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Home My WebLink About20260168 Resolution Approve Administrative Services Agreement for Self-Funded Dental Benefits Plan and Authorize Chair to Sign — Ameritas Life Insurance Corporation Whereas, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and Whereas, the Board has been presented with an Administrative Services Agreement for Self-Funded Dental Benefits Plan between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Ameritas Life Insurance Corporation, commencing January 1, 2026, with further terms and conditions being as stated in said agreement, and Whereas, after review, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. Now, therefore, be it resolved by the Board of County Commissioners of Weld County, Colorado, that the Administrative Services Agreement for Self-Funded Dental Benefits Plan between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Ameritas Life Insurance Corporation, be, and hereby is, approved. Be it further resolved by the Board that the Chair be, and hereby is, authorized to sign said agreement. The Board of County Commissioners of Weld County, Colorado, approved the above and foregoing Resolution, on motion duly made and seconded, by the following vote on the 28th day of January, A.D., 2026, nunc pro tunc January 1, 2026: Scott K. James, Chair: Aye Jason S. Maxey, Pro-Tem: Aye � �- I. 4 Perry L. Buck: Aye I AI Lynette Peppier: Aye Kevin D. Ross: Aye r ,,;� ,( 1, Approved as to Form: N®s ,/' Bruce Barker, County Attorney Attest: Esther E. Gesick, Clerk to the Board cc: PE( s//'D/AP/8?) 2026-0168 ua \ ado PE0037 Con4 iC4- ID.F i0302 BOARD OF COUNTY COMMISSIONERS PASS-AROUND REVIEW PASS-AROUND TITLE: Approval—Ameritas Dental Moving to Self-Funded (ASO) DEPARTMENT: HR DATE: 1/06/2026 PERSON REQUESTING: Allison Palmer& Jill Scott Brief description of the problem/issue: The current fully insured dental plan limits cost control and transparency. Moving to a self-funded (ASO) arrangement with Ameritas will provide greater flexibility and potential savings. Right now, Weld County pays a set premium each month for dental insurance, whether employees use the plan a lot or not. By switching to a self-funded (ASO) plan with Ameritas, the County will pay only for actual dental claims plus a small fee for administration, which can save money and give us more control over costs. What options exist for the Board? Approve moving the employee dental plan to a self-funded (ASO) arrangement with Ameritas. Consequences: If approved, Weld County will assume responsibility for paying actual dental claims rather than fixed monthly premiums. However, the County's financial risk is minimal because dental claims are capped by annual maximums per member. Staying fully insured would mean continuing to pay premiums that include insurer profit and limiting potential savings. Impacts: Employees will see no change to their dental benefits, provider network, or how claims are processed. The main difference will be that employees will now receive dental ID cards from Ameritas in the mail. Because claim costs are capped, this is a low-risk change that provides the County with greater cost control and transparency. Costs (Current Fiscal Year/Ongoing or Subsequent Fiscal Years): Beginning in FY2026, the County will pay actual dental claims as they occur plus an administrative fee of$4.08 per employee per month to Ameritas. Future costs will depend on claim activity but are expected to be comparable to or lower than current premium costs. Recommendation: Support Recommendation Schedule Place on BOCC Agenda Work Session Other/Comments: Perry L. Buck Scott K. James Jason S. Maxey Lynette Peppier ✓ Kevin D. Ross t 2026-0168 2 PE 0 ADMINISTRATIVE SERVICES AGREEMENT BETWEEN AMERITAS LIFE INSURANCE CORP. AND WELD COUNTY GOVERNMENT DBA WELD COUNTY Table of Contents Section I Scope of Agreement Section II. Services to be Provided by Ameritas Section III Obligations of Plan Sponsor Section IV. Banking Arrangements Section V Administrative Service Charge Schedule Section VI. Term and Termination Section VII. General Provisions Administrative Services Agreement This Administrative Services Agreement("Agreement") is between Weld County Government Dba Weld County ("Plan Sponsor"), and Ameritas Life Insurance Corp., a Nebraska corporation ("Ameritas"),and is effective upon the date set forth herein. Throughout the Agreement Ameritas and Plan Sponsor may be referred to individually as"Party"or collectively as "Parties." WHEREAS, Plan Sponsor has established and will administer an employee Dental benefit plan ("Plan")according to the Employee Retirement Income Security Act of 1974("ERISA")or the Public Health Service Act("PHSA"), as applicable, for its employees and their dependents; WHEREAS, Plan Sponsor desires to utilize the services of Ameritas to assist in its duties to administer the Plan; and WHEREAS, Ameritas has agreed to provide such non-fiduciary administrative services in connection with the Plan such as processing of claims and other services under the terms and conditions of this Agreement. NOW, THEREFORE, in consideration of the premises and mutual promises contained in this Agreement, Plan Sponsor and Ameritas hereby agree as follows: Section I. Scope of Agreement Ameritas agrees to perform certain non-fiduciary administrative services,such as claim processing and other services specified herein for the Plan,as amended,as described in Addendum A. Section II. Services to be Provided by Ameritas Ameritas shall perform the following administrative services in connection with the Plan: A. Process claims and determine the Plan benefits applicable to Covered Employees and their dependents (collectively, "Covered Persons"), including coordination of benefits, where applicable, in accordance with the terms of the Plan and as specified to Ameritas by Plan Sponsor, using Ameritas' claim paying system as specified to Ameritas by Plan Sponsor. Ameritas will process claims incurred on or after the Effective Date of this Agreement and received while this Agreement is still in effect. B. Notify a Covered Person of the initial denial of a claim(benefits)and his or her right of review of the denial as specified by the Plan Sponsor and in accordance with the terms of the Plan. C. Issue checks in payment of benefits payable under the Plan which, subject to the terms of this Agreement, shall be paid through the bank account as set forth in Section IV. of this Agreement. D. Answer benefits and claims questions and inquiries of Covered Persons and providers through toll free telephone number. E. Communicate with Plan Sponsor as is necessary to verify eligibility of Covered Persons. F. Provide to Plan Sponsor estimated Plan benefit costs after the Initial Term, and Plan design and underwriting services in connection with benefit revisions, addition of new benefits, and extensions of coverage to new Covered Persons,as requested by the Plan Sponsor. G. Bond all of its employees who will be handling funds of Plan Sponsor. H. Prepare reports regarding the Plan for use by Plan Sponsor in accounting for and managing the Plan,which shall include the standard reports identified in Addendum D. I. Prepare and provide form 1099 MED for each provider of services, in accordance with IRS rules. J. Provide Plan identification cards, Ameritas PPO dentist lists, if applicable, and a description of the Plan,as set forth in Addendum A, for each of the Plan Sponsor eligible employees. K. Assist Plan Sponsor upon requests in connection with the general administration of the Plan, administration and record keeping systems for the ongoing operation of the Plan and reconciliation of claims paid. As mutually agreed by the Parties,Ameritas will provide forms, including claims forms,related to the general administration of the Plan. L. Maintain all benefit payment records as to requests for benefits for a period of seven(7)years following the month in which the fmal benefit payment was made, or such longer period as required by applicable law. In the event of discontinuance of this Agreement,Ameritas, upon the Plan Sponsor's request and their expense, shall promptly forward to Plan Sponsor the subject records in its possession in the format identically maintained by Ameritas at the time the Agreement is discontinued. During the time in which Ameritas is to maintain benefit payment records,Ameritas shall be permitted, if it so desires,and unless otherwise prohibited by law,to destroy hard copies whenever the information has been transferred to microfiche or such other similar process which permits the retention of such information. M. If it is determined that any payment has been made under this Agreement to an ineligible person, or if it is determined that more or less than the correct amount has been paid by Ameritas,Ameritas will make a diligent attempt to recover the overpayment or will adjust the underpayment in accordance with Ameritas'established claim practices. However,in no event shall such recovery or adjustment be performed in a manner violative of any state's Unfair Claims Practices Act. Ameritas shall not initiate court proceedings for any such recovery. In the event,however,that Ameritas is sued by any beneficiary seeking to recover an adjustment to an alleged underpayment, then the decision whether to defend such court suit shall be the responsibility of Plan Sponsor. Plan Sponsor may direct Ameritas to enter into a settlement or to forego the defense to any such action, provided, however, that Plan Sponsor shall ensure that Ameritas is fully reimbursed and indemnified for any and all payments made by reason of such decision by Plan Sponsor. N. If the Plan includes PPO benefits,Ameritas shall arrange for those contracted dental providers comprising the Ameritas PPO Network to render services to those Covered Persons who seek such services from a member of the Ameritas PPO Network. Ameritas' foregoing obligation, when measured at an individual provider level, is subject to the provider's then-current patient load and ability to accept new patients. Ameritas represents and warrants that in exchange for rendering services to the Covered Persons,each participating provider member of the Ameritas PPO Network agrees to accept the amount set forth in their respective fee schedule as payment in full for procedures listed on the fee schedules and further, that the participating providers have agreed to bill Covered Persons only for the cost of services not covered under the Plan. Section III. Obligations of Plan Sponsor Plan Sponsor or Plan Sponsor's subcontractor shall: A. Promptly and diligently provide eligibility information for Covered Persons under the Plan, on or after the Effective Date of this Agreement,to Ameritas in a format mutually agreed upon by Plan Sponsor and Ameritas. B. Provide benefit information,eligibility information and periodic(at least monthly)updates of additions,deletions and changes with regard to Covered Persons by an agreed upon medium. C. Designate personnel with authority to answer questions relative to eligibility so that accurate eligibility information is available to Ameritas upon request. D. Maintain and administer the Plan in compliance with ERISA or the PHSA,as applicable; provide discretionary authority and exercise control respecting Plan management and claims decisions. Section IV. Banking Arrangements During the term of this Agreement: A. All benefit payments made by Ameritas on behalf of the Plan will be issued by Ameritas on checks payable through Ameritas' bank of choice. B. Ameritas will send to Plan Sponsor, or, upon request and authorization, an entity designated by Plan Sponsor("Designee"),the Weekly Paid/Denied Claim Report identified in Addendum D. Accompanying this report will be a cover letter setting forth the total amount paid as reflected by the report. Three (3) business days after sending, Plan Sponsor or Designee will pay or cause to be paid to Ameritas the amount listed in the letter in a mutually agreed upon format. Plan Sponsor will complete and provide all necessary authorizations to accommodate the payment. C. Failure to reimburse Ameritas in accordance with the above will result in interest being charged on the unpaid amount from the date due until fully paid at a rate equal to the lower of a) ten percent(10%) per year or, b)the maximum rate allowable by applicable usury laws and may result in the discontinuance of the Agreement in accordance with Section VI. Section V. Administrative Service Charge Schedule A. Except as otherwise provided hereafter, the administrative service charge for each month of this Agreement shall be as specified in Addendum B("Administrative Service Charge"),both for the Initial Term of this Agreement and for any Subsequent Agreement Period unless adjusted by Ameritas in accordance with Section V(E) or otherwise agreed by the Parties. Initial Term and Subsequent Agreement Period shall be as defined in Section VI.,below. B. The Administrative Service Charge as applied and provided for in Addendum B,will start on the first day of the month falling on or after the date the applicable coverage is effective. The Administrative Service Charge for the applicable coverage will cease on the last day of the month falling on or after the date of termination of the applicable coverage. There will be no pro rata charges or credits for partial month. C. Ameritas will refund unearned Administrative Service Charges to Plan Sponsor for up to three (3)months before the date Ameritas receives evidence that a refund is due. D. Prior to the first (1st) day of each month of this Agreement, Ameritas will submit a report to Plan Sponsor, or, if applicable to Designee, identifying the Covered Person(s) and listing the Administrative Charges for the month. Remittance of the Administrative Service Charges shall be due by the first(1st)of the month and past due on the tenth(10th)of the month. Such report and remittance shall be subject to audit and adjustment,as necessary,by Ameritas within ninety (90)days of receipt. E. The Administrative Service Charge may be adjusted by Ameritas at the start of any Subsequent Agreement Period following the Initial Term, provided Ameritas has given Plan Sponsor at least thirty (30) days advance written notice of its intent to adjust the Administrative Service Charge. Subsequent Agreement Period shall be as defined in Section VI., below. Should Ameritas fail to timely deliver any Administrative Service Charge change notice, the Administrative Service Charge contained in the notice shall still be effective but not until the first month following the month in which the advance notice period required hereunder ended. Upon the delivery of such Administrative Service Charge change notice,Addendum B attached hereto shall be deemed to be modified without any further action by the parties. F. During the Initial Term of this Agreement, Plan Sponsor may be eligible for a refund of a portion of the Administrative Services Charges or the Ameritas PPO Access Fees (if applicable) it paid, if Ameritas does not meet the guarantees identified in Addendum C. The refund will be paid to Plan Sponsor within sixty (60) days of the end of the Initial Term in which the guarantee was not met. The calculation of the amount of the refund is described in Addendum C. Section VI. Term and Termination A. Term 1. Although executed on the dates shown below, this Agreement shall be effective as of 1/1/2026(the"Effective Date")through 12/31/2028 (This time period shall be considered the"Initial Term"). 2. Subject to budgeting and appropriation,this Agreement shall be automatically renewed for successive twelve (12) month periods beginning the first day following the expiration of the Initial Term and each anniversary of such date thereafter,unless terminated as provided for herein. Such renewal periods shall be considered"Subsequent Agreement Periods." B. Termination 1. Termination without cause. This Agreement may be terminated without cause by either Party at the expiration of the Initial Term or any subsequent term with at least thirty (30) days written notice to the other Party in advance of such date. The Parties may also mutually agree in writing to terminate at any time. 2. Termination with Cause. Either Party has the right to terminate this Agreement upon at least 30 days' advance written notice of such termination to the other Party if the Party to whom such notice is given breaches any material provision of this Agreement. The Party claiming the right to terminate shall provide the facts underlying its claim of breach and cite the relevant sections of this Agreement that are claimed to have been breached. Remedy of such breach to the satisfaction of the other Party,within 30 days of the receipt of such notice, shall revive this Agreement for the remaining portion of its then-current term, subject to any other rights of termination contained in this Agreement. C. Effect of Termination 1. Termination of this Agreement for whatever reason, shall not terminate the rights or liabilities of either Party arising out of a period prior to termination. 2. Ameritas will continue to process all claims received on or before the date the Agreement is terminated. Upon request,and with appropriate guarantees of funding and agreement to Administrative Service Charges from Plan Sponsor, Ameritas will, for a period of ninety (90) days subsequent to the date of termination of this Agreement, continue to process those standard claims containing expenses for services performed prior to the date of termination of this Agreement which claims are received during said ninety (90) day period. At the expiration of said ninety (90) day period, Ameritas will cease all claim processing in accordance with(3)hereof. 3. Plan Sponsor agrees to reimburse Ameritas in the same manner as provided for in accordance with Section IV. B., for benefit payments made subsequent to the date of termination until all payments made by Ameritas have been reimbursed by Plan Sponsor. Section VII. General Provisions A. Plan Administration 1. The Plan Sponsor is the fiduciary with respect to the management, and administration of the Plan and Ameritas does not insure or underwrite the liability of the Plan Sponsor under the Plan. Ameritas shall not have discretionary authority or control over plan management or disposition of assets of the Plan (including final claim decisions). In no event shall Ameritas be responsible for Plan Sponsor's compliance with the requirements of ERISA or PHSA if applicable. Ameritas shall not be responsible for complying with the provisions of any federal or state laws and regulations pertaining to the Plan and Plan administration (except as to its non-fiduciary administrative functions regarding processing claims and customer claims service). The Plan Sponsor has final complete discretion to construe or interpret the provisions of the Plan, to determine eligibility for benefits from the Plan, to determine the type and extent of benefits, to be provided by the Plan, and to make final claims decisions under the Plan. Plan Sponsor's decisions in such matters shall be controlling,binding,and final. By this Agreement,Plan Sponsor is delegating to Ameritas such authority as is necessary to process or otherwise resolve undisputed claims,eligibility questions, or other matters governed by this Agreement, but the Plan Sponsor reserves ultimate authority with respect to those and all other aspects of the Plan. 2. Ameritas shall have no responsibility to provide Summary Plan Descriptions or other disclosures required under the PHSA; comply with COBRA or state continuation of coverage requirements; or to comply with HIPAA portability requirements. If such obligations exist, they shall be the sole responsibility of Plan Sponsor and not the responsibility of Ameritas. B. Indemnification 1. General Indemnity. Subject to the limitations on liability contained in Section VII.B.2, below, each Party("Indemnitor")shall indemnify and hold the other Party harmless to the extent permitted under Colorado law from and against any and all claims, suits, liabilities, obligations, damages and expenses (including reasonable attorneys' fees and expenses of litigation) arising out of either Indemnitor's (or Indemnitor's agent, employee, subcontractor,or Designee)performance or failure to perform in accordance with the terms of this Agreement or any negligence or willful misconduct of any kind on the part of Indemnitor. Ameritas or Plan Sponsor, as applicable, shall reasonably cooperate with the indemnifying Party in connection with the indemnifying Parry's obligations under this section. 2. Limitation of Liability. Except for breach by either Party of Sections VII.C.or D.,below, neither Party shall be liable to the other for any indirect, special, incidental, exemplary, reliance,punitive or consequential damages arising out of or related to this agreement,even if advised of the possibility thereof. 3. Survival. The provisions of this Section VII. B. shall survive the expiration or termination of the Agreement. 4. Non-Waiver. No term or condition of this Agreement shall be construed or interpreted as a waiver, express or implied, of the monetary limitations or any of the other immunities, rights,benefits, protections, or other provisions,of the Colorado Governmental Immunity Act C.R.S.24-10-101 et seq.,as applicable now or hereafter amended. C. Proprietary Interest Plan Sponsor acknowledges that the claims paying, administration and eligibility systems employed by Ameritas and, if applicable, the Ameritas PPO Network and the listing of the dental providers participating therein,have been developed by Ameritas and that Ameritas has a proprietary interest therein. Plan Sponsor further agrees that at no time shall Plan Sponsor or any of its employees use such other than for the intended purposes of this Agreement. D. Confidentiality and Privacy Except as otherwise provided in this Agreement, all information communicated to one Party by the other Party,whether before or after the Effective Date of this Agreement,was and shall be,to the extent permitted by law,received in confidence and shall be used only for purposes of this Agreement. No such information, including without limitation the provisions of this Agreement, shall be disclosed by the recipient Party to other persons including its own employees, except as may be necessary by reason of legal, accounting, regulatory or administrative requirements under this Agreement. The Parties further agree to comply with all applicable laws respecting privacy and security, including HIPAA, and agree to abide by the HIPAA Busineses•ifssociate Addendum, which is incorporated herein and attached hereto as Addendum E. The provisions of such Business Associate Addendum shall control as to all matters falling within the scope of such Business Associate Addendum. E. Examination of Records Each Party shall have the right to examine any records of the other relating to the other Parry's obligations under this Agreement provided, however, such examination shall take place on a regular working day in a manner agreed to between the Parties and in a manner designed to protect the confidentiality of an individual's medical information. The cost of any such examination shall be borne by the Party requesting the examination. F. Entire Agreement,Amendments,May be signed in Counterparts,Notices This Agreement and attached Addendums, shall constitute the entire agreement between the Parties and all prior oral agreements shall be merged into this written Agreement. This Agreement may be amended from time to time by written agreement between the Parties. The Parties may execute this Agreement in one or more counterparts,each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. An electronic signature shall be deemed as effective as an original executed signature page. The Parties may provide notice to each other as follows: In the case of Ameritas: Ameritas Life Insurance Corp. 5900 0 Street P.O. Box 81889 Lincoln,Nebraska 68501-1889 Attn: Group Department In the case of Plan Sponsor: WELD COUNTY GOVERNMENT DBA WELD COUNTY 1150 Q STREET GREELEY, CO 80631 ATTN: ALLISON PALMER Plan Sponsor and Ameritas have caused this Agreement to be executed on the dates set forth below. WELD COUNTY GOVERNMENT DBA AMERITAS LIFE INSURANCE CORP. WELD C UNTY By: a , — By: Bruce E. Mieth, Ph.D. Print: Scott K. James Senior Vice President—Group Operations Title: Chair, Board of Weld County Commissioners Date: January 21, 2026 Date: JAN 2 8 2026 Attest: adrAwV g A' Clerk to the Board40 00...tior 11 Sp By: Ill l l Oi.4 I /_r IPi) + ::. Deputy Clerk to the Boar.' s "�g61 .`=`///��. 'I F�= f .. n,., ZOM-0l A Addendum A Plan Booklet GROUP DENTAL PLAN WELD COUNTY GOVERNMENT DBA WELD COUNTY WELD COUNTY Plan Number: 10-302252 Administered by: Ameritas Ameritas Life Insurance Corp. TABLE OF CONTENTS Name of Provision Page Number Schedule of Benefits Begins on 9040 Benefit Information,including Deductibles,Benefit Percentage,&Maximums Definitions Late Entrant,Dependent 9060 Conditions for Coverage 9070 Eligibility Eligibility Period Elimination Period Contribution Requirement Effective Date Termination Date Dental Expense Benefits 9219 Alternate Benefit provision Limitations,including Elimination Periods, Missing Tooth Clause,Cosmetic Clause,Late Entrant Table of Dental Procedures 9232 Covered Procedures,Frequencies,Criteria Coordination of Benefits 9300 General Provisions 9310 Claim Forms Proof of Loss Payment of Benefits ERISA Information and Notice of Your Rights ERISA Notice 9035 SCHEDULE OF BENEFITS OUTLINE OF COVERAGE The Coverage for each Member and each Covered Dependent will be based on the Member's class shown in this Schedule of Benefits. Benefit Class Class Description Class 1 Eligible Employee Electing The Low Dental Plan DENTAL EXPENSE BENEFITS When you select a Participating Provider,a discounted fee schedule is used which is intended to provide you,the Member,reduced out of pocket costs. Deductible Amount: Combined Type 1,Type 2,and Type 3 Procedures-Each Visit $20 Benefit Percentage: Type 1 Procedures 100% Type 2 Procedures 50% Type 3 Procedures 50% Maximum Amount-Each Benefit Period $750 In no event will expenses incurred for Type 1 Procedures count toward the Maximum Benefit. 9040 DEFINITIONS COMPANY refers to Ameritas Life Insurance Corp. The words"we", "us"and"our"refer to Company. Our Home Office address is 5900 "0" Street,Lincoln,Nebraska 68510. PLANHOLDER refers to the Planholder stated on the face page of this document. MEMBER refers to a person: a. who is a Member of the eligible class;and b. who has qualified for coverage by completing the eligibility period, if any;and c. for whom the coverage has become effective. CHILD. Child refers to the child of the Member or a child of the Member's spouse,if they otherwise meet the definition of Dependent. DEPENDENT refers to: a. a Member's spouse. b. each child less than 26 years of age,for whom the Member or the Member's spouse is legally responsible,or is eligible under the federal laws identified below,including: i. natural born children; ii. adopted children,eligible from the date of placement for adoption; iii. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws. Spouses of Dependents and children of Dependents may not be enrolled under this plan. Additionally,if the Planholder's separate medical plans are considered to have"grandfathered status"as defined in the federal Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act,Dependents may not be eligible Dependents under such medical plans if they are eligible to enroll in an eligible employer-sponsored health plan other than a group health plan of a parent for plan years beginning before January 1,2014. Dependents that are ineligible under the Planholder's separate medical plans will be ineligible under this Plan as well. c. each child age 26 or older who: i. is Totally Disabled as defined below;and ii. becomes Totally Disabled while covered as a dependent under b. above. Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child's attaining the limiting age. Any costs for providing continuing proof will be at our expense. 9060 TOTAL DISABILITY describes the Member's Dependent as: 1.Continuously incapable of self-sustaining employment because of mental or physical handicap;and 2.Chiefly dependent upon the Member for support and maintenance. DEPENDENT UNIT refers to all of the people who are covered as the dependents of any one Member. PROVIDER refers to any person who is licensed by the law of the state in which treatment is provided within the scope of the license. PARTICIPATING AND NON-PARTICIPATING PROVIDERS. A Participating Provider is a Provider who has a contract with Us to provide services to Members at a discount. A Participating Provider is also referred to as a"Network Provider." The terms and conditions of the agreement with our Network Providers are available upon request.Members are required to pay the difference between the plan payment and the Participating Provider's contracted fees for covered services. A Non-Participating Provider is any other Provider and may also be referred to as an"Out-of-Network Provider." Members are required to pay the difference between the plan payment and the Provider's actual fee for covered services. Therefore,the out-of-pocket expenses may be lower if services are provided by a Participating Provider. LATE ENTRANT refers to any person: a. whose Effective Date of coverage is more than 31 days from the date the person becomes eligible for coverage;or b. who has elected to become covered again after canceling a fee contribution agreement. PLAN EFFECTIVE DATE refers to the date coverage under the plan becomes effective. The Plan Effective Date for the Planholder is January 1,2026.The effective date of coverage for a Member is shown in the Planholder's records. All coverage will begin at 12:01 A.M.on the Effective Date. It will end after 11:59 P.M. on the Termination Date. All times are stated as Standard Time of the residence of the Member. CONDITIONS FOR COVERAGE ELIGIBILITY ELIGIBLE CLASS FOR MEMBERS. The members of the eligible class(es)are shown on the Schedule of Benefits. Each member of the eligible class(referred to as"Member")will qualify for such coverage on the day he or she completes the required eligibility period,if any. Members choosing to elect coverage will hereinafter be referred to as"Member." If employment is the basis for membership,a member of the Eligible Class for Coverage is any eligible employee electing the low dental plan working at least 30 hours per week. If membership is by reason other than employment,then a member of the Eligible Class for Coverage is as defined by the Planholder. If both spouses are Members and if either of them covers their dependent children,then the spouse,whoever elects,will be considered the dependent of the other. As a dependent,the person will not be considered a Member of the Eligible Class,but will be eligible for coverage as a dependent. ELIGIBLE CLASS FOR DEPENDENT COVERAGE. Each Member of the eligible class for dependent coverage is eligible for the Dependent Coverage under the plan and will qualify for this Dependent Coverage on the first of the month falling on or first following the latest of: 1. the day he or she qualifies for coverage as a Member; 2. the day he or she first becomes a Member;or 3. the day he or she first has a dependent. For dependent children,a newborn child will be considered an eligible dependent upon reaching their 2"d birthday. The child may be added at birth or within 31 days of the 2nd birthday. A Member must be covered to also cover his or her dependents. If employment is the basis for membership,a member of the Eligible Class for Dependent Coverage is any eligible employee electing the low dental plan working at least 30 hours per week and has eligible dependents. If membership is by reason other than employment,then a member of the Eligible Class for Coverage is as defined by the Planholder. Any spouse who elects to be a dependent rather than a member of the Eligible Class for Personal Coverage, as explained above,is not a member of the Eligible Class for Dependent Coverage. When a member of the Eligible Class for Dependent Coverage dies and,if at the date of death,has dependents covered,the Planholder has the option of offering the dependents of the deceased employee continued coverage. If elected by the Planholder and the affected dependents,the name of such deceased employee will continue to be listed as a member of the Eligible Class for Dependent Coverage. CONTRIBUTION REQUIREMENTS. Member Coverage: A Member is required to contribute to the payment of his or her coverage fees. Dependent Coverage: A Member is required to contribute to the payment of coverage fees for his or her dependents. SECTION 125. This plan is provided as part of the Planholder's Section 125 Plan. Each Member has the option under the Section 125 Plan of participating or not participating in this plan. If a Member does not elect to participate when initially eligible,the Member may elect to participate at a subsequent Election Period. This Election Period will be held each year and those who elect to participate in this plan at that time will have their coverage become effective on January 1. 9070 Members may change their election option only during an Election Period,except for a change in family status. Such events would be marriage,divorce,birth of a child,death of a spouse or child,or termination of employment of a spouse. ELIGIBILITY PERIOD. For Members on the Plan Effective Date of the plan,coverage is effective immediately. For persons who become Members after the Plan Effective Date of the plan,qualification will occur on the first of the month falling on or first following the eligibility period of 30 calendar day(s)of continuous active employment. OPEN ENROLLMENT. If a Member does not elect to participate when initially eligible,the Member may elect to participate at the Planholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this plan at that time will have their coverage become effective on January 1. If employment is the basis for membership in the Eligible Class for Members,a Member whose eligibility terminates and is established again,may or may not have to complete a new eligibility period before he or she can again qualify for coverage. ELIMINATION PERIOD. Certain covered expenses may be subject to an elimination period,please refer to the TABLE OF DENTAL PROCEDURES,DENTAL EXPENSE BENEFITS,and if applicable,the ORTHODONTIC EXPENSE BENEFITS pages for details. EFFECTIVE DATE. Each Member has the option of being covered and covering his or her Dependents. To elect coverage,he or she must agree in writing to contribute to the payment of the coverage fees. The Effective Date for each Member and his or her Dependents,will be the first of the month falling on or first following: 1. the date on which the Member qualifies for coverage, if the Member agrees to contribute on or before that date. 2. the date on which the Member agrees to contribute,if that date is within 31 days after the date he or she qualifies for coverage. 3. the date we accept the Member and/or Dependent for coverage when the Member and/or Dependent is a Late Entrant. The Member and/or Dependent will be subject to any limitation concerning Late Entrants. EXCEPTIONS. If employment is the basis for membership,a Member must be in active service on the date the coverage,or any increase in coverage,is to take effect. If not,the coverage will not take effect until the day he or she returns to active service. Active service refers to the performance in the customary manner by an employee of all the regular duties of his or her employment with his or her employer on a full time basis at one of the employer's business establishments or at some location to which the employer's business requires the employee to travel. A Member will be in active service on any regular non-working day if he or she is not totally disabled on that day and if he or she was in active service on the regular working day before that day. If membership is by reason other than employment,a Member must not be totally disabled on the date the coverage,or any increase in coverage,is to take effect. The coverage will not take effect until the day after he or she ceases to be totally disabled. TERMINATION DATES MEMBERS. The coverage for any Member,will automatically terminate on the end of the month falling on or next following the earliest of: 1. the date the Member ceases to be a Member; 2. the last day of the period for which the Member has contributed,if required,to the payment of coverage fees;or 3. the date the plan is terminated. DEPENDENTS. The coverage for all of a Member's dependents will automatically terminate on the end of the month falling on or next following the earliest of: 1. the date on which the Member's coverage terminates; 2. the date on which the Member ceases to be a Member; 3. the last day of the period for which the Member has contributed,if required,to the payment of coverage fees;or 4. the date all Dependent Coverage under the plan is terminated. The coverage for any Dependent will automatically terminate on the end of the month falling on or next following the day before the date on which the dependent no longer meets the definition of a dependent. See"Definitions." CONTINUATION OF COVERAGE. If coverage ceases according to TERMINATION DATE,some or all of the coverages may be continued. Contact your plan administrator for details. DENTAL EXPENSE BENEFITS We will determine dental expense benefits according to the terms of the group plan for dental expenses incurred by a Member. A Covered person has the freedom of choice to receive treatment from any Provider. DETERMINING BENEFITS. The benefits payable will be determined by totaling all of the Covered Expenses submitted into each benefit type as shown in the Table of Dental Procedures. This amount is reduced by the Deductible,if any. The result is then multiplied by the Benefit Percentage(s)shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount,if any,shown in the Schedule of Benefits. BENEFIT PERIOD. Benefit Period refers to the period shown in the Table of Dental Procedures. DEDUCTIBLE. The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered Expenses that must be incurred and paid by each Covered person prior to any benefits being paid. MAXIMUM AMOUNT. The Maximum Amount shown in the Schedule of Benefits is the maximum amount that may be paid for the Covered Expenses incurred by a Member. COVERED EXPENSES. Covered Expenses include: 1. only those expenses for dental procedures performed by a Provider;and 2. only those expenses for dental procedures listed and outlined on the Table of Dental Procedures. Covered Expenses are subject to"Limitations." See Limitations and Table of Dental Procedures. Benefits payable for Covered Expenses also will be based on the lesser of: 1. the actual charge of the Provider. 2. the Maximum Allowable Charge("MAC")as covered under your plan. 3. the Maximum Allowable Benefit("MAB")as covered under your plan,if services are provided by a Non Participating Provider. MAC-The Maximum Allowable Charge is derived from the array of Provider charges within a particular ZIP code area. These allowances are the charges accepted by dentists who are Participating Providers. The MAC is reviewed and updated periodically to reflect increasing Provider fees within the ZIP code area. MAB -The Maximum Allowable Benefit is derived from a blending of submitted provider charges within a ZIP code area.These allowances are an option for policyholders who want to offer affordable yet comprehensive coverage. The MAB is reviewed and updated periodically to reflect increasing provider fees within the ZIP code area. ALTERNATIVE PROCEDURES. If two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care,the amount of the Covered Expense will be equal to the charge for the least expensive procedure. This provision is NOT intended to dictate a course of treatment. Instead,this provision is designed to determine the amount of the plan allowance for a submitted treatment when an adequate and appropriate alternative procedure is available. Accordingly,you may choose to apply the alternate benefit amount determined under this provision toward payment of the submitted treatment. We may request pre-operative dental radiographic images,periodontal charting and/or additional diagnostic data to determine the plan allowance for the procedures submitted. We strongly encourage pre-treatment estimates so you understand your benefits before any treatment begins. Ask your Provider to submit a claim form for this purpose. 9219 EXPENSES INCURRED. An expense is incurred at the time the impression is made for an appliance or change to an appliance. An expense is incurred at the time the tooth or teeth are prepared for a prosthetic crown, appliance,or fixed partial denture. For root canal therapy,an expense is incurred at the time the pulp chamber is opened. All other expenses are incurred at the time the service is rendered or a supply furnished. LIMITATIONS.Covered Expenses will not include and benefits will not be payable for expenses incurred: 1. in the first 12 months that a person is covered if the person is a Late Entrant; except for evaluations,prophylaxis(cleanings),and fluoride application. 2. for appliances,restorations,or procedures to: a. alter vertical dimension; b. restore or maintain occlusion;or c. splint or replace tooth structure lost as a result of abrasion or attrition. 3. for any procedure begun after the covered person's coverage under this plan terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Member's coverage under this Plan terminates. 4. to replace lost or stolen appliances. 5. for any treatment which is for cosmetic purposes. 6. for any procedure not shown in the Table of Dental Procedures.(There may be additional frequencies and limitations that apply,please see the Table of Dental Procedures for details). 7. for orthodontic treatment under this benefit provision. (If orthodontic expense benefits have been included in this plan,please refer to the Schedule of Benefits and Orthodontic Expense Benefits provision found on 9260). 8. for which the Covered person is entitled to benefits under any worker's compensation or similar law,or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit. 9. for charges which the Covered person is not liable or which would not have been made had no coverage been in force. 10. for services that are not required for necessary care and treatment or are not within the generally accepted parameters of care. 11. because of war or any act of war,declared or not. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under this section;and is based upon the Current Dental Terminology©American Dental Association. No benefits are payable for a procedure that is not listed. ➢ Your benefits are based on a Calendar Year. A Calendar Year runs from January 1 through December 31. > Benefit Period means the period from January 1 of any year through December 31 of the same year. But during the first year a person is covered,a benefit period means the period from his or her effective date through December 31 of that year. ➢ Covered Procedures are subject to all plan provisions,procedure and frequency limitations,and/or consultant review. > Reference to "traumatic injury"under this plan is defined as injury caused by external forces (ie. outside the mouth)and specifically excludes injury caused by internal forces such as bruxism(grinding of teeth). ➢ Benefits for replacement prosthetic crown, appliance, or fixed partial denture will be based on the prior placement date. Frequencies which reference Benefit Period will be measured forward within the limits defined as the Benefit Period. All other frequencies will be measured forward from the last covered date of service. ➢ Radiographic images,periodontal charting and supporting diagnostic data may be requested for our review. > We recommend that a pre-treatment estimate be submitted for all anticipated work that is considered to be expensive by our Member. > A pre-treatment estimate is not a pre-authorization or guarantee of payment or eligibility;rather it is an indication of the estimated benefits available if the described procedures are performed. 9232 TYPE 1 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Maximum Allowable Benefit PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations ROUTINE ORAL EVALUATION D0120 Periodic oral evaluation-established patient. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver. D0150 Comprehensive oral evaluation-new or established patient. D0180 Comprehensive periodontal evaluation-new or established patient. COMPREHENSIVE EVALUATION:D0150,D0180 • Coverage is limited to 1 of each of these procedures per provider. • In addition,D0150,D0180 coverage is limited to 1 of any of these procedures per 6 month(s). • D0120,D0145,also contribute(s)to this limitation. • If frequency met,will be considered at an alternate benefit of a DO120/D0145 and count towards this frequency. ROUTINE EVALUATION:D0120,D0145 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D0150,D0180,also contribute(s)to this limitation. • Procedure D0120 will be considered for individuals age 3 and over. Procedure D0145 will be considered for individuals age 2 and under. BITEWINGS D0270 Bitewing-single radiographic image. D0272 Bitewings-two radiographic images. D0273 Bitewings-three radiographic images. D0274 Bitewings-four radiographic images. D0277 Vertical bitewings-7 to 8 radiographic images. BITEWINGS:D0270,D0272,D0273,D0274 • Coverage is limited to 1 of any of these procedures per 12 month(s). • D0277,also contribute(s)to this limitation. • The maximum amount considered for x-ray radiographic images taken on one day will be equivalent to an allowance of a D0210. VERTICAL BITEWINGS:D0277 • Coverage is limited to 1 of any of these procedures per 5 year(s). • The maximum amount considered for x-ray radiographic images taken on one day will be equivalent to an allowance of a D0210. PRE-DIAGNOSTIC TEST D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions,not to include cytology or biopsy procedures. TESTS:D0431 • Coverage is limited to 1 of any of these procedures per 2 year(s). • Benefits are considered for persons from age 35 and over. PROPHYLAXIS(CLEANING)AND FLUORIDE D1110 Prophylaxis-adult. D1120 Prophylaxis-child. D1206 Topical application of fluoride varnish. D1208 Topical application of fluoride-excluding varnish. D9932 Cleaning and inspection of removable complete denture,maxillary. D9933 Cleaning and inspection of removable complete denture,mandibular. D9934 Cleaning and inspection of removable partial denture,maxillary. D9935 Cleaning and inspection of removable partial denture,mandibular. FLUORIDE:D1206,D1208 • Coverage is limited to 1 of any of these procedures per 6 month(s). • Benefits are considered for persons age 15 and under. PROPHYLAXIS:D 1110,D 1120 TYPE I PROCEDURES • Coverage is limited to 1 of any of these procedures per 6 month(s). • D4346,D4910,also contribute(s)to this limitation. • An adult prophylaxis(cleaning)is considered for individuals age 14 and over. A child prophylaxis(cleaning)is considered for individuals age 13 and under. Benefits for prophylaxis (cleaning)are not available when performed on the same date as periodontal procedures. CLEANING AND INSPECTION OF REMOVABLE DENTURE:D9932,D9933,D9934,D9935 • Coverage is limited to 1 of any of these procedures per 6 month(s). • Benefits are not available when performed on the same date as prophylaxis(cleaning)or periodontal maintenance. SEALANTS AND CARIES MEDICAMENTS D1351 Sealant-per tooth. D1353 Sealant repair-per tooth. D1354 Application of caries arresting medicament-per tooth. D1355 Caries preventive medicament application-per tooth. SEALANT:D1351,D1353 • Coverage is limited to 1 of any of these procedures per 3 year(s). • D1354,D1355,also contribute(s)to this limitation. • Benefits are considered for persons age 15 and under. • Benefits are considered on permanent molars only,excluding 3rd molars(wisdom teeth). • Coverage is allowed on the occlusal surface only. TYPE 2 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Maximum Allowable Benefit PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations -See Limitations LIMITED ORAL EVALUATION D0140 Limited oral evaluation-problem focused. D0170 Re-evaluation-limited,problem focused(established patient;not post-operative visit). LIMITED ORAL EVALUATION:D0140,D0170 • Coverage is allowed for accidental injury only. If not due to an accident,will be considered at an alternate benefit of a DO120/D0145 and count towards this frequency. COMPLETE SERIES OR PANORAMIC D0210 Intraoral-comprehensive series of radiographic images. D0330 Panoramic radiographic image. COMPLETE SERIES/PANORAMIC:D0210,D0330 • Coverage is limited to 1 of any of these procedures per 5 year(s). OTHER XRAYS D0220 Intraoral-periapical first radiographic image. D0230 Intraoral-periapical each additional radiographic image. D0240 Intraoral-occlusal radiographic image. D0250 Extra-oral-2D projection radiographic image created using a stationary radiation source,and detector. D0251 Extra-oral posterior dental radiographic image. PERIAPICAL:D0220,D0230 • The maximum amount considered for x-ray radiographic images taken on one day will be equivalent to an allowance of a D0210. ORAL PATHOLOGY/LABORATORY D0472 Accession of tissue,gross examination,preparation and transmission of written report. D0473 Accession of tissue,gross and microscopic examination,preparation and transmission of written report. D0474 Accession of tissue,gross and microscopic examination,including assessment of surgical margins for presence of disease,preparation and transmission of written report. ORAL PATHOLOGY LABORATORY:D0472,D0473,D0474 • Coverage is limited to 1 of any of these procedures per 12 month(s). • Coverage is limited to 1 examination per biopsy/excision. AMALGAM RESTORATIONS(FILLINGS) D2140 Amalgam-one surface,primary or permanent. D2150 Amalgam-two surfaces,primary or permanent. D2160 Amalgam-three surfaces,primary or permanent. D2161 Amalgam-four or more surfaces,primary or permanent. AMALGAM RESTORATIONS:D2140,D2150,D2160,D2161 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2330,D2331,D2332,D2335,D2391,D2392,D2393,D2394,D2990,D9911,also contribute(s)to this limitation. RESIN RESTORATIONS(FILLINGS) D2330 Resin-based composite-one surface,anterior. D2331 Resin-based composite-two surfaces,anterior. D2332 Resin-based composite-three surfaces,anterior. D2335 Resin-based composite-four or more surfaces(anterior). D2391 Resin-based composite-one surface,posterior. D2392 Resin-based composite-two surfaces,posterior. D2393 Resin-based composite-three surfaces,posterior. D2394 Resin-based composite-four or more surfaces,posterior. D2410 Gold foil-one surface. TYPE 2 PROCEDURES D2420 Gold foil-two surfaces. D2430 Gold foil-three surfaces. D2990 Resin infiltration of incipient smooth surface lesions. COMPOSITE RESTORATIONS:D2330,D2331,D2332,D2335,D2391,D2392,D2393,D2394,D2990 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2140,D2150,D2160,D2161,D9911,also contribute(s)to this limitation. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. GOLD FOIL RESTORATIONS:D2410,D2420,D2430 • Gold foils are considered at an alternate benefit of an amalgam/composite restoration. PALLIATIVE D9110 Palliative treatment of dental pain-per visit. PALLIATIVE TREATMENT:D9110 • Not covered in conjunction with other procedures,except diagnostic x-ray radiographic images. PROFESSIONAL CONSULTNISIT/SERVICES D9310 Consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician. D9430 Office visit for observation(during regularly scheduled hours)-no other services performed. D9440 Office visit-after regularly scheduled hours. D9930 Treatment of complications(post-surgical)-unusual circumstances,by report. CONSULTATION:D9310 • Coverage is limited to 1 of any of these procedures per provider. OFFICE VISIT:D9430,D9440 • Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services rendered or visit,whichever is greater. THERAPEUTIC DRUG D9610 Therapeutic parenteral drug,single administration. D9612 Therapeutic parenteral drugs,two or more administrations,different medications. MISCELLANEOUS D0486 Laboratory accession of transepithelial cytologic sample,microscopic examination, preparation and transmission of written report. D2951 Pin retention-per tooth,in addition to restoration. D9911 Application of desensitizing resin for cervical and/or root surfaces,per tooth. DESENSITIZATION:D9911 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D2140,D2150,D2160,D2161,D2330,D2331,D2332,D2335,D2391,D2392,D2393,D2394, D2990,also contribute(s)to this limitation. • Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. TYPE 3 PROCEDURES PAYMENT BASIS - NON PARTICIPATING PROVIDERS - Maximum Allowable Benefit PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations SPACE MAINTAINERS D1510 Space maintainer-fixed,unilateral-per quadrant. D1516 Space maintainer-fixed-bilateral,maxillary. D1517 Space maintainer-fixed-bilateral,mandibular. D1520 Space maintainer-removable,unilateral-per quadrant. D1526 Space maintainer-removable-bilateral,maxillary. D1527 Space maintainer-removable-bilateral,mandibular. D1551 Re-cement or re-bond bilateral space maintainer-maxillary. D1552 Re-cement or re-bond bilateral space maintainer-mandibular. D1553 Re-cement or re-bond unilateral space maintainer-per quadrant. D 1556 Removal of fixed unilateral space maintainer-per quadrant. D1557 Removal of fixed bilateral space maintainer-maxillary. D1558 Removal of fixed bilateral space maintainer-mandibular. D1575 Distal shoe space maintainer-fixed,unilateral-per quadrant. SPACE MAINTAINER:D 1510,D 1516,D1517,D1520,D1526,D1527,D1575 • Benefits are considered for persons age 15 and under. • Coverage is limited to space maintenance for unerupted teeth,following extraction of primary teeth. Allowances include all adjustments within 6 months of placement date. STAINLESS STEEL CROWN(PREFABRICATED CROWN) D2390 Resin-based composite crown,anterior. D2928 Prefabricated porcelain/ceramic crown-permanent tooth. D2929 Prefabricated porcelain/ceramic crown-primary tooth. D2930 Prefabricated stainless steel crown-primary tooth. D2931 Prefabricated stainless steel crown-permanent tooth. D2932 Prefabricated resin crown. D2933 Prefabricated stainless steel crown with resin window. D2934 Prefabricated esthetic coated stainless steel crown-primary tooth. STAINLESS STEEL CROWN:D2390,D2928,D2929,D2930,D2931,D2932,D2933,D2934 • Replacement is limited to 1 of any of these procedures per 12 month(s). • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. INLAY RESTORATIONS D2510 Inlay-metallic-one surface. D2520 Inlay-metallic-two surfaces. D2530 Inlay-metallic-three or more surfaces. D2610 Inlay-porcelain/ceramic-one surface. D2620 Inlay-porcelain/ceramic-two surfaces. D2630 Inlay-porcelain/ceramic-three or more surfaces. D2650 Inlay-resin-based composite-one surface. D2651 Inlay-resin-based composite-two surfaces. D2652 Inlay-resin-based composite-three or more surfaces. INLAY:D2510,D2520,D2530,D2610,D2620,D2630,D2650,D2651,D2652 • Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from caries(tooth decay)or traumatic injury. ONLAY RESTORATIONS D2542 Onlay-metallic-two surfaces. D2543 Onlay-metallic-three surfaces. D2544 Onlay-metallic-four or more surfaces. D2642 Onlay-porcelain/ceramic-two surfaces. D2643 Onlay-porcelain/ceramic-three surfaces. D2644 Onlay-porcelain/ceramic-four or more surfaces. D2662 Onlay-resin-based composite-two surfaces. D2663 Onlay-resin-based composite-three surfaces. TYPE 3 PROCEDURES D2664 Onlay-resin-based composite-four or more surfaces. ONLAY:D2542,D2543,D2544,D2642,D2643,D2644,D2662,D2663,D2664 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D2510,D2520,D2530,D2610,D2620,D2630,D2650,D2651,D2652,D2710,D2712,D2720, D2721,D2722,D2740,D2750,D2751,D2752,D2753,D2780,D2781,D2782,D2783,D2790, D2791,D2792,D2794,D6600,D6601,D6602,D6603,D6604,D6605,D6606,D6607,D6608, D6609,D6610,D6611,D6612,D6613,D6614,D6615,D6624,D6634,D6710,D6720,D6721, D6722,D6740,D6750,D6751,D6752,D6753,D6780,D6781,D6782,D6783,D6784,D6790, D6791,D6792,D6794,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Coverage is limited to necessary placement resulting from caries(tooth decay)or traumatic injury. • Benefits will not be considered if procedure D2390,D2928,D2929,D2930,D2931,D2932, D2933 or D2934 has been performed within 12 months. CROWNS SINGLE RESTORATIONS D2710 Crown-resin-based composite(indirect). D2712 Crown-3/4 resin-based composite(indirect). D2720 Crown-resin with high noble metal. D2721 Crown-resin with predominantly base metal. D2722 Crown-resin with noble metal. D2740 Crown-porcelain/ceramic. D2750 Crown-porcelain fused to high noble metal. D2751 Crown-porcelain fused to predominantly base metal. D2752 Crown-porcelain fused to noble metal. D2753 Crown-porcelain fused to titanium and titanium alloys. D2780 Crown-3/4 cast high noble metal. D2781 Crown-3/4 cast predominantly base metal. D2782 Crown-3/4 cast noble metal. D2783 Crown-3/4 porcelain/ceramic. D2790 Crown-full cast high noble metal. D2791 Crown-full cast predominantly base metal. D2792 Crown-full cast noble metal. D2794 Crown-titanium and titanium alloys. CROWN:D2710,D2712,D2720,D2721,D2722,D2740,D2750,D2751,D2752,D2753,D2780,D2781,D2782, D2783,D2790,D2791,D2792,D2794 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D2510,D2520,D2530,D2542,D2543,D2544,D2610,D2620,D2630,D2642,D2643,D2644, D2650,D2651,D2652,D2662,D2663,D2664,D6600,D6601,D6602,D6603,D6604,D6605, D6606,D6607,D6608,D6609,D6610,D6611,D6612,D6613,D6614,D6615,D6624,D6634, D6710,D6720,D6721,D6722,D6740,D6750,D6751,D6752,D6753,D6780,D6781,D6782, D6783,D6784,D6790,D6791,D6792,D6794,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Coverage is limited to necessary placement resulting from caries(tooth decay)or traumatic injury. • Benefits will not be considered if procedure D2390,D2928,D2929,D2930,D2931,D2932, D2933 or D2934 has been performed within 12 months.Coverage is limited to necessary placement resulting from decay or traumatic injury. RECEMENT D2910 Re-cement or re-bond inlay,onlay,veneer or partial coverage restoration. D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core. D2920 Re-cement or re-bond crown. D2921 Reattachment of tooth fragment,incisal edge or cusp. D6092 Re-cement or re-bond implant/abutment supported crown. TYPE 3 PROCEDURES D6093 Re-cement or re-bond implant/abutment supported fixed partial denture. D6930 Re-cement or re-bond fixed partial denture. SEDATIVE FILLING D2940 Placement of interim direct restoration. D2991 Application of hydroxyapatite regeneration medicament-per tooth. CORE BUILD-UP D2950 Core buildup,including any pins when required. CORE BUILDUP:D2950 • A pretreatment is strongly suggested for D2950. This is reviewed by our dental consultants and benefits are allowed when diagnostic data indicates significant tooth structure loss. POST AND CORE D2952 Post and core in addition to crown,indirectly fabricated. D2954 Prefabricated post and core in addition to crown. VENEERS D2960 Labial veneer(resin laminate)-direct. D2961 Labial veneer(resin laminate)-indirect. D2962 Labial veneer(porcelain laminate)-indirect. LABIAL VENEERS:D2960,D2961,D2962 • Replacement is limited to 1 of any of these procedures per 5 year(s). • Frequency is waived for accidental injury. • Benefits are considered on anterior teeth only. • Coverage is limited to necessary placement resulting from caries(tooth decay)or traumatic injury. FIXED CROWN AND PARTIAL DENTURE REPAIR D2980 Crown repair necessitated by restorative material failure. D2981 Inlay repair necessitated by restorative material failure. D2982 Onlay repair necessitated by restorative material failure. D2983 Veneer repair necessitated by restorative material failure. D6980 Fixed partial denture repair necessitated by restorative material failure. D9120 Fixed partial denture sectioning. ENDODONTICS MISCELLANEOUS D3220 Therapeutic pulpotomy(excluding final restoration)-removal of pulp coronal to the dentinocemental junction and application of medicament. D3221 Pulpal debridement,primary and permanent teeth. D3222 Partial Pulpotomy for apexogenesis-permanent tooth with incomplete root development. D3230 Pulpal therapy(resorbable filling)-anterior,primary tooth(excluding final restoration). D3240 Pulpal therapy(resorbable filling)-posterior,primary tooth(excluding final restoration). D3333 Internal root repair of perforation defects. D3351 Apexification/recalcification-initial visit(apical closure/calcific repair of perforations,root resorption,etc.). D3352 Apexification/recalcification-interim medication replacement(apical closure/calcific repair of perforations,root resorption,pulp space disinfection,etc.). D3353 Apexification/recalcification-final visit(includes completed root canal therapy-apical closure/calcific repair of perforations,root resorption,etc.). D3357 Pulpal regeneration-completion of treatment. D3430 Retrograde filling-per root. D3450 Root amputation-per root. D3920 Hemisection(including any root removal),not including root canal therapy. D3921 Decoronation or submergence of an erupted tooth. ENDODONTICS MISCELLANEOUS:D3333,D3430,D3450,D3920,D3921 • Procedure D3333 is limited to permanent teeth only. ENDODONTIC THERAPY(ROOT CANALS) D3310 Endodontic therapy,anterior tooth. TYPE 3 PROCEDURES D3320 Endodontic therapy,premolar tooth(excluding final restorations). D3330 Endodontic therapy,molar tooth(excluding final restorations). D3332 Incomplete endodontic therapy;inoperable,unrestorable or fractured tooth. D3346 Retreatment of previous root canal therapy-anterior. D3347 Retreatment of previous root canal therapy-premolar. D3348 Retreatment of previous root canal therapy-molar. ROOT CANALS:D3310,D3320,D3330,D3332 • Benefits are considered on permanent teeth only. • Allowances include intraoperative radiographic images and cultures but exclude final restoration. RETREATMENT OF ROOT CANAL:D3346,D3347,D3348 • Coverage is limited to 1 of any of these procedures per 12 month(s). • D3310,D3320,D3330,also contribute(s)to this limitation. • Benefits are considered on permanent teeth only. • Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative radiographic images and cultures but exclude final restoration. SURGICAL ENDODONTICS D3355 Pulpal regeneration-initial visit. D3356 Pulpal regeneration-interim medication replacement. D3410 Apicoectomy-anterior. D3421 Apicoectomy-premolar(first root). D3425 Apicoectomy-molar(first root). D3426 Apicoectomy(each additional root). D3471 Surgical repair of root resorption-anterior. D3472 Surgical repair of root resorption-premolar. D3473 Surgical repair of root resorption-molar. D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption-anterior. D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption-premolar. D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption-molar. SURGICAL PERIODONTICS D4210 Gingivectomy or gingivoplasty-four or more contiguous teeth or tooth bounded spaces per quadrant. D4211 Gingivectomy or gingivoplasty-one to three contiguous teeth or tooth bounded spaces per quadrant. D4240 Gingival flap procedure,including root planing-four or more contiguous teeth or tooth bounded spaces per quadrant. D4241 Gingival flap procedure,including root planing-one to three contiguous teeth or tooth bounded spaces per quadrant. D4260 Osseous surgery(including elevation of a full thickness flap and closure)-four or more contiguous teeth or tooth bounded spaces per quadrant. D4261 Osseous surgery(including elevation of a full thickness flap and closure)-one to three contiguous teeth or tooth bounded spaces per quadrant. D4263 Bone replacement graft-retained natural tooth-first site in quadrant. D4264 Bone replacement graft-retained natural tooth-each additional site in quadrant. D4265 Biologic materials to aid in soft and osseous tissue regeneration,per site. D4270 Pedicle soft tissue graft procedure. D4273 Autogenous connective tissue graft procedure(including donor and recipient surgical sites) first tooth,implant,or edentulous tooth position in graft. D4274 Mesial/distal wedge procedure,single tooth(when not performed in conjunction with surgical procedures in the same anatomical area). D4275 Non-autogenous connective tissue graft(including recipient site and donor material)first tooth,implant or edentulous tooth position in graft. D4276 Combined connective tissue and pedicle graft,per tooth. D4277 Free soft tissue graft procedure(including recipient and donor surgical sites)first tooth, implant,or edentulous tooth position in graft. D4278 Free soft tissue graft procedure(including recipient and donor surgical sites)each additional contiguous tooth,implant or edentulous tooth position in same graft site. D4283 Autogenous connective tissue graft procedure(including donor and recipient surgical sites)- each additional contiguous tooth,implant or edentulous tooth position in same graft site. TYPE 3 PROCEDURES D4285 Non-autogenous connective tissue graft procedure(including recipient surgical site and donor material)-each additional contiguous tooth,implant or edentulous tooth position in same graft site. BONE GRAFTS: D4263,D4264,D4265 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. GINGIVECTOMY:D4210,D4211 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. OSSEOUS SURGERY:D4240,D4241,D4260,D4261 • Each quadrant is limited to 1 of each of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. TISSUE GRAFTS:D4270,D4273,D4275,D4276,D4277,D4278,D4283,D4285 • Each quadrant is limited to 2 of any of these procedures per 3 year(s). • Coverage is limited to treatment of periodontal disease. CROWN LENGTHENING D4249 Clinical crown lengthening-hard tissue. NON-SURGICAL PERIODONTICS D4341 Periodontal scaling and root planing-four or more teeth per quadrant. D4342 Periodontal scaling and root planing-one to three teeth,per quadrant. D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue,per tooth,by report. ANTIMICROBIAL AGENTS:D4381 • Each quadrant is limited to 2 of any of these procedures per 2 year(s). PERIODONTAL SCALING&ROOT PLANING:D4341,D4342 • Each quadrant is limited to 1 of each of these procedures per 2 year(s). FULL MOUTH DEBRIDEMENT D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit. FULL MOUTH DEBRIDEMENT:D4355 • Coverage is limited to 1 of any of these procedures per 5 year(s). PERIODONTAL MAINTENANCE D4346 Scaling in presence of generalized moderate or severe gingival inflammation- full mouth, after oral evaluation. D4910 Periodontal maintenance. PERIODONTAL MAINTENANCE:D4346,D4910 • Coverage is limited to 1 of any of these procedures per 6 month(s). • D 1110,D 1120,also contribute(s)to this limitation. • Benefits are not available if performed on the same date as any other periodontal service. Procedure D4910 is contingent upon evidence of full mouth active periodontal therapy. Procedure D4346 is limited to persons age 14 and over. PROSTHODONTICS-FIXED/REMOVABLE(DENTURES) D5110 Complete denture-maxillary. D5120 Complete denture-mandibular. D5130 Immediate denture-maxillary. D5140 Immediate denture-mandibular. D5211 Maxillary partial denture-resin base(including retentive/clasping materials,rests and teeth). D5212 Mandibular partial denture-resin base(including retentive/clasping materials,rests and teeth). D5213 Maxillary partial denture-cast metal framework with resin denture bases(including retentive/clasping materials,rests and teeth). D5214 Mandibular partial denture-cast metal framework with resin denture bases(including retentive/clasping materials,rests and teeth). TYPE 3 PROCEDURES D5221 Immediate maxillary partial denture-resin base(including retentive/clasping materials,rests and teeth). D5222 Immediate mandibular partial denture-resin base(including retentive/clasping materials, rests and teeth). D5223 Immediate maxillary partial denture-cast metal framework with resin denture bases (including retentive/clasping materials,rests and teeth). D5224 Immediate mandibular partial denture-cast metal framework with resin denture bases (including retentive/clasping materials,rests and teeth). D5225 Maxillary partial denture-flexible base(including retentive/clasping materials,rests,and teeth). D5226 Mandibular partial denture-flexible base(including retentive/clasping materials,rests,and teeth). D5227 Immediate maxillary partial denture-flexible base(including any clasps,rests and teeth). D5228 Immediate mandibular partial denture-flexible base(including any clasps,rests and teeth). D5282 Removable unilateral partial denture-one piece cast metal(including retentive/clasping materials,rests,and teeth),maxillary. D5283 Removable unilateral partial denture-one piece cast metal(including retentive/clasping materials,rests,and teeth),mandibular. D5284 Removable unilateral partial denture-one piece flexible base(including retentive/clasping materials,rests,and teeth)-per quadrant. D5286 Removable unilateral partial denture-one piece resin(including retentive/clasping materials, rests,and teeth)-per quadrant. D5670 Replace all teeth and acrylic on cast metal framework(maxillary). D5671 Replace all teeth and acrylic on cast metal framework(mandibular). D5810 Interim complete denture(maxillary). D5811 Interim complete denture(mandibular). D5820 Interim partial denture(including retentive/clasping materials,rests,and teeth),maxillary. D5821 Interim partial denture(including retentive/clasping materials,rests,and teeth),mandibular. D5863 Overdenture-complete maxillary-natural tooth borne. D5864 Overdenture-partial maxillary-natural tooth borne. D5865 Overdenture-complete mandibular-natural tooth borne. D5866 Overdenture-partial mandibular-natural tooth borne. D5876 Add metal substructure to acrylic complete denture-per arch. D6110 Implant/abutment supported removable denture for edentulous arch-maxillary. D6111 Implant/abutment supported removable denture for edentulous arch-mandibular. D6112 Implant/abutment supported removable denture for partially edentulous arch-maxillary. D6113 Implant/abutment supported removable denture for partially edentulous arch-mandibular. D6114 Implant/abutment supported fixed denture for edentulous arch-maxillary. D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular. D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary. D6117 Implant/abutment supported fixed denture for partially edentulous arch-mandibular. D6118 Implant/abutment supported interim fixed denture for edentulous arch-mandibular. D6119 Implant/abutment supported interim fixed denture for edentulous arch-maxillary. COMPLETE DENTURE:D5110,D5120,D5130,D5140,D5863,D5865,D5876,D6110,D6111,D6114,D6115 • Replacement is limited to 1 of any of these procedures per 10 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months after placement date. Procedures D5863, D5865,D6110,D6111,D6114 and D6115 are considered at an alternate benefit of a D5110/D5120.Benefits for procedure D5876 is contingent upon the related denture being covered. PARTIAL DENTURE:D5211,D5212,D5213,D5214,D5221,D5222,D5223,D5224,D5225,D5226,D5227,D5228, D5282,D5283,D5284,D5286,D5670,D5671,D5864,D5866,D6112,D6113,D6116,D6117 • Replacement is limited to 1 of any of these procedures per 10 year(s). • Frequency is waived for accidental injury. • Allowances include adjustments within 6 months of placement date.Procedures D5864,D5866, D6112,D6113,D6116 and D6117 are considered at an alternate benefit of a D5213/D5214. DENTURE ADJUSTMENTS D5410 Adjust complete denture-maxillary. D5411 Adjust complete denture-mandibular. TYPE 3 PROCEDURES D5421 Adjust partial denture-maxillary. D5422 Adjust partial denture-mandibular. DENTURE ADJUSTMENT:D5410,D5411,D5421,D5422 • Coverage is limited to dates of service more than 6 months after placement date. DENTURE REPAIR D5511 Repair broken complete denture base,mandibular. D5512 Repair broken complete denture base,maxillary. D5520 Replace missing or broken teeth-complete denture-per tooth. D5611 Repair resin partial denture base,mandibular. D5612 Repair resin partial denture base,maxillary. D5621 Repair cast partial framework,mandibular. D5622 Repair cast partial framework,maxillary. D5630 Repair or replace broken retentive/clasping materials per tooth. D5640 Replace missing or broken teeth-partial denture-per tooth. ADD TOOTH/CLASP TO EXISTING PARTIAL D5650 Add tooth to existing partial denture-per tooth. D5660 Add clasp to existing partial denture-per tooth. DENTURE REBASES D5710 Rebase complete maxillary denture. D5711 Rebase complete mandibular denture. D5720 Rebase maxillary partial denture. D5721 Rebase mandibular partial denture. • D5725 Rebase hybrid prosthesis. DENTURE RELINES D5730 Reline complete maxillary denture(direct). D5731 Reline complete mandibular denture(direct). D5740 Reline maxillary partial denture(direct). D5741 Reline mandibular partial denture(direct). D5750 Reline complete maxillary denture(indirect). D5751 Reline complete mandibular denture(indirect). D5760 Reline maxillary partial denture(indirect). D5761 Reline mandibular partial denture(indirect). D5765 Soft liner for complete or partial removable denture-indirect. DENTURE RELINE:D5730,D5731,D5740,D5741,D5750,D5751,D5760,D5761,D5765 • Coverage is limited to service dates more than 6 months after placement date. TISSUE CONDITIONING D5850 Tissue conditioning,maxillary. D5851 Tissue conditioning,mandibular. PROSTHODONTICS-FIXED D6058 Abutment supported porcelain/ceramic crown. D6059 Abutment supported porcelain fused to metal crown(high noble metal). D6060 Abutment supported porcelain fused to metal crown(predominantly base metal). D6061 Abutment supported porcelain fused to metal crown(noble metal). D6062 Abutment supported cast metal crown(high noble metal). D6063 Abutment supported cast metal crown(predominantly base metal). D6064 Abutment supported cast metal crown(noble metal). D6065 Implant supported porcelain/ceramic crown. D6066 Implant supported crown-porcelain fused to high noble alloys. D6067 Implant supported crown-high noble alloys. D6068 Abutment supported retainer for porcelain/ceramic FPD. D6069 Abutment supported retainer for porcelain fused to metal FPD(high noble metal). D6070 Abutment supported retainer for porcelain fused to metal FPD(predominantly base metal). D6071 Abutment supported retainer for porcelain fused to metal FPD(noble metal). D6072 Abutment supported retainer for cast metal FPD(high noble metal). TYPE 3 PROCEDURES D6073 Abutment supported retainer for cast metal FPD(predominantly base metal). D6074 Abutment supported retainer for cast metal FPD(noble metal). D6075 Implant supported retainer for ceramic FPD. D6076 Implant supported retainer for FPD-porcelain fused to high noble alloys. D6077 Implant supported retainer for metal FPD-high noble alloy. D6082 Implant supported crown-porcelain fused to predominantly base alloys. D6083 Implant supported crown-porcelain fused to noble alloys. D6084 Implant supported crown-porcelain fused to titanium and titanium alloys. D6086 Implant supported crown-predominantly base alloys. D6087 Implant supported crown-noble alloys. D6088 Implant supported crown-titanium and titanium alloys. D6094 Abutment supported crown-titanium and titanium alloys. D6097 Abutment supported crown-porcelain fused to titanium and titanium alloys. D6098 Implant supported retainer-porcelain fused to predominantly base alloys. D6099 Implant supported retainer for FPD-porcelain fused to noble alloys. D6120 Implant supported retainer-porcelain fused to titanium and titanium alloys. D6121 Implant supported retainer for metal FPD-predominantly base alloys. D6122 Implant supported retainer for metal FPD-noble alloys. D6123 Implant supported retainer for metal FPD-titanium and titanium alloys. D6194 Abutment supported retainer crown for FPD-titanium and titanium alloys. D6195 Abutment supported retainer-porcelain fused to titanium and titanium alloys. D6205 Pontic-indirect resin based composite. D6210 Pontic-cast high noble metal. D6211 Pontic-cast predominantly base metal. D6212 Pontic-cast noble metal. D6214 Pontic-titanium and titanium alloys. D6240 Pontic-porcelain fused to high noble metal. D6241 Pontic-porcelain fused to predominantly base metal. D6242 Pontic-porcelain fused to noble metal. D6243 Pontic-porcelain fused to titanium and titanium alloys. D6245 Pontic-porcelain/ceramic. D6250 Pontic-resin with high noble metal. D6251 Pontic-resin with predominantly base metal. D6252 Pontic-resin with noble metal. D6545 Retainer-cast metal for resin bonded fixed prosthesis. D6548 Retainer-porcelain/ceramic for resin bonded fixed prosthesis. D6549 Resin retainer-for resin bonded fixed prosthesis. D6600 Retainer inlay-porcelain/ceramic,two surfaces. D6601 Retainer inlay-porcelain/ceramic,three or more surfaces. D6602 Retainer inlay-cast high noble metal,two surfaces. D6603 Retainer inlay-cast high noble metal,three or more surfaces. D6604 Retainer inlay-cast predominantly base metal,two surfaces. D6605 Retainer inlay-cast predominantly base metal,three or more surfaces. D6606 Retainer inlay-cast noble metal,two surfaces. D6607 Retainer inlay-cast noble metal,three or more surfaces. D6608 Retainer onlay-porcelain/ceramic,two surfaces. D6609 Retainer onlay-porcelain/ceramic,three or more surfaces. D6610 Retainer onlay-cast high noble metal,two surfaces. D6611 Retainer onlay-cast high noble metal,three or more surfaces. D6612 Retainer onlay-cast predominantly base metal,two surfaces. D6613 Retainer onlay-cast predominantly base metal,three or more surfaces. D6614 Retainer onlay-cast noble metal,two surfaces. D6615 Retainer onlay-cast noble metal,three or more surfaces. D6624 Retainer inlay-titanium. D6634 Retainer onlay-titanium. D6710 Retainer crown-indirect resin based composite. D6720 Retainer crown-resin with high noble metal. D6721 Retainer crown-resin with predominantly base metal. D6722 Retainer crown-resin with noble metal. D6740 Retainer crown-porcelain/ceramic. D6750 Retainer crown-porcelain fused to high noble metal. TYPE 3 PROCEDURES D6751 Retainer crown-porcelain fused to predominantly base metal. D6752 Retainer crown-porcelain fused to noble metal. D6753 Retainer crown-porcelain fused to titanium and titanium alloys. D6780 Retainer crown-3/4 cast high noble metal. D6781 Retainer crown-3/4 cast predominantly base metal. D6782 Retainer crown-3/4 cast noble metal. D6783 Retainer crown-3/4 porcelain/ceramic. D6784 Retainer crown 3/4-titanium and titanium alloys. D6790 Retainer crown-full cast high noble metal. D6791 Retainer crown-full cast predominantly base metal. D6792 Retainer crown-full cast noble metal. D6794 Retainer crown-titanium and titanium alloys. D6940 Stress breaker. FIXED PARTIAL CROWN:D6710,D6720,D6721,D6722,D6740,D6750,D6751,D6752,D6753,D6780, D6781, D6782,D6783,D6784,D6790,D6791,D6792,D6794 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D2510,D2520,D2530,D2542,D2543,D2544,D2610,D2620,D2630,D2642,D2643,D2644, D2650,D2651,D2652,D2662,D2663,D2664,D2710,D2712,D2720,D2721,D2722,D2740, D2750,D2751,D2752,D2753,D2780,D2781,D2782,D2783,D2790,D2791,D2792,D2794, D6600,D6601,D6602,D6603,D6604,D6605,D6606,D6607,D6608,D6609,D6610,D6611, D6612,D6613,D6614,D6615,D6624,D6634,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390,D2928,D2929,D2930,D2931,D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL INLAY:D6600,D6601,D6602,D6603,D6604,D6605,D6606,D6607,D6624 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D2510,D2520,D2530,D2542,D2543,D2544,D2610,D2620,D2630,D2642,D2643,D2644, D2650,D2651,D2652,D2662,D2663,D2664,D2710,D2712,D2720,D2721,D2722,D2740, D2750,D2751,D2752,D2753,D2780,D2781,D2782,D2783,D2790,D2791,D2792,D2794, D6608,D6609,D6610,D6611,D6612,D6613,D6614,D6615,D6634,D6710,D6720,D6721, D6722,D6740,D6750,D6751,D6752,D6753,D6780,D6781,D6782,D6783,D6784,D6790, D6791,D6792,D6794,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390,D2928,D2929,D2930,D2931,D2932. D2933 or D2934 has been performed within 12. FIXED PARTIAL ONLAY:D6608,D6609,D6610,D6611,D6612,D6613,D6614,D6615,D6634 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D2510,D2520,D2530,D2542,D2543,D2544,D2610,D2620,D2630,D2642,D2643,D2644, D2650,D2651,D2652,D2662,D2663,D2664,D2710,D2712,D2720,D2721,D2722,D2740, D2750,D2751,D2752,D2753,D2780,D2781,D2782,D2783,D2790,D2791,D2792,D2794, D6600,D6601,D6602,D6603,D6604,D6605,D6606,D6607,D6624,D6710,D6720,D6721, D6722,D6740,D6750,D6751,D6752,D6753,D6780,D6781,D6782,D6783,D6784,D6790, D6791,D6792,D6794,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. • Benefits will not be considered if procedure D2390,D2928,D2929,D2930,D2931,D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL PONTIC:D6205,D6210,D6211,D6212,D6214,D6240,D6241,D6242,D6243,D6245,D6250, D6251,D6252 TYPE 3 PROCEDURES • Replacement is limited to 1 of any of these procedures per 10 year(s). • D5211,D5212,D5213,D5214,D5221,D5222,D5223,D5224,D5225,D5226,D5282,D5283, D5284,D5286,D6058,D6059,D6060,D6061,D6062,D6063,D6064,D6065,D6066,D6067, D6068,D6069,D6070,D6071,D6072,D6073,D6074,D6075,D6076,D6077,D6082,D6083, D6084,D6086,D6087,D6088,D6094,D6097,D6098,D6099,D6120,D6121,D6122,D6123, D6194,D6195,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED CROWN:D6058,D6059,D6060,D6061,D6062,D6063,D6064,D6065,D6066,D6067, D6082,D6083,D6084,D6086,D6087,D6088,D6094,D6097 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D5211,D5212,D5213,D5214,D5221,D5222,D5223,D5224,D5225,D5226,D5282,D5283, D5284,D5286,D6194,D6205,D6210,D6211,D6212,D6214,D6240,D6241,D6242,D6243, D6245,D6250,D6251,D6252,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED RETAINER:D6068,D6069,D6070,D6071,D6072,D6073,D6074,D6075,D6076,D6077, D6098,D6099,D6120,D6121,D6122,D6123,D6194,D6195 • Replacement is limited to 1 of any of these procedures per 10 year(s). • D5211,D5212,D5213,D5214,D5221,D5222,D5223,D5224,D5225,D5226,D5282,D5283, D5284,D5286,D6058,D6059,D6060,D6061,D6062,D6063,D6064,D6065,D6066,D6067, D6082,D6083,D6084,D6086,D6087,D6088,D6094,D6097,D6205,D6210,D6211,D6212, D6214,D6240,D6241,D6242,D6243,D6245,D6250,D6251,D6252,also contribute(s)to this limitation. • Frequency is waived for accidental injury. • Porcelain and resin benefits are considered for anterior and bicuspid teeth only. • Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. NON-SURGICAL EXTRACTIONS D7111 Extraction,coronal remnants-primary tooth. D7140 Extraction,erupted tooth or exposed root(elevation and/or forceps removal). SURGICAL EXTRACTIONS D7210 Extraction,erupted tooth requiring removal of bone and/or sectioning of tooth,and including elevation of mucoperiosteal flap if indicated. D7220 Removal of impacted tooth-soft tissue. D7230 Removal of impacted tooth-partially bony. D7240 Removal of impacted tooth-completely bony. D7241 Removal of impacted tooth-completely bony,with unusual surgical complications. D7250 Removal of residual tooth roots(cutting procedure). D7251 Coronectomy-intentional partial tooth removal,impacted teeth only. D7252 Partial extraction for immediate implant placement. OTHER ORAL SURGERY D7260 Oroantral fistula closure. D7261 Primary closure of a sinus perforation. D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth. D7272 Tooth transplantation(includes reimplantation from one site to another and splinting and/or stabilization). D7280 Exposure of an unerupted tooth. D7282 Mobilization of erupted or malpositioned tooth to aid eruption. D7283 Placement of device to facilitate eruption of impacted tooth. TYPE 3 PROCEDURES D7310 Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces,per quadrant. D7311 Alveoplasty in conjunction with extractions-one to three teeth or tooth spaces,per quadrant. D7320 Alveoloplasty not in conjunction with extractions-four or more teeth or tooth spaces,per quadrant. D7321 Alveoplasty not in conjunction with extractions-one to three teeth or tooth spaces,per quadrant. D7340 Vestibuloplasty-ridge extension(secondary epithelialization). D7350 Vestibuloplasty-ridge extension(including soft tissue grafts,muscle reattachment,revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). D7410 Excision of benign lesion up to 1.25 cm. D7411 Excision of benign lesion greater than 1.25 cm. D7412 Excision of benign lesion,complicated. D7413 Excision of malignant lesion up to 1.25 cm. D7414 Excision of malignant lesion greater than 1.25 cm. D7415 Excision of malignant lesion,complicated. D7440 Excision of malignant tumor-lesion diameter up to 1.25 cm. D7441 Excision of malignant tumor-lesion diameter greater than 1.25 cm. D7450 Removal of benign odontogenic cyst or tumor-lesion diameter up to 1.25 cm. D7451 Removal of benign odontogenic cyst or tumor-lesion diameter greater than 1.25 cm. D7460 Removal of benign nonodontogenic cyst or tumor-lesion diameter up to 1.25 cm. D7461 Removal of benign nonodontogenic cyst or tumor-lesion diameter greater than 1.25 cm. D7465 Destruction of lesion(s)by physical or chemical method,by report. D7471 Removal of lateral exostosis(maxilla or mandible). D7472 Removal of torus palatinus. D7473 Removal of torus mandibularis. D7485 Reduction of osseous tuberosity. D7490 Radical resection of maxilla or mandible. D7509 Marsupialization of odontogenic cyst. D7510 Incision and drainage of abscess-intraoral soft tissue. D7520 Incision and drainage of abscess-extraoral soft tissue. D7530 Removal of foreign body from mucosa,skin,or subcutaneous alveolar tissue. D7540 Removal of reaction producing foreign bodies,musculoskeletal system. D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone. D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. D7910 Suture of recent small wounds up to 5 cm. D7911 Complicated suture-up to 5 cm. D7912 Complicated suture-greater than 5 cm. D7961 Buccal/labial frenectomy(frenulectomy). D7962 Lingual frenectomy(frenulectomy). D7963 Frenuloplasty. D7970 Excision of hyperplastic tissue-per arch. D7972 Surgical reduction of fibrous tuberosity. D7979 Non-surgical sialolithotomy. D7980 Surgical sialolithotomy. D7983 Closure of salivary fistula. REMOVAL OF BONE TISSUE:D7471,D7472,D7473 • Coverage is limited to 5 of any of these procedures per lifetime. BIOPSY OF ORAL TISSUE D7285 Incisional biopsy of oral tissue-hard(bone,tooth). D7286 Incisional biopsy of oral tissue-soft. D7287 Exfoliative cytological sample collection. D7288 Brush biopsy-transepithelial sample collection. APPLIANCE THERAPY D8210 Removable appliance therapy. D8220 Fixed appliance therapy. APPLIANCE THERAPY:D8210,D8220 • Coverage is limited to the correction of thumb-sucking. TYPE 3 PROCEDURES ANESTHESIA-LOCAL/NITROUS D9215 Local anesthesia in conjunction with operative or surgical procedures. D9230 Administration of nitrous oxide. ANESTHESIA-GENERAL/IV D9219 Evaluation for moderate sedation,deep sedation or general anesthesia. D9222 Administration of deep sedation/general anesthesia-first 15 minute increment,or any portion thereof. D9223 Administration of deep sedation/general anesthesia-each subsequent 15 minute increment, or any portion thereof. D9224 Administration of general anesthesia with advanced airway-first 15 minute increment,or any portion thereof. D9225 Administration of general anesthesia with advanced airway-each subsequent 15 minute increment,or any portion thereof. D9239 Administration of moderate sedation-intravenous first 15 minute increment,or any portion thereof. D9243 Administration of moderate sedation-intravenous-each subsequent 15 minute increment,or any portion thereof. GENERAL ANESTHESIA:D9222,D9223,D9224,D9225,D9239,D9243 • Coverage is only available with a cutting procedure.A maximum of four(D9222,D9223, D9224,D9225,D9239,D9243,D9246 or D9247)will be considered. OCCLUSAL ADJUSTMENT D9951 Occlusal adjustment-limited. D9952 Occlusal adjustment-complete. OCCLUSAL ADJUSTMENT:D9951,D9952 • Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of periodontal disease. COORDINATION OF BENEFITS This section applies if a covered person has dental coverage under more than one Plan definition below. All benefits provided under this plan are subject to this section. EFFECT ON BENEFITS. The Order of Benefit Determination rules below determine which Plan will pay as the primary Plan. If all or any part of an Allowable Expense under this Plan is an Allowable Expense under any other Plan,then benefits will be reduced so that,when they are added to benefits payable under any other Plan for the same service or supply,the total does not exceed 100%of the total Allowable Expense. If another Plan is primary and this Plan is considered secondary,the amount by which benefits have been reduced during the Claim Determination Period will be used by us to pay the Allowable Expenses not otherwise paid which were incurred by you in the same Claim Determination Period. We will determine our obligation to pay for Allowable Expenses as each claim is submitted,based on all claims submitted in the current Claim Determination Period. DEFINITIONS. The following apply only to this provision of the plan. 1. "Plan"refers to the group plan and any of the following plans,whether insured or uninsured,providing benefits for dental services or supplies: a. Any group or blanket insurance policy. b. Any group Blue Cross,group Blue Shield,or group prepayment arrangement. c. Any labor/management,trusteed plan, labor organization,employer organization,or employee organization plan,whether on an insured or uninsured basis. d. Any coverage under a governmental plan that allows coordination of benefits,or any coverage required or provided by law. This does not include a state plan under Medicaid(Title XVIII and XIX of the Social Security Act as enacted or amended). It also does not include any plan whose benefits by law are excess to those of any private insurance program or other non-governmental program. 2. "Plan"does not include the following: a. Individual or family benefits provided through insurance contracts,subscriber contracts,coverage through individual HMOs or other prepayment arrangements. b. Coverages for school type accidents only,including athletic injuries. 3. "Allowable Expense"refers to any necessary,reasonable and customary item of expense at least a portion of which is covered under at least one of the Plans covering the person for whom that claim is made. When a Plan provides services rather than cash payments,the reasonable cash value of each service will be both an Allowable Expense and a benefit paid. Benefits payable under another Plan include benefits that would have been payable had a claim been made for them. 4. "Claim Determination Period"refers to a Benefit Period,but does not include any time during which a person has no coverage under this Plan. 5. "Custodial Parent"refers to a parent awarded custody of a minor child by a court decree. In the absence of a court decree,it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation. 9300 ORDER OF BENEFIT DETERMINATION. When two or more Plans pay benefits,the rules for determining the order of payment are as follows: 1. A Plan that does not have a coordination of benefits provision is always considered primary and will pay benefits first. 2. If a Plan also has a coordination of benefits provision,the first of the following rules that describe which Plan pays its benefits before another Plan is the rule to use: a. The benefits of a Plan that covers a person as an employee,member or subscriber are determined before those of a Plan that covers the person as a dependent. b. If a Dependent child is covered by more than one Plan,then the primary Plan is the Plan of the parent whose birthday is earlier in the year if: i. the parents are married; ii. the parents are not separated(whether or not they ever have been married); or iii. a court decree awards joint custody without specifying that one party has the responsibility to provide dental coverage. If both parents have the same birthday,the Plan that covered either of the parents longer is primary. c. If the Dependent child is covered by divorced or separated parents under two or more Plans, benefits for that Dependent child will be determined in the following order: i. the Plan of the Custodial Parent; ii. the Plan of the spouse of the Custodial Parent; iii. the Plan of the non-Custodial Parent;and then iv. the Plan of the spouse of the non-Custodial Parent. However, if the specific terms of a court decree establish a parent's responsibility for the child's dental expenses and the Plan of that parent has actual knowledge of those terms,that Plan is primary. This rule applies to Claim Determination Periods or Benefit Periods commencing after the Plan is given notice of the court decree. d. The benefits of a Plan that cover a person as an employee who is neither laid off nor retired(or as that employee's dependent)are determined before those of a Plan that covers that person as a laid-off or retired employee(or as that employee's dependent). If the other Plan does not have this rule, and if, as a result,the Plans do not agree on the order of benefits, this rule will be ignored. e. If a person whose coverage is provided under a right of continuation provided by a federal or state law also is covered under another Plan,the Plan covering the person as an employee, member, subscriber or retiree(or as that person's dependent) is primary, and the continuation coverage is secondary. If the other Plan does not have this rule, and if, as a result,the Plans do not agree on the order of benefits,this rule will be ignored. f. The benefits of a Plan that has covered a person for a longer period will be determined first. If the preceding rules do not determine the primary Plan,the allowable expenses shall be shared equally between the Plans meeting the definition of Plan under this provision. In addition,this Plan will not pay more than what it would have paid had it been primary. RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION. We may without your consent and notice to you: 1. Release any information with respect to your coverage and benefits under the plan;and 2. Obtain from any other insurance company,organization or person any information with respect to your coverage and benefits under another Plan. You must provide us with any information necessary to coordinate benefits. FACILITY OF PAYMENT. When other Plans make payments that should have been made under this Plan according to the above terms,we will,at our discretion,pay to any organizations making these payments any amounts that we decide will satisfy the intent of the above terms. Amounts paid in this way will be benefits paid under this Plan. We will not be liable to the extent of these payments. RIGHT OF RECOVERY. When we make payments for Allowable Expenses in excess of the amount that will satisfy the intent of the above terms,we will recover these payments,to the extent of the excess,from any persons or organizations to or for whom these payments were made. The amount of the payments made includes the reasonable cash value of any benefits provided in the form of services. GENERAL PROVISIONS NOTICE OF CLAIM. Written notice of a claim must be given to us within 30 days after the incurred date of the services provided for which benefits are payable. Notice must be given to us at our Home Office,or to one of our agents. Notice should include the Planholder's name,Member's name,and plan number. If it was not reasonably possible to give written notice within the 30 day period stated above,we will not reduce or deny a claim for this reason if notice is filed as soon as is reasonably possible. CLAIM FORMS. When we receive the notice of a claim,we will send the claimant forms for filing proof of loss. If these forms are not furnished within 15 days after the giving of such notice,the claimant will meet our proof of loss requirements by giving us a written statement of the nature and extent of loss within the time limit for filing proofs of loss. PROOF OF LOSS. Written proof of loss must be given to us within 90 days after the incurred date of the services provided for which benefits are payable. If it is impossible to give written proof within the 90 day period,we will not reduce or deny a claim for this reason if the proof is filed as soon as is reasonably possible. TIME OF PAYMENT. We will pay all benefits immediately when we receive due proof. Any balance remaining unpaid at the end of any period for which we are liable will be paid at that time. PAYMENT OF BENEFITS. All benefits will be paid to the Member unless otherwise agreed upon through your authorization or Provider contracts. FACILITY OF PAYMENT. If a Member or beneficiary is not capable of giving us a valid receipt for any payment or if benefits are payable to the estate of the Member,then we may,at our option,pay the benefit up to an amount not to exceed$5,000 to any relative by blood or connection by marriage of the Member who is considered by us to be equitably entitled to the benefit. Any equitable payment made in good faith will release us from liability to the extent of payment. PROVIDER-PATIENT RELATIONSHIP. The Member may choose any Provider who is licensed by the law of the state in which treatment is provided within the scope of their license. We will in no way disturb the Provider-patient relationship. LEGAL PROCEEDINGS. No legal action can be brought against us until 60 days after the Member sends us the required proof of loss. No legal action against us can start more than five years after proof of loss is required. INCONTESTABILITY. Any statement made by the Planholder to obtain the Plan is a representation and not a warranty. No misrepresentation by the Planholder will be used to deny a claim or to deny the validity of the Plan unless: 1. The Plan would not have been issued if we had known the truth;and 2. We have given the Planholder a copy of a written instrument signed by the Planholder that contains the misrepresentation. The validity of the Plan will not be contested after it has been in force for one year,except for nonpayment of fees or fraudulent misrepresentations. WORKER'S COMPENSATION. The coverage provided under the Plan is not a substitute for coverage under a worker's compensation or state disability income benefit law and does not relieve the Planholder of any obligation to provide such coverage. 9310 ERISA INFORMATION AND NOTICE OF YOUR RIGHTS A. Eligibility and Benefits Provided Under the Group Plan Please refer to the Conditions for Coverage within the Group Plan and Document of Coverage for a detailed description of the eligibility for participation under the plan as well as the benefits provided. If this plan includes a participating provider(PPO)option,provider lists are furnished without charge,as a separate document. If you have any questions about your benefits or concerns about our services related to this Group Plan,you may call Customer Service Toll Free at 1-800-999-9789. B. Qualified Medical Child Support Order("QMCSO") QMCSO Determinations. A Plan participant or beneficiary can obtain,without charge,a copy of the Plan's procedures governing Qualified Medical Child Support Order determinations from the Plan Administrator. C. Termination Of The Group Plan The Group Plan which provides benefits for this plan may be terminated by the Planholder at any time with prior written notice to Ameritas Life Insurance Corp. It will terminate automatically if the Planholder fails to pay the required fees.Ameritas Life Insurance Corp.may terminate the Group Plan on any Fee Due Date if the number of persons covered is less than the required minimum,or if Ameritas Life Insurance Corp.believes the Planholder has failed to perform its obligations relating to the Group Plan. After the first Plan year,Ameritas Life Insurance Corp.may also terminate the Group Plan on any Fee Due Date for any reason by providing a 30-day advance written notice to the Planholder. The Group Plan may be changed in whole or in part.No change or amendment will be valid unless it is approved in writing by a Ameritas Life Insurance Corp.executive officer. D. Claims For Benefits Claims procedures are furnished automatically,without charge,as a separate document. E. Continuation of Coverage Provisions(COBRA) COBRA(Consolidated Omnibus Budget Reconciliation Act of 1985)gives Qualified Beneficiaries the right to elect COBRA continuation after the Plan ends because of a Qualifying Event. The law generally covers group health plans maintained by employers with 20 or more employees in the prior year. The law does not,however,apply to plans sponsored by the Federal government and certain church-related organizations. i. Definitions For This Section Qualified Beneficiary means a Covered Person who is covered by the plan on the day before a qualifying event.Any child born to or placed for adoption with a covered employee during the period of COBRA coverage is considered a qualified beneficiary. A Qualifying Event occurs when: 1. The Member dies(hereinafter referred to as Qualifying Event 1); ERISA Notice 2. The Member's employment terminates for reasons other than gross misconduct as determined by the Employer(hereinafter referred to as Qualifying Event 2); 3. The Member's work hours fall below the minimum number required to be a Member (hereinafter referred to as Qualifying Event 3); 4. The Member becomes divorced or legally separated from a Spouse(hereinafter referred to as Qualifying Event 4); 5. The Member becomes entitled to receive Medicare benefits under Title XVII of the Social Security Act(hereinafter referred to as Qualifying Event 5); 6. The Child of a Member ceases to be a Dependent(hereinafter referred to as Qualifying Event 6); 7. The Employer files a petition for reorganization under Title 11 of the U.S. Bankruptcy Code,provided the Member is retired from the Employer and is covered on the date the petition is filed(hereinafter referred to as Qualifying Event 7). ii. Electing COBRA Continuation A. Each Qualified Beneficiary has the right to elect to continue coverage that was in effect on the day before the Qualifying Event.The Qualified Beneficiary must apply in writing within 60 days of the later of: 1. The date on which this plan would otherwise end; 2. The date on which the Employer or Plan Administrator gave the Qualified Beneficiary notice of the right to COBRA continuation. B. A Qualified Beneficiary who does not elect COBRA Continuation coverage during their original election period may be entitled to a second election period if the following requirements are satisfied: 1. The Member's Coverage ended because of a trade related termination of their employment,which resulted in being certified eligible for trade adjustment assistance; 2. The Member is certified eligible for trade adjustment assistance(as determined by the appropriate governmental agency)within 6 months of the date Coverage ended due to the trade related termination of their employment;and 3. The Qualified Beneficiary must apply in writing within 60 days after the first day of the month in which they are certified eligible for trade adjustment assistance. iii. Notice Requirements 1. When the Member becomes covered,the Plan Administrator must inform the Member and Spouse in writing of the right to COBRA continuation. 2. The Qualified Beneficiary must notify the Plan Administrator in writing of Qualifying Event 4 or 6 above within 60 days of the later of: a. The date of the Qualifying Event;or b. The date on which the Qualified Beneficiary loses coverage due to the Qualifying Event. 3. A Qualified Beneficiary,who is entitled to COBRA continuation due to the occurrence of Qualifying Event 2 or 3 and who is disabled at any time during the first 60 days of continuation coverage as determined by the Social Security Administration pursuant to Title II or XVI of the Social Security Act,must notify the Plan Administrator of the disability in writing within 60 days of the later of: a. The date of the disability determination; b. The date of the Qualifying Event;or c. The date on which the Qualified Beneficiary loses coverage due to the Qualifying Event. 4. Each Qualified Beneficiary who has become entitled to COBRA continuation with a maximum duration of 18 or 29 months must notify the Plan Administrator of the occurrence of a second Qualifying Event within 60 days of the later of: a. The date of the Qualifying Event;or b. The date on which the Qualified Beneficiary loses coverage due to the Qualifying Event. 5. The Employer must give the Plan Administrator written notice within 30 days of the occurrence of Qualifying Event 1,2,3, 5,or 7. 6. Within 14 days of receipt of the Employer's notice,the Plan Administrator must notify each Qualified Beneficiary in writing of the right to elect COBRA continuation. In order to protect your rights,Members and Qualified Beneficiaries should inform the Plan Administrator in writing of any change of address. iv. COBRA Continuation Period 1. 18-month COBRA Continuation Each Qualified Beneficiary may continue Coverage for up to 18 months after the date of Qualifying Event 2 or 3. 2. 29-month COBRA Continuation Each Qualified Beneficiary,who is entitled to COBRA continuation due to the occurrence of Qualifying Event 2 or 3 and who is disabled at any time during the first 60 days of continuation coverage as determined by the Social Security Administration pursuant to Title II or XVI of the Social Security Act,may continue coverage for up to 29 months after the date of the Qualifying Event. All Covered Persons in the Qualified Beneficiary's family may also continue coverage for up to 29 months. 3. 36-Month COBRA Continuation If you are a Dependent,you may continue coverage for up to 36 months after the date of Qualifying Event 1,4,5,or 6. Each Qualified Beneficiary who is entitled to continue Coverage for 18 or 29 months may be eligible to continue coverage for up to 36 months after the date of their original Qualifying Event if a second Qualifying Event occurs while they are on continuation coverage. Note: The total period of COBRA continuation available in 1 through 3 will not exceed 36 months. 4. COBRA Continuation For Certain Bankruptcy Proceedings If the Qualifying Event is 7,the COBRA continuation period for a retiree or retiree's Spouse is the lifetime of the retiree. Upon the retiree's death, the COBRA continuation period for the surviving Dependents is 36 months from the date of the retiree's death. v. Fee Requirements The Plan continued under this provision will be retroactive to the date the Plan would have ended because of a Qualifying Event. The Qualified Beneficiary must pay the initial required fee not later than 45 days after electing COBRA continuation,and monthly fee on or before the Fee Due Date thereafter. The monthly fee is a percentage of the total fee (both the portion paid by the employee and any portion paid by the employer)currently in effect on each Fee Due Date. The fee may change after you cease to be Actively at Work. The percentage is as follows: 18 month continuation- 102% 29 month continuation- 102%during the first 18 months, 150%during the next 11 months 36 month continuation- 102% vivi. When COBRA Continuation Ends COBRA continuation ends on the earliest of: 1. The date the Group Plan terminates; 2. 31 days after the date the last period ends for which a required fee payment was made; 3. The last day of the COBRA continuation period 4 The date the Qualified Beneficiary first becomes entitled to Medicare coverage under Title XVII of the Social Security Act; 5. The first date on which the Qualified Beneficiary is: (a)covered under another group Dental Plan and (b)not subject to any preexisting condition limitation in that Plan. F. Your Rights under ERISA As a participant in this Plan,you are entitled to certain rights and protections under the Employment Retirement Income Security Act of 1974(ERISA). ERISA provides that all plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine,without charge,at the plan administrator's office and at other specified locations,such as work-sites and union halls,all documents governing the plan, including contracts and collective bargaining agreements,and a copy of the latest annual report (Form 5500 Series)filed by the plan with the U.S.Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration. Obtain,upon written request to the plan administrator,copies of documents governing the operation of the plan, including contracts and collective bargaining agreements,and copies of the latest annual report(Form 5500 Series)and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the plan's annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself,spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan,called"fiduciaries"of the plan,have a duty to operate and administer this plan prudently and in the interest of you and other plan participants and beneficiaries. No one,including your employer,your union,or any other person,may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored,in whole or in part,you have a right to know why this was done,to obtain copies of documents relating to the decision without charge,and to appeal any denial,all within certain time schedules. Under ERISA,there are steps you can take to enforce the above rights. For instance,if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days,you may file suit in a Federal court. In such a case,the court may require the plan administrator to provide the materials and pay you up to$110 a day until you receive the materials,unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part,you may file suit in a state or Federal court. If it should happen that plan fiduciaries misuse the plan's money,or if you are discriminated against for asserting your rights,you may seek assistance from the U.S.Department of Labor,or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose,the court may order you to pay these costs and fees,for example,if it finds your claim is frivolous. Assistance with Your Rights If you have any questions about your plan,you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA,or if you need assistance in obtaining documents from the plan administrator,you should contact the nearest office of the Pension and Welfare Benefits Administration,U.S. Department of Labor,listed in your telephone directory or the Division of Technical Assistance and Inquiries,Pension and Welfare Benefits Administration,U.S.Department of Labor,200 Constitution Avenue N.W.,Washington,D.C.20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration. CLAIMS REVIEW PROCEDURES AS REQUIRED UNDER EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) The following provides information regarding the claims review process and your rights to request a review of any part of a claim that is denied. Please note that certain state laws may also require specified claims payment procedures as well as internal appeal procedures and/or independent external review processes. Therefore, in addition to the review procedures defined below,you may also have additional rights provided to you under state law. CLAIMS FOR BENEFITS Claims may be submitted by mailing the completed claim form along with any requested information to: Ameritas Life Insurance Corp. PO Box 82520 Lincoln,NE 68501 NOTICE OF DECISION OF CLAIM We will evaluate your claim promptly after we receive it. Dental Utilization Review Program. Generally,utilization review means a set of criteria designed to monitor the use of,or evaluate the medical necessity,appropriateness,or efficiency of health care services. We have established a utilization review program to ensure that any guidelines and criteria used to evaluate the medical necessity of a healthcare service are clearly documented and include procedures for applying such criteria based on the needs of the individual patients. The program was developed in conjunction with licensed dentists and is reviewed at least annually to ensure that criteria are applied consistently and are current with dental technology, evidence-based research and any dental trends. We will provide you written notice regarding the payment under the claim within 30 calendar days following receipt of the claim. This period may be extended for an additional 15 days,provided that we have determined that an extension is necessary due to matters beyond our control,and notify you,prior to the expiration of the initial 30-day period,of the circumstances requiring the extension of time and the date by which we expect to render a decision. If the extension is due to your failure to provide information necessary to decide the claim,the notice of extension shall specifically describe the required information we need to decide the claim. If we request additional information,you will have 45 days to provide the information. If you do not provide the requested information within 45 days,we may decide your claim based on the information we have received. If we deny any part of your claim,you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Plan on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision,along with your right to receive a copy of these guidelines,free of charge,upon request. d. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to exclude expenses that are experimental or investigational,or are not necessary or accepted according to generally accepted standards of Dental practice. e. A description of any additional information needed to support your claim and why such information is necessary. f. Information concerning your right to a review of our decision. g. Information concerning your right to bring a civil action for benefits under section 502(a)of ERISA following an adverse benefit determination on review. APPEAL PROCEDURE If all or part of a claim is denied,you may request a review in writing within 180 days after receiving notice of the benefit denial. You may send us written comments or other items to support your claim. You may review and receive copies of any non-privileged information that is relevant to your appeal. There will be no charge for such copies. You may request the names of the experts we consulted who provided advice to us about your claim. The appeal review will be conducted by the Plan's named fiduciary and will be someone other than the person who denied the initial claim and will not be subordinate to that person.The person conducting the review will not give deference to the initial denial decision. If the denial was based in whole or in part on a medical judgment, including determinations with regard to whether a service was considered experimental,investigational,and/or not medically necessary,the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original judgment and will not be subordinate to that person. Our review will include any written comments or other items you submit to support your claim. We will review your claim promptly after we receive your request. If your appeal is about urgent care,you may call Toll Free at 877-897-4328,and an Expedited Review will be conducted. Verbal notification of our decision will be made within 72 hours,followed by written notice within 3 calendar days after that. If your appeal is about benefit decisions related to clinical or medical necessity,a Standard Consultant Review will be conducted. A written decision will be provided within 30 calendar days of the receipt of the request for appeal. If your appeal is about benefit decisions related to coverage,a Standard Administrative Review will be conducted. A written decision will be provided within 60 calendar days of the receipt of the request for appeal. If we deny any part of your claim on review,you will receive a written notice of denial containing: a. The reasons for our decision. b. Reference to the parts of the Group Plan on which our decision is based. c. Reference to any internal rule or guideline relied upon in making our decision along with your right to receive a copy of these guidelines,free of charge,upon request. d. Information concerning your right to receive, free of charge,copies of non-privileged documents and records relevant to your claim. e. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to exclude expenses that are experimental or investigational,or are not necessary or accepted according to generally accepted standards of Dental practice. f. Information concerning your right to bring a civil action for benefits under section 502(a)of ERISA. Certain state laws also require specified internal appeal procedures and/or external review processes. In addition to the review procedures defined above,you may also have additional rights provided to you under state law. Please review your certificate of coverage for such information,call us,or contact your state regulatory agency for assistance. In any event,you need not exhaust such state law procedures prior to bringing civil action under Section 502(a)of ERISA. Any request for appeal should be directed to: Quality Control,P.O.Box 82657,Lincoln,NE 68501-2657. Addendum B - Administrative Service Charges Administrative Service Charges The Administrative Service Charges from Effective Date through 12/31/2028 $4.08 per Covered Persons per month Fees shown above are based on the services outlined in Section II. Services to be Provided by Ameritas. Addendum C - Performance Guarantees Initial Term Performance Commitments and Penalties Category Defined Commitment Measure Penalty Turnaround 90% of clean claims will be processed within 10 Aggregate Time business days of receipt, measured on an annual - S500 basis. All Claims Financial accuracy rate of 99%, measured on an Claims annual basis. A financial error is considered as Aggregate Accuracy- any item incorrectly processed on a claim that - S500 Financial results in the underpayment or overpayment of All Claims benefits on that claim. Processing accuracy rate of 96%, measured on an annual basis. A processing error is considered Claims as any item incorrectly processed on a claim that Aggregate Accuracy- does not result in a payment error on that claim. - S500 Processing Any item incorrectly processed on a claim equals All Claims one error and no more than one processing error is counted per claim. Call - Service Ameritas guarantees a service level of 80% of Aggregate Level calls answered in 30 seconds, measured on an - S500 annual basis for all calls received. All Calls Call Call abandonment rate of 5 or less, measured Aggregate Jo Abandonment S500 on an annual basis. Rate All Calls Total Initial Term Guarantee $2,500 Addendum D - Summary of Reports Weekly Reports Paid/Denied Claims Report Monthly Reports Fees List Bill Annual Reports Experience Detail Report Customer Reporting Package Claim Payment Summary Claim Payment Breakdown by Procedure Type Claim Summary—PPO vs.Non-PPO Claim Payment analysis by Procedure Group Claim Payment analysis by Category within Procedure Group Claims Savings Categories Claims Savings Categories—PPO Claims Savings Categories—Non-PPO PPO Savings Illustration Fees include this reporting package. Deviations from these reports and/or frequency will be priced accordingly. ADDENDUM E HIPAA BUSINESS ASSOCIATE ADDENDUM This HIPAA Business Associate Addendum ("BAA") supplements and is made a part of the Administrative Services Agreement ("Service Agreement") by and between Ameritas ("Business Associate") and the party identified in the Service Agreement above ("Covered Entity"). Covered Entity and Business Associate shall be collectively referred to herein as the("Parties"). RECITALS A. Covered Entity and Business Associate have entered or may enter into one or more services agreements(collectively the"Service Agreement")pursuant to which Business Associate is or will be providing those certain agreed upon services for and on behalf of Covered Entity,some of which may involve Business Associate's use, disclosure or creation of Protected Health Information. B. Covered Entity and Business Associate intend to protect the privacy and provide for the security of Protected Health Information received, created, used, and disclosed to or by Business Associate pursuant to the Service Agreement in compliance with HIPAA and HITECH(each as defined below). C. As part of the HIPAA and HITECH,the Standards for Privacy and the Standards for Security of Individually Identifiable Health Information codified at 45 CFR Parts 160, 162 and 164 require Covered Entity to enter into a contract with Business Associate that includes and imposes on Business Associate specific duties, obligations and requirements with respect to Business Associate's use, disclosure, creation and general handling of Protected Health Information, as set forth in, but not limited to, Title 45, §§ 164.502(e) and 164.504(e) of the Code of Federal Regulations("CFR")and as otherwise provided in this BAA. In consideration of the mutual promises below and the exchange of information pursuant to this BAA, the Parties agree as follows: 1) Definitions. a) Specific Definitions. i) "Breach" shall have the meaning given to such term under the Privacy Rule, at 45 CFR § 164.402. ii) "Business Associate" shall have the meaning set forth above. iii) "Compliance Date" shall mean, in each case, the date by which compliance with a particular provision is required under HITECH;provided that, in any case for which that date occurs prior to the effective date of this BAA,the Compliance Date shall mean the effective date of this BAA. iv) "Covered Entity" shall have the meaning set forth above. v) "Data Aggregation"shall have the meaning given to such term under the Privacy Rule at 45 CFR§ 164.501. vi) "Designated Record Set" shall have the meaning given to such term under the Privacy Rule,at 45 CFR§ 164.501. vii) "Electronic Health Record" shall have the meaning given to such term in 42 USC 17921(5). viii) "Electronic Media"has the meaning in CFR§160.103,which is: (1) Electronic storage media including memory devices in computers(hard drives)and any removable or transportable digital memory medium, such as magnetic tape or disk, optical disk,or digital memory card; or (2) Transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the Internet, extranet, leased lines, dialup lines, private networks, and the physical movement of removable or transportable electronic storage media. Certain transmissions, including paper, via facsimile, and via telephone, are not considered transmissions via electronic media because the information did not exist in electronic form before the transmission. ix) "Electronic Protected Health Information" (or "EPHI") has the meaning of 45 CFR § 160.103 and is defined as protected health information contained in or transmitted on electronic media received from us or created or received on behalf of us. x) "Health Care Operations" shall have the meaning given to such term under the Privacy Rule at 45 CFR 164.501. xi) "HIPAA"shall mean the Health Insurance Portability and Accountability Act,42 U.S.C. §§ 1320d through 1320d-8, as amended from time to time, and all associated existing and future implementing regulations,when effective and as amended from time to time. xii) "HITECH" shall mean Subtitle D of the Health Information Technology for Economic and Clinical Health Act (a.k.a. the "HITECH Act") provisions of the American Recovery and Reinvestment Act of 2009, 42 U.S.C. §§17921-17954, as amended from time to time, and all associated existing and future implementing regulations, when effective and as amended from time to time. xiii) "Individual" shall mean the person who is the subject of PHI and shall include a person who qualifies as a personal representative in accordance with the Privacy Rule. xiv) "Privacy Rule" shall mean the standard for Privacy of Individually Identifiable Health Information codified at 45 CFR Parts 160 and 164. xv) "Protected Health Information"("PHI")has the meaning in 45 CFR§ 164.304. xvi) "Required by Law"shall mean a mandate contained in law that compels a covered entity to make a use or disclosure of PHI and that is enforceable in a court of law. xvii) "Security Rule"shall mean the standard for Security of Individually Identifiable Health Information codified at 45 CFR Parts 160, 162 and 164. xviii)"Security Incident" has the meaning in 45 CFR § 164.304, which is the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations. xix) "Subcontractor" shall have the meaning given to such term at 45 CFR § 160.103 and includes any agent/agency relationships. xx) "Unsecured Protected Health Information" (or "unsecured PHI") shall mean Protected Health Information has the meaning as set forth in 45 C.F.R. 164.402.that is not rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of a technology or methodology specified by the Secretary in the regulations or guidance issued pursuant to 42 U.S.C. §§17932(h)(2). xxi) "Unsuccessful Security Incident"shall mean,without limitation,pings and other broadcast attacks on Business Associate's firewall,port scans,unsuccessful log-on attempts,denial of service attacks, and any combination of the above, so long as no such incident results in unauthorized access, use, disclosure, modification or destruction of PHI or intentional interference with system operations in an information system that contains PHI. b) Catch-all Definition. Terms used,but not otherwise defined, in this Addendum shall have the same meaning as those terms in the Privacy Rule and Security Rule. 2) Obligations of Business Associate. a) Permitted Uses. Business Associate shall not use PHI except for the purpose of performing Business Associate's obligations under the Service Agreement and as permitted or required by this BAA. Further, Business Associate shall not use PHI in any manner that would constitute a violation of the Privacy Rule if so used by Covered Entity. However, Business Associate may (i) use PHI for the proper management and administration of Business Associate and to carry out the legal responsibilities of Business Associate, and (ii) provide Data Aggregation services relating to the health care operations of Covered Entity if such services are provided by Business Associate to Covered Entity under the Service Agreement. b) Permitted Disclosures. Business Associate shall not disclose PHI in any manner that would constitute a violation of HITECH and HIPAA(including without limitation the Privacy Rule) if disclosed by Covered Entity. However, Business Associate may disclose PHI in a manner permitted pursuant to the Service Agreement, for the proper management and administration of Business Associate;and as required by law. Additionally, Business Associate may disclose PHI in a manner allowed by law if Covered Entity specifically authorizes the disclosure. In no event shall Business Associate be permitted to receive remuneration, either directly or indirectly, in exchange for PHI, except as may be approved by Covered Entity in its sole discretion and then, only to the extent permitted by 42 U.S.C. § 17935(d). To the extent that Business Associate discloses PHI to a third party,Business Associate must prior to making any such disclosure obtain, (i)reasonable assurances from such third party that such PHI will be held confidential as provided pursuant to this BAA and only disclosed as required by law or for the purposes for which it was disclosed to such third party,and(ii)an agreement from such third party to immediately notify Business Associate of any breaches of confidentiality of the PHI,to the extent it has obtained knowledge of such breach. c) Appropriate Safeguards. i) Business Associate will comply with all applicable federal and states laws and regulations and implement administrative,physical,and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of EPHI that it creates, receives,maintains,or transmits on behalf of the Covered Entity as required by the Security Rule and as of the Compliance Date of 42 U.S.C. § 17931,comply with the Security Rule requirements set forth in 45 C.F.R. §§ 164.308, 164.310, 164.312,and 164.316; ii) Business Associate agrees to ensure that any agent, including a subcontractor,to whom it provides EPHI agrees to implement reasonable and appropriate safeguards to protect it; and iii) Business Associate will report to Covered Entity as soon as reasonably practicable(i)any use or disclosure of protected health information not provided for by this BAA of which it becomes aware in accordance with 45 C.F.R. § 164.504(e)(2)(ii)(C); and/or (ii) any security incident affecting EPHI of which Business Associate becomes aware in accordance with 45 C.F.R. § 164.314(a)(2)(C) provided, however, that the Parties acknowledge and agree that this Section constitutes notice by Business Associate to Covered Entity of the ongoing existence and occurrence of Unsuccessful Security Incidents for which no additional notice to Ameritas shall be required;and iv) Business Associate agrees to promptly report to Covered Entity any Breach of which it becomes aware as soon as reasonably practicable following Business Associate's discovery of any Breach involving Covered Entity's unsecured PHI. The foregoing report shall include identification of each Individual whose PHI Business Associate reasonably believes to have been accessed, acquired, or disclosed during such Breach. As soon as possible thereafter,and to the extent known,Business Associate shall also provide Covered Entity with a description of(i) what happened, including the date of the Breach and the date of the discovery,(ii)the types of unsecured PHI involved in the Breach,(iii)any steps individuals should take to protect themselves from potential harm from the Breach, and (iv) what Business Associate is doing to investigate the Breach, to mitigate harm to individuals,and to protect against any further Breaches. d) Restrictions on Disclosures. Business Associate will restrict its disclosures of the Individual's PHI in the same manner as would be required for Covered Entity. If Business Associate receives an Individual's request for restrictions,Business Associate shall forward such request to Covered Entity within ten(10)business days. e) Subcontractors. Business Associate shall ensure that any Subcontractor, to whom it provides PHI agree in writing to the same or substantially similar restrictions and conditions that apply to Business Associate with respect to such PHI.Business Associate will advise Covered Entity if any such Subcontractor breaches its agreement with Business Associate with respect to the disclosure or use of Covered Entity's Protected Health Information or EPHI. f) Access to Protected Information. Business Associate shall make PHI maintained by Business Associate or its agents or subcontractors in Designated Record Sets available to Covered Entity for inspection and copying to enable Covered Entity to fulfill its obligations under the Privacy Rule, including,but not limited to 45 CFR Section 164.524. g) Amendment of PHI. Upon receipt of a request from Covered Entity for an amendment of PHI or a record about an individual contained in a Designated Record Set, Business Associate or its agents or subcontractors shall make such PHI available to Covered Entity for amendment and incorporate any such amendment to enable Covered Entity to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 CFR Section 164.526. If any individual requests an amendment of PHI directly from Business Associate or its agents or subcontractors, Business Associate shall notify Covered Entity in writing within ten(10)days of the request. Any decision to deny the requested amendment of PHI maintained by Business Associate or its agents or subcontractors shall be the sole responsibility of Covered Entity. h) Accounting Rights. Upon request for an accounting of disclosures of PHI from Covered Entity, Business Associate and its agents or subcontractors shall make available to Covered Entity the information required to provide an accounting of disclosures to enable Covered Entity to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 CFR Section 164.528. As set forth in,and as limited by,45 CFR section 164.528,Business Associate shall not provide an accounting to Covered Entity of disclosures: (i)to carry out treatment, payment or health care operations, as set forth in 45 CFR Section 164.502; (ii)to individuals of PHI about them as set forth in 45 CFR 164.502; (iii) to persons involved in the individual's care or other notification purposes as set forth in 45 CFR Section 164.510; (iv) for national security or intelligence purposes as set forth in 45 CFR Section 164.512(k)(2); or (v) to correctional institutions or law enforcement officials as set forth in 45 CFR Section 164.512(k)(5). Business Associate agrees to implement a process that allows for an accounting to be collected and maintained by Business Associate and its agents or subcontractors for at least six (6) years prior to the request, but not before the compliance date of the Privacy rule. In the event that the request for an accounting is delivered directly to Business Associate or its agents or subcontractors, Business Associate shall forward it to Covered Entity. It shall be Covered Entity's responsibility to prepare and deliver any such accounting requested. Business Associate shall not disclose any PHI except as set forth in Sections 2(b)of this BAA. i) Governmental Access to Records. If requested, Business Associate shall make its internal practices,books and records relating to the use and disclosure of PHI available to the Secretary of the U.S. Department of Health and Human Services (the "Secretary") for purposes of determining Covered Entity's compliance with Privacy Rule in accordance with 45 CFR 164.504(e)(ii)(I). j) Minimum Necessary. Business Associate (and its agents and subcontractors) shall only request,use and disclose the minimum amount of PHI necessary to accomplish the purpose of the request,use or disclosure and consistent with Covered Entity's minimum necessary policies and procedures. k) Data Ownership. Business Associate acknowledges that Business Associate has no ownership rights with respect to the PHI. I) Retention of PHI. Upon termination of the Service Agreement for any reason, Business Associate shall return or destroy all PHI that Business Associate or its agents or subcontractors still maintain in any form and shall retain no copies of such PHI. If return or destruction is not feasible, Business Associate shall continue to extend the legally required protections of this BAA to such information, and limit further use of such PHI to those purposes that make the return or destruction of such PHI infeasible. If Business Associate elects to destroy the PHI, Business Associate shall certify in writing to Covered Entity that such PHI has been destroyed. m) Electronic Health Record. In the event that Business Associate in connection with rendering the services under the Service Agreement uses or maintains an Electronic Health Record of PHI of or about an individual,the Business Associate will provide an electronic copy of such PHI in accordance with 42 U.S.C. § 17935(e) as of its Compliance Date. Moreover, in the event that Business Associate uses or maintains an Electronic Health Record of PHI of or about an individual,then Business Associate shall make an accounting of disclosures of such PHI in accordance with the requirements for accounting of disclosures made through an Electronic Health Record in 42 U.S.C. 17935(c),as of its Compliance Date. n) Business Associate will not make or cause to be made any communication about a product or service that is prohibited by 42 U.S.C. § 17936(a)as of its Compliance Date. o) Business Associate will not make or cause to be made any written fundraising communication that is prohibited by 42 U.S.C. § 17936(b)as of its Compliance Date. p) Pursuant to the Privacy Rule, made applicable to Business Associate by HITECH, Business Associate shall adopt, implement, and follow privacy policies and procedures in the same manner and to the same extent as if it were a Covered Entity. q) Pursuant to the Security Rule, made applicable to Business Associate by HITECH, Business Associate shall adopt, implement, and follow security policies and procedures in the same manner and to the same extent as if it were a Covered Entity. 3) Obligations of Covered Entity. a) Covered Entity shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of PHI transmitted to Business Associate pursuant to this BAA, in accordance with the Covered Entity and requirements of the Privacy Rule, until such PHI is received by Business Associate. b) Covered Entity shall notify Business Associate of any limitation(s) in its notice of privacy practices of Covered Entity in accordance with 45 CFR § 164.520, to the extent that such limitation may affect Business Associate's use or disclosure of PHI. c) Covered Entity shall notify Business Associate of any changes in,or revocation of,permission by Individual to use or disclose PHI, to the extent that such changes may affect Business Associate's use or disclosure of PHI. d) Covered Entity shall notify Business Associate of any restriction to the use or disclosure of PHI that Covered Entity has agreed to in accordance with 45 CFR§ 164.522,to the extent that such restriction may affect Business Associate's use or disclosure of PHI. 4) Term and Termination. a) Term. This BAA shall be effective as of the effective date of the underlying Service Agreement and shall terminate when all of the PHI provided by Covered Entity to Business Associate,or created or received by Business Associate on behalf of Covered Entity,is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroy PHI, protections are extended to such information, in accordance with the termination provision in this section. b) Material Breach. A breach by Business Associate of any provision of this BAA,as determined by Covered Entity, shall constitute a material breach of the Service Agreement and shall provide grounds for immediate termination of the Service Agreement by Covered Entity pursuant to the Service Agreement. c) Reasonable Steps to Cure Breach. If Covered Entity knows of a pattern of activity or practice of Business Associate that constitutes a material breach or violation of Business Associate's obligations under the provisions of this BAA or another arrangement and does not terminate the Service Agreement pursuant to Section 4 (b), then Covered Entity shall take reasonable steps to cure such breach or end such violation, as applicable. If Covered Entity's efforts to cure such breach or end such violation are unsuccessful, Covered Entity shall either (i) terminate the Service Agreement, if feasible,or(ii) if termination of the Service Agreement is not feasible, Covered Entity shall report Business Associate's breach or violation to the Secretary of the Department of Health and Human Services. d) Judicial or Administrative Proceedings. Either party may terminate the Service Agreement, effective immediately, if(i) the other party is named as a defendant in a criminal proceeding for a violation of HIPAA, HITECH or other security or privacy laws or (ii) a finding or stipulation that the other party has violated any requirement of HIPAA, HITECH or other security or privacy laws is made in any administrative or civil proceeding in which the party has been joined. 5) Disclaimer. Covered Entity makes no warranty or representation that compliance by Business Associate with this BAA, HIPAA or HITECH will be adequate or satisfactory for Business Associate's own purposes. Business Associate is solely responsible for all decisions made by Business Associate regarding the safeguarding of PHI. 6) Certifications. To the extent Covered Entity determines that such examination is necessary to comply with Covered Entity's legal obligations pursuant to HIPAA and HITECH relating to certification of its security practices, Covered Entity or its authorized agents or contractors, may, at Covered Entity's expense, examine Business Associate's facilities, systems, procedures and records as may be necessary for such agents or contractors to certify to Covered Entity the extent to which Business Associate's security safeguards comply with HIPAA, HITECH or this BAA. 7) Amendment to Comply with Law. The Parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of this BAA may be required to provide for procedures to ensure compliance with such developments. The Parties specifically agree to take such action as is necessary to implement the amendments and requirements of HIPAA (including without limitation the Privacy Rule), HITECH and other applicable laws relating to the security or confidentiality of PHI. The Parties understand and agree that Covered Entity must receive satisfactory written assurance from Business Associate that Business Associate will adequately safeguard all PHI. Upon the request of either party,the other party agrees to promptly enter into negotiations concerning the terms of an amendment to this BAA embodying written assurances consistent with the amendments and requirements of HIPAA (including without limitation the Privacy rule), HITECH or other applicable laws. Covered Entity may terminate the Service Agreement upon thirty (30) days written notice in the event (i) Business Associate does not promptly enter into negotiations to amend this BAA when requested by Covered Entity pursuant to this Section or(ii) Business Associate does not enter into an amendment to this BAA providing assurances regarding the safeguarding of PHI that Covered Entity, in its sole discretion, deems sufficient to satisfy the Covered Entity and requirements of HIPAA, including without limitation the Privacy Rule, and HITECH. 8) Assistance in Litigation or Administrative Proceedings. Business Associate shall make itself,and any subcontractors, employees or agents assisting Business Associate in the performance of its obligations under the Service Agreement,available to Covered Entity,at no cost to Covered Entity, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against Covered Entity, its directors, officers or employers based upon a claimed violation of HIPAA,including without limitation the Privacy Rule,HITECH or other laws relating to security and privacy, except where Business Associate or its subcontractor, employee or agent is a named adverse party. 9) No Third-Party Beneficiaries. Nothing express or implied in this BAA is intended to confer, nor shall anything herein confer, upon any person other than Covered Entity,Business Associate and their respective successors or assigns,any rights,remedies,obligations or liabilities whatsoever. 10)Effect on Agreement. Except as specifically required to implement the purposes of this BAA, or to the extent inconsistent with this BAA,all other terms of the Service Agreement shall remain in force and effect. 11)Indemnification. In addition to any indemnification obligations, which are a part of the Service Agreement, the Business Associate hereby indemnifies and agrees to hold the Covered Entity harmless against any and all claims, liabilities, obligations, costs or damage, including Civil Monetary Penalties, arising from a breach by the Business Associate of its obligations in connection with this BAA or HITECH,or HIPAA. 12)Interpretation. This BAA shall be interpreted as broadly as necessary to implement and comply with HIPAA and HITECH. The Parties agree that any ambiguity in this BAA shall be resolved in favor of a meaning that complies and is consistent with HIPAA and HITECH in light of any interpretation and/or guidance on HIPAA, the Privacy Regulation and/or the Security Regulation issued by HHS from time to time. 13)Counterparts: Facsimiles. This BAA may be executed in any number of counterparts, each of which shall be deemed an original. Facsimile copies hereof shall be deemed to be originals. 14)Disputes. If any controversy,dispute or claim arises between the Parties with respect to this BAA, the Parties shall make good faith efforts to resolve such matters informally. Contract Form Entity Information Entity Name* Entity ID* New Entity? Please use the job AMERITAS LIFE INSURANCE CORP SUP-51 006 aid linked here to add a ❑supplier in Workday. Contract Name* Contract ID Parent Contract ID AMERITAS SELF-FUNDED (ASO) 1 0302 Requires Board Approval Contract Status Contract Lead* YES CTB REVIEW BPETERSON Department Project # Contract Lead Email bpeterson@weld.gov Contract Description* MOVING TO A SELF-FUNDED (ASO) ARRANGEMENT WITH AMERITAS WILL PROVIDE GREATER FLEXIBILITY AND POTENTIAL COST SAVINGS. Contract Description 2 AMERITAS WILL PROVIDE DENTAL CLAIMS PROCESSING, NETWORK ACCESS, AND PLAN ADMINISTRATION SERVICES, WHILE THE COUNTY WILL ONLY PAY ACTUAL DENTAL CLAIMS PLUS A SMALL FEE FOR ADMINISTRATION. Contract Type* Department Requested BOCC Agenda Due Date AGREEMENT HUMAN RESOURCES Date* 01 /24/2026 01 /28/2026 Amount* Department Email $0.00 CM- Will a work session with BOCC be required?* HumanResources@weld.g NO Renewable* ov YES Does Contract require Purchasing Dept. to be Department Head Email included? Automatic Renewal CM-HumanResources- YES DeptHead@weld.gov Grant County Attorney IGA GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COU NTYATTORNEY@WEL D.GOV If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* Renewal Date* 01 /01 /2026 12/31 /2028 01 /01 /2029 Termination Notice Period Committed Delivery Date Expiration Date Contact Information Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date Approval Process Department Head Finance Approver Legal Counsel JILL SCOTT CHRIS D'OVIDIO BYRON HOWELL DH Approved Date Finance Approved Date Legal Counsel Approved Date 01 /23/2026 01 /27/2026 01 /27/2026 Final Approval BOCC Approved Tyler Ref# AG 012826 BOCC Signed Date Originator BOCC Agenda Date BPETERSON 01 /28/2026 Hello