Dental Plan Provisions

	Basic and Voluntary Dental Benefits
Case Size	Available to employer groups of 51 or more eligible employees
Rate Guarantee Period	1 Year
Annual Maximum Options	$1000 / $1500 / $2000
Deductible Options (per calendar year)	$25 Individual / $75 Family $50 Individual / $150 Family
Deductible Waivers	In-network Preventative Services
In-network Coinsurance Options	100/90/50 MAC or 100/80/50 MAC or 80/80.50 MAC MAC = Maximum Allowable Charge
Out-of-Network Coinsurance Options	100/80/50 CMAC or 100/60/50 CMAC or 80/60/50 CMAC CMAC = Customary Maximum Allowable Charge
Limit for Reasonable and Customary Charges	85th Percentile
Service Classes	Diagnostic & Preventative: Exams routine x-rays, cleanings, fluoride treatments and sealant for children (age limitations may apply). Basic: Fillings, extractions, endodontic services (root canal therapy) and periodontal procedures (treatment of gum disorders) Major: Crowns, Dentures and Bridges Orthodontia (Optional): See benefit below
Orthodontic Benefit Option	Available to children (age limitations may apply) 50% coinsurance Lifetime Maximums: $1000 or %1500
Pre-treatment Review	$300

	Basic Dental Employer-paid	Voluntary Dental Employee-paid
Participation Requirements	For non-contributory plans, all eligible employees must be enrolled; For contributory plans, a minimum of 75% of eligible employees and dependents not covered by another group-dental plan must enroll.	The greater of 25% or 10 eligible employees must be enrolled
Waiting Periods	Preventative: None Basic: None Major: None Orthodontia: None	Preventative: None Basic: 6 months Major: 12 months Orthodontia: 24 months

* All plans are available to groups of 51 or more employees. Products are not available in all states. The benefits outlined here are for illustrative purposes only and should not be considered a proposal for coverage. Limitations and exclusions apply. Additional plan options are available with underwriting approval.