Certificate. The Summary of Benefits lists the Deductible that applies to you.

Delta Dental

Arizona Dental Insurance Service, Inc. d.b.a. Delta Dental of Arizona, an Arizona nonprofit dental and optometric service corporation providing dental benefits.

Delta Dental Member Company

An individual Delta Dental entity that is a member of the Delta Dental Plans Association, the nation’s largest, most experienced system of dental health plans.

Page 3 | DDAZ-0465-rev0824

Dental Plan

The dental benefits established for Enrollees based on the contract between Delta Dental and the Group. The benefits and coverage of this Dental Plan are described in this Certificate and the Summary of Benefits.

Dentist

A person licensed to practice dentistry in the state or jurisdiction in which dental services are performed.

♦ Delta Dental In-Network Dentist (“Participating Dentist”) Dentist who has signed an agreement with the Delta Dental Member Company in their state to participate in the Delta Dental PPO and/or Delta Dental Premier networks.

♦ Delta Dental PPOTM Dentist (“PPO Dentist”) Dentist who has signed an agreement with the Delta Dental Member Company in their state to participate in the Delta Dental PPO network.

♦ Delta Dental Premier® Dentist (“Premier Dentist”) Dentist who has signed an agreement with the Delta Dental Member Plan in their state to participate in the Delta Dental Premier network.

♦ Out-of-Network Dentist (“Nonparticipating Dentist”) Dentist who has not signed an agreement with any Delta Dental Member Company to participate in the Delta Dental PPO or Delta Dental Premier networks.

♦ Out-of-Country Dentist Dentist whose office is located outside the United States and its territories. Out-of-Country Dentists are not eligible to sign participating agreements with Delta Dental.

Wherever a definition or provision of this Certificate differs from another state’s Delta Dental Member Company agreement with Participating Dentists, the agreement in that state with that Dentist will be controlling.

Deny/Denied/Denial

When a Claim for a particular service is denied for payment due to certain contractual limitations and/or exclusions that apply to this Dental Plan. You will be responsible for paying your Dentist the applicable amount for such service regardless of the Dentist’s participating status.

Dependent(s)

Your dependent(s) as defined by your Group’s rules of eligibility for this Dental Plan.

Enrollee(s)

Any Subscriber or Dependent with coverage under this Dental Plan. Also known as “Member.”

Group

The employer, organization, group, or association sponsoring this Dental Plan.

In-Network Fee Schedules

A list of charges for specific dental services, procedures and treatments agreed upon by the Group.

♦ Delta Dental PPO Dentist Fee Schedule The maximum fee allowed per procedure for services rendered by a Delta Dental PPO Dentist as determined by that Dentist’s local Delta Dental Member Company.

♦ Delta Dental Premier Dentist Fee Schedule The maximum fee allowed per procedure for services rendered by a Delta Dental Premier Dentist as determined by that Dentist’s local Delta Dental Member Company.

Note: Regardless of whether you see a Delta Dental PPO Dentist or a Delta Dental Premier Dentist, certain types of dental plans limit benefits paid for services rendered to the PPO Dentist Fee Schedule. See How Payment is Made - Delta Dental PPO Maximum Allowable Charge in this Certificate.

Maximum Approved Fee

The Maximum Approved Fee is the lowest of:

♦ The Submitted Amount.

♦ For Participating Dentists, the maximum fee that the local Delta Dental Member Company approves for a given procedure in a given region and/or specialty based upon applicable PPO or Premier Dentist Fee Schedules and internal procedures.

♦ The lowest fee regularly charged, offered, or received by an individual Dentist for a dental service or supply, irrespective of the Dentist’s contractual agreement with another dental benefits organization.

Participating Dentists agree not to charge Delta Dental patients more than the Maximum Approved Fee for a Covered Service. In all cases, Delta Dental will make the final determination regarding the Maximum Approved Fee for a Covered Service.

Nonparticipating Dentist Fee

The maximum fee allowed per procedure for services rendered by a Nonparticipating Dentist as determined by Delta Dental.

Open Enrollment Period

The period of time, as determined by the Group, during which a Subscriber may enroll themselves and their Dependents for Benefits under this Dental Plan.

Out-of-Country Dentist Fee

The maximum fee allowed per procedure for services rendered by an Out-of-Country Dentist as determined by Delta Dental.

Pre-Treatment Estimate

A voluntary and optional process where Delta Dental issues a written estimate of dental benefits that may be available under your coverage for your proposed dental treatment. Your Dentist submits the proposed dental treatment to Delta Dental in advance of providing the treatment.

A Pre-Treatment Estimate is for informational purposes only and is not required before you receive any dental care. It is not a prerequisite or condition for approval of future dental benefits payment. You will receive the same Benefits under this Dental Plan whether or not a Pre-Treatment Estimate is requested. The benefits estimate provided on a Pre-Treatment Estimate notice is

Page 4 | DDAZ-0465-rev0824 based on benefits available on the date the notice is issued.

It is not a guarantee of future dental benefits or payment.

Processing Policies

Delta Dental’s policies and guidelines used for Pre- Treatment Estimates and payment of Claims. The Processing Policies may be amended from time to time.

Proof of Loss

Written proof that the Enrollee has incurred dental expenses for which dental benefits are payable under the Plan. No dental benefit will be paid until proof of loss is satisfied. Proof of loss must be provided at the Enrollee’s expense.

Special Enrollment Period

A period outside of the Open Enrollment Period in which you or your Dependent can obtain coverage under this Dental Plan due to a qualifying life event.

Spouse

Your legal spouse. Refer to your Group’s rules for information on eligibility of a Spouse as a Dependent under this Dental Plan.

Submitted Amount

The amount a Dentist bills to Delta Dental for a specific treatment or service. A Participating Dentist cannot charge you or your Dependents for the difference between this amount and the Maximum Approved Fee.

Also known as “Billed Amount.”

Subscriber(s)

You, when the Group notifies Delta Dental that you are eligible to receive Benefits under this Dental Plan.

Summary of Benefits

A description of the specific provisions of your group dental coverage. The Summary of Benefits is and should be read as a part of this Certificate and supersedes any contrary provision of this Certificate.

III. Enrolling in This Dental Plan

The Open Enrollment Period, if applicable, will be established by the Group and will occur on an annual basis.

During the Open Enrollment Period, all eligible persons as defined by your Group may enroll in this Dental Plan. You and/or your Dependents may not enroll in this Dental Plan at any other time during the applicable Benefit Year except in the following instances:

a. Newly hired or rehired employees (if applicable): You will be eligible to enroll on the date for which employment compensation begins or, if applicable, that date plus the number of days specified as a waiting period by your Group. Rehired employees rehired less than 12 months following the date of termination may rejoin without an eligibility waiting period. If you are reinstated during the same benefit year in which the termination date occurred, any deductibles and maximums you met before termination will apply. Benefit waiting periods or portions thereof that you satisfied will be credited to you. An employee rehired 12 months or later from date of termination must meet same requirements as a newly hired employee. The date of rehire will become the date of hire.

b. New Spouse: Your new Spouse will be eligible to enroll on the date of marriage.

c. Newborn: Your newborn child will be eligible to enroll on the date of birth.

d. Legal adoptions or guardianships: Your newly adopted Child(ren) and/or the Child(ren) that you and/or your Spouse have legal guardianship over will be eligible to enroll on the date that the legal petition/court order for adoption or guardianship, becomes final, or the date on which Child(ren) placed for adoption/foster care begins residing with you and you meet all of the legal requirements for the placement of the Child(ren) under applicable state and/or federal law including completion of the application and approval procedures for adoption.

e. New Stepchild: Your new stepchild will be eligible to enroll on the date that the Child’s natural parent becomes a Dependent.

f. Coverage for a Dependent Child shall terminate on attainment of the limiting age specified in the Summary of Benefits unless such Child is and continues to be both (i) incapable of self-sustaining employment by reason of intellectual disability or physical disability and (ii) is chiefly dependent on you for support and maintenance You must furnish proof of the child’s incapacity and dependency within 31 days of the Child’s attainment of the limiting age and subsequently as required by Delta Dental but not more frequently than once per year after the 2-year period following the Child’s attainment of the limiting age.

g. To the extent Group permits Dependents other than those defined in this Certificate to enroll in this Dental Plan, such Dependents will be eligible to enroll as set forth by your Group.

h. All others will be permitted to enroll on the date that Delta Dental approves in writing the enrollment or listing of the Enrollee, unless compelled by a court or administrative order to otherwise provide Benefits for a Dependent.

IV. Selecting a Dentist

You may choose any Dentist. However, your out-of-pocket costs are likely to be less if you go to a Delta Dental Participating Dentist.

If you do not have a Dentist or wish to verify that a Dentist is a Participating Dentist, contact your Group to obtain a Participating Dentist directory or you can view Delta Dental’s online Dentist directory at www.deltadentalaz.com/find or call 800.352.6132.

Note that the contract between Delta Dental and your Dentist may have changed. To maximize the value of your dental benefits, when making your appointment, confirm that your dentist is a Participating Dentist with Delta Dental.

http://www.deltadentalaz.com/find

Page 5 | DDAZ-0465-rev0824

Delta Dental’s Participating Dentists (In-Network)

Delta Dental’s Participating Dentists have agreed to accept a discounted fee for Covered Services, plus your out-of-pocket financial responsibility (Deductibles, Coinsurance).

Participating Dentists agree not to charge Delta Dental patients more than the Maximum Approved Fee for a Covered Service. In all cases, Delta Dental will make the final determination regarding the Maximum Approved Fee for a Covered Service.

Participating Dentists will file Claims for you and Delta Dental will pay Participating Dentists directly.

V. Accessing Your Benefits

To utilize your dental benefits, follow these steps:

1. Please read this Certificate and the Summary of Benefits carefully so you are familiar with your Benefits, payment methods, and terms of this Dental Plan.

2. Confirm your Dentist’s participation in this Dental Plan’s network.

3. Make an appointment with your Dentist and tell them that you have dental benefits with Delta Dental of Arizona. If your Dentist is not familiar with this Dental Plan or has any questions, have them contact Delta Dental.

4. After you receive your dental treatment, you or the dental office staff will file a Claim form, completing the information portion with:

a. The Subscriber’s full name and address

b. The Subscriber’s Member ID number

c. The name and date of birth of the Enrollee receiving dental care

d. The Group’s name and number

Member Portal

To get the most out of your Dental Plan, go to www.deltadentalaz.com/member and set up your online account where you can learn about your Benefits and access key functions such as printing your ID card, viewing your Benefits, checking claim status, and downloading Explanations of Benefits.

Claim Forms

You can download the latest version of Delta Dental’s claim form from the Member Portal. Additionally, most dental offices have Claim forms available. Participating Dentists will fill out and submit your dental Claims for you.

Mail Claims and completed information requests to:

Delta Dental of Arizona Attn: Group Plan Claims P.O. Box 9092 Farmington Hills, MI 48333-9092

At the Enrollee's expense, it is necessary to submit completed claims, with the Enrollee’s signed authorization for Delta Dental to obtain information, and any other items we may reasonably require in support of the claim.

This information may be obtained from any provider or insurance company. Delta Dental reserves the right to reject or suspend a claim based on lack of dental information or records.

You may request a claim form from Delta Dental. If we do not provide the requested forms within 15 days after the request is made, the claim may be submitted in a letter which provides written proof of the claim covering the occurrence, the character, and the extent of the loss. The requirements for proof of loss will be considered satisfied if Delta Dental timely receives the Delta Dental claim forms or a written statement as outlined above.

Before approving a claim, Delta Dental will be entitled to receive, as the law allows, any information from any examining dentist who is providing dental services to that Enrollee and any records of treatment provided to an Enrollee, as may be required to administer the claim. Delta Dental may investigate an Enrollee’s claims at any time. At Delta Dental’s expense, we may have a dental professional of our choice examine the Enrollee and/or review X-rays and other dental services information. Delta Dental may deny or suspend payment of dental Benefits if the Enrollee or the Dentist providing care fails to cooperate with a review or examination by the dental professional that Delta Dental selects.

Pre-Treatment Estimate

A Pre-Treatment Estimate is not required to receive payment, but it allows Claims to be processed more efficiently and allows you to know what services may be covered before your Dentist provides them. You and your Dentist should review your Pre-Treatment Estimate Notice before treatment. Once treatment is complete, the dental office will submit a Claim to Delta Dental for payment.

Availability of dental benefits at the time your treatment is completed depends on several factors.

These factors include, but are not limited to, your continued eligibility for benefits, your available annual and/or lifetime Benefit Maximum Payments, any coordination of benefits, the status of your Dentist, this Dental Plan’s limitations and any other provisions, together with any additional information or changes to your dental treatment. A request for a Pre- Treatment Estimate is not a Claim or a preauthorization, precertification or other reservation of future Benefits.

It is recommended that you ask your dentist to complete a Pre-Treatment Estimate and submit the form to:

Delta Dental of Arizona Attn: Group Plan Claims P.O. Box 9092 Farmington Hills, MI 48333-9092

Pre-Treatment Estimates are only valid for the procedure and for the dentist who submitted the Pre- Treatment Estimate request and may not be transferred to any other dentist. All fee information is confidential.

Benefits will not be paid for dental services provided after your coverage ends, including services for which Pre-Treatment Estimates have been issued. See Loss of Eligibility During Treatment in this Certificate for more information.

http://www.deltadentalaz.com/member

Page 6 | DDAZ-0465-rev0824

Written Notice of Claim and Time of Payment

Because the amount of your Benefits is not conditioned on a Pre-Treatment Estimate decision by Delta Dental, all Claims under this Dental Plan are post-service Claims. All Claims for Benefits should be filed with Delta Dental within 90 days and in no event, must be filed within 1 year of the date the services were completed. Once a Claim is filed, Delta Dental will adjudicate a complete claim within 30 days of receiving

it. If there is not enough information to adjudicate your Claim, Delta Dental will notify you or your Dentist within 30 days. The notice will (a) describe the information needed,

(b) explain why it is needed, (c) request an extension of time in which to decide the Claim, and (d) inform you or your Dentist that the information must be received within 45 days or your Claim will be Denied if the services were performed by a Nonparticipating Dentist, or not chargeable to the Enrollee if the services were performed by a Participating Dentist. You will receive a copy of any notice sent to your Dentist. Once Delta Dental receives the requested information, it has 15 days to adjudicate your Claim. If you or your Dentist does not supply the requested information, Delta Dental will Deny your Claim. In such case, you will be responsible for all charges if the services were performed by a Nonparticipating Dentist or an Out-of-Country Dentist. If the services were performed by a Participating Dentist, the services will not be chargeable to the Enrollee.

Authorized Representative

You may also appoint an authorized representative to deal with Delta Dental on your behalf with respect to any Claim you file or any review of a Denied Claim you wish to pursue (see the Claims Appeal Procedure section). You should contact your Group, call Delta Dental’s Customer Service department, toll-free, at 800.352.6132 or write Delta Dental at P.O. Box 43000, Phoenix, AZ 85080-3000 to request a form to designate the person you wish to appoint as your representative. Delta Dental will only recognize the person whom you have authorized on the last dated form filed with Delta Dental. Once you have appointed an authorized representative, Delta Dental will communicate directly with your representative. If you have not designated a representative, Delta Dental will communicate directly with you.

Questions and Assistance

Questions regarding your coverage should be directed to your Group or call Delta Dental’s Customer Service department, toll-free, at 800.352.6132. You may also write to Delta Dental’s Customer Service department at P.O. Box 43000, Phoenix, AZ 85080-3000. When writing to Delta Dental, please include your name, the Group’s name and number, the Enrollee’s Member ID number, and your daytime telephone number.

VI. How Payment is Made

Delta Dental shall make payments for Covered Services in accordance with the type of plan selected by the Group.

The type of plan selected, along with the Deductibles, Coinsurance, Benefit Maximum Payments, and other important Dental Plan information, will be identified in your Summary of Benefits.

Generally, you will have to satisfy some Deductibles and pay some Coinsurance toward the amounts you incur for Covered Services. The Dental Plan will not reimburse you for any expenses that are not Covered Services.

How the Deductible Works

1. Enrollees must pay toward Covered Services to satisfy the Deductible each Benefit Year before Delta Dental begins paying for services.

2. When covered dental expenses equal or exceed the Deductible amount incurred and submitted to Delta Dental, the Deductible will be satisfied.

3. Charges incurred for dental services that are not benefitted during a Benefit Waiting Period will not be applied toward the Deductible.

4. If this Dental Plan has a family Deductible, any amount applied to each Enrollee’s Deductible will count toward a family Deductible maximum. Once the family Deductible maximum is met, no further Deductible(s) is required. No Enrollee may contribute more than that Enrollee’s individual Deductible amount toward the family Deductible maximum.

Coinsurance (Co-Pay %)

Coinsurance is how you and the Dental Plan will split the cost of certain Covered Services after the Deductible is met. Once you have met the Deductible, Delta Dental pays a percentage of the expenses, and you are responsible for paying the rest. The applicable percentage paid by Delta Dental is shown in your Summary of Benefits.

Benefit Maximum Payment

The maximum dollar amount Delta Dental will pay for each Enrollee in any Benefit Year or lifetime for Covered Services.

The Benefit Maximum Payment will apply even if coverage is interrupted or if the Enrollee has been covered both as a Subscriber and a Dependent. You cannot transfer all or any portion of your Benefit Maximum Payment from person to person or year to year. All Covered Services that do not have a Specific Benefit Maximum Payment, as described below, will apply to the annual Benefit Maximum Payment for the Benefit Year regardless of coinsurance level.

Specific Benefit Maximum Payment

Some benefits may have a specific benefit maximum payment. When a service or procedure has a specific benefit maximum payment, the specific benefit maximum payment will determine the maximum benefits paid for those services/procedures without regard to the annual Benefit Maximum Payment, and no benefits will be paid over that specific benefit maximum payment amount, whether or not the Enrollee has exhausted their annual Benefit Maximum Payment for the Benefit Year. The types of benefits which may have a specific benefit maximum payment include periodontics, orthodontics and temporomandibular joint (TMJ) procedures. Please refer to your Summary of Benefits for any procedures that have a specific benefit maximum payment.

Page 7 | DDAZ-0465-rev0824

Types of Plans

Refer to your Summary of Benefits to identify the type of Dental Plan you have. Benefits will be paid in accordance with the plan type.

Delta Dental PPO Plus PremierTM

If your Dentist is a Participating Dentist, Delta Dental will base payment on the Maximum Approved Fee for Covered Services.

Delta Dental will send payment directly to Participating Dentists and you will be responsible for any applicable Coinsurance and/or Deductibles. Unless prohibited by state law, you will be responsible for the Maximum Approved Fee for most commonly performed non-covered services. For other non-covered services, you will be responsible for the Dentist's Submitted Amount.

If your Dentist is a Nonparticipating Dentist, Delta Dental will base payment on the Nonparticipating Dentist Fee for Covered Services.

Except as otherwise provided in the Summary of Benefits, you may assign your benefits payable to your Nonparticipating Dentist and Delta Dental will send the payment directly to the Nonparticipating Dentist on your behalf. Otherwise, Delta Dental will send payment to you and you will be responsible for making full payment to the Nonparticipating Dentist. You will be responsible for any difference between Delta Dental’s payment and the Dentist’s Submitted Amount.

If your Dentist is an Out-of-Country Dentist, Delta Dental will base payment on the Out-of-Country Dentist Fee for Covered Services.

For Covered Services rendered by an Out-of-Country Dentist, Delta Dental will send payment to you unless otherwise required by law or contract, and you will be responsible for making full payment to the Dentist. You will be responsible for any difference between Delta Dental’s payment and the Dentist’s Submitted Amount.

Delta Dental PPO - Maximum Allowable Charge

Regardless of your Dentist’s participating status, Delta Dental will base its payment on the lesser of the Submitted Amount or the PPO Dentist Schedule.

Delta Dental will send payment directly to Participating Dentists and you will be responsible for any applicable Coinsurance and/or Deductibles. If your Dentist is not a PPO Dentist, but is a Delta Dental Premier Dentist, you will also be responsible for any difference between the PPO Dentist Fee Schedule and the Delta Dental Premier Dentist Fee Schedule for Covered Services, in addition to Coinsurance and/or Deductibles. Unless prohibited by state law, you will be responsible for the Maximum Approved Fee for most commonly performed non-covered services. For other non-covered services, you will be responsible for the Dentist's Submitted Amount.

Except as otherwise provided in the Summary of Benefits, you may assign your benefits payable to your Nonparticipating Dentist and Delta Dental will send the payment directly to the Nonparticipating Dentist on your behalf. Otherwise, Delta Dental will send payment to you and you will be responsible for making full payment to the Nonparticipating Dentist. You will be responsible for any difference between Delta Dental’s payment and the Dentist’s Submitted Amount.

For Covered Services rendered by an Out-of-Country Dentist, Delta Dental will send payment to you unless otherwise required by law or contract, and you will be responsible for making full payment to the Dentist. You will be responsible for any difference between Delta Dental’s payment and the Dentist’s Submitted Amount.

Orthodontics

If this Dental Plan includes orthodontics, it will be identified on and paid as reflected in your Summary of Benefits.

Covered Services Requiring Multiple Visits

In the event a Covered Service requires more than one visit with your Dentist, payment for the Covered Service will be rendered upon Completion Date.

VII. Benefit Categories

The Benefits covered by this Dental Plan are set forth in your Summary of Benefits. Please read this Certificate together with the Summary of Benefits for a complete description of Covered Services. Also noted in the Summary of Benefits are the following:

a. Deductibles, Coinsurance and Benefit Maximum Payments;

b. The Benefit Year;

c. Coinsurance levels at which dental services will be covered (Routine, Basic or Major);

d. The Benefit Waiting Periods (if applicable).

Dental services are covered under this Dental Plan when they are performed and completed by a licensed dentist in a dental office (or by teledentistry as permitted by applicable law and this Dental Plan) and when necessary and appropriate as determined by the standards of generally accepted dental practices.

The Dental Plan will not pay Benefits for expenses incurred for any service not listed in either this Certificate or Summary of Benefits. If a statement or benefit in the Summary of Benefits conflicts with a statement in this Certificate, the statement in the Summary of Benefits applies to this Dental Plan and you should ignore the conflicting statement in this Certificate.

Covered dental services are subject to the Exclusions and Limitations described in this Certificate and Summary of Benefits. Please review them carefully.

VIII. Exclusions and Limitations

General Exclusions

Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Benefits. All charges for these services will be your responsibility:

1. Services for injuries or conditions payable under workers’ compensation or employer’s liability laws.

2. Services received from any government agency, political subdivision, community agency, Page 8 | DDAZ-0465-rev0824 foundation, or similar entity. Note: This provision does not apply to any programs provided under Medicaid or Medicare.

3. Services not performed in accordance with the laws of the State of Arizona.

4. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist under the supervision of a licensed Dentist. Treatment rendered by any other licensed dental professional may be covered solely as determined by Delta Dental.

5. A service or procedure that is not generally accepted by the American Dental Association and Delta Dental’s Processing Policies.

6. Services or supplies to treat any condition, other than oral or dental disease, for correction of congenital or developmental malformations.

7. Services or procedures performed in conjunction with dental services not covered under this Dental Plan.

8. Cosmetic surgery or dentistry for aesthetic reasons or orthognathic surgery.

9. Services performed or completed, or appliances completed, before a person became eligible under this Dental Plan or those which are performed during the Benefit Waiting Period. This exclusion does not apply to orthodontic treatment in progress (if a Covered Service).

10. Prescription drugs (except intramuscular injectable antibiotics), premedication, medicaments/ solutions, and relative analgesia.

11. General anesthesia and intravenous sedation, except for covered oral surgical procedures or necessary to medically concurrent conditions documented by a medical physician, in which case a limited benefit may apply as specified in claim Processing Policies. The following conditions must be met:

a. Performed by a Dentist licensed to perform general anesthesia.

b. Administered in a dental office.

12. Charges or fees for hospitalization, laboratory tests, histopathological examinations and miscellaneous tests.

13. Charges in excess of the Maximum Approved Fee.

14. Charges for failure to keep a scheduled visit with the Dentist.

15. Any claim received more than 12 months from the date of service or 12 months after the termination of this Dental Plan, whichever comes first.

16. Any adjustments to previously received claims, including submissions of additional information, received more than 12 months from the initial payment date or initial date of the requested information.

17. Services or supplies, as determined by Delta Dental, for which no valid dental need can be demonstrated.

18. Services or supplies, as determined by Delta Dental that are experimental or investigational in nature, including services or supplies required to treat complications from experimental or investigational procedures.

19. Services or supplies, as determined by Delta Dental, which are specialized techniques.

20. Services or supplies for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.

21. All Benefits available under this Dental Plan are subject to the Benefit Maximum Payment limitations set forth in your Summary of Benefits.

22. If a Deductible amount is stated in the Summary of Benefits, Delta Dental will not pay for any services or supplies, in whole or in part, to which the Deductible applies until the Deductible amount is met.

23. Services or supplies received due to an act of war, declared or undeclared, or terrorism.

24. Services or supplies covered under a hospital, surgical/medical, or prescription drug program.

25. Services or supplies that are not within the categories of Benefits selected by the Group and that are not covered under the terms of this Certificate and the Summary of Benefits.

Specific Exclusions

Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Benefits. All charges for these services will be your responsibility.

1. Fluoride rinses, self-applied fluorides, or desensitizing medicaments.

2. Study models, casts and other ancillary services not covered under this Dental Plan unless orthodontics is included as a covered benefit in the Summary of Benefits.

3. Temporary dentures, other than those provided under the terms of this Dental Plan.

4. Preventive control programs (including oral hygiene instruction, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, etc.).

5. Replacement of lost, missing, or stolen appliances of any type or replacement or repair of orthodontic appliances or space maintainers.

6. Cosmetic dentistry, including repairs to facings posterior to the second bicuspid position.

7. Veneers.

8. Prefabricated crowns used as final restorations on permanent teeth.

9. Appliances, surgical procedures, and restorations for increasing vertical dimension; for altering, restoring, or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction, or erosion; or for periodontal splinting. If Orthodontic Services are Covered Services under your Summary of Benefits, this exclusion may not apply to you.

10. Implant/abutment supported interim fixed denture for edentulous arch.

Page 9 | DDAZ-0465-rev0824

11. Soft occlusal guard appliances.

12. Paste-type root canal fillings on permanent teeth.

13. Replacement, repair, relines, or adjustments of occlusal guards.

14. Services associated with overdentures.

15. Metal bases on removable prostheses.

16. The replacement of teeth beyond the normal complement of teeth.

17. Personalization or characterization of any service or appliance.

18. Temporary crowns used for temporization during crown or bridge fabrication.

19. Precision attachments and stress breakers.

20. Biologic materials to aid in soft and osseous tissue regeneration when submitted on the same…