CLICK HERE TO VIEW MARYLAND PLANS AND RATES

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1 CLICK HERE TO VIEW MARYLAND PLANS AND RATES Dental disease is preventable. Dominion plans encourage the early detection of dental problems and routine maintenance. We help you take better care of your teeth and now it can cost you less to do it. Dominion gives you the choice of three different dental options - choose the one that s right for you and your family. Choose our Select Plan (same as a DHMO) or Discount Program 2 and use a pre-qualified network dentist, or choose one of our three Access PPO Plans, which allow you to visit any licensed dentist. Dominion also offers a vision plan 3 with access to a leading provider network. When you enroll, membership ID cards and detailed benefit information will be mailed to your home address. The dental benefits you ve been waiting for are now available! We Work For Your Benefit. Dominion Dental Services (Dominion) is a leading administrator of dental and vision 3 benefits in the Mid-Atlantic. 4 Among our nearly 500,000 customers are leading health plans, employer groups, municipalities, associations and individuals. 204 Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pretreatment estimates and no claim forms (except in the case of out-of-area emergencies). 2 This not an insurance plan. It is a reduced fee-forservice program designed specifically for individuals. Members pay a predetermined reduced fee for listed services provided by contracted providers. Dominion does not pay providers for services provided by contracted providers. 3 Vision plans are underwritten by Avalon Insurance Company (a Dominion affiliate) and are marketed and administered by Dominion Dental Services USA, Inc. 4 Includes DC, Delaware, Maryland, Pennsylvania and Virginia.

2 Three Unique Dental Programs to Choose From! Discount Program 7000x Discount Program 7000x provides access to substantial discounts on most dental procedures. To receive the discounts you must obtain services from a general dentist from our Discount dental network, who will provide services and charge you according to a discounted fee schedule. If specialty care is required, your general dentist will refer you to a participating specialist who will provide care at a 25% discount. You will pay only the discounted member fees directly to your dentist at the time of service. There are no claim forms, waiting periods, maximum limits, pre-authorization requirements or deductibles. Access to discounts for over 250 procedures is included. The complete list of discounted procedures and member fees will be mailed to you with your membership card. A summary of the procedures and member fees is included in this brochure. Discount Program Services Include: 2 No charge for routine annual cleanings No charge for oral examinations No charge for topical fluoride for children These no-charge procedures account for over 35% of dental services most frequently performed for adults and almost 60% of the most frequently performed services for children. 3 Receive more extensive care (fillings, dentures, crowns, root canals, periodontal care, oral surgery, etc.) at fees 35% to 60% lower than usual and customary charges (please see the Plan Comparison chart). Discounted fees available for adult and child orthodontia! *Please note the Discount Program is not a pediatric dental essential health benefit offered by a stand-alone dental plan under the Affordable Care Act. If you are interested in pediatric dental essential health benefit coverage, please consider the Select Plan 705xa or the Access PPO options. Select Plan 705xa 4 Select Plan 705xa offers great value and extended coverage for your premium dollar. You must choose a general dentist from our Select Plan dental network. Your general dentist will provide services and charge you according to the Description of Benefits and Member Copayments. If specialty care is required, your general dentist will refer you to a participating specialist who will provide care at a 25% discount. You will pay any copayments due under the Select Plan directly to your plan dentist at the time of service. There are no waiting periods, maximum limits, pre-authorization requirements or deductibles. Over 250 procedures are covered. The complete list of covered procedures will be mailed to you with your membership card. A summary of covered procedures and copayments is included in this brochure. Select Plan 705xa Benefits Include: No charge for routine semiannual cleanings No charge for oral examinations No charge for bitewing X-rays These no-charge procedures account for over 65% of dental services most frequently performed for adults. 3 You will receive more extensive care (fillings, dentures, crowns, root canals, periodontal care, oral surgery, etc.) at fees 55% to 75% lower than usual and customary charges (please see the Plan Comparison chart). Orthodontia is also covered! Access PPO Adults - 3 Different Plan Options Access PPO is designed to provide members with maximum access to dentists. Members may seek dental services from any licensed dentist or use a participating Access PPO network dentist for greater coverage. When dental care is received and expenses incurred, payments will be made in accordance with the list of benefits and services in the Coverage Schedule that will be mailed to you with your membership card. A summary of the plans benefits can be found in the Plan Comparison in this brochure. In-Network Access PPO Adults Benefits Include: No charge for routine semiannual cleanings No charge for oral examinations No charge for bitewing X-rays These no-charge procedures account for over 65% of dental services most frequently performed for adults. 3 We offer plan options that cover more extensive care (fillings, dentures, crowns, root canals, periodontal care, oral surgery, etc.). Please see the Access PPO Plan Comparison chart for full coverage details on the plan options. Please look closely at the annual deductibles and maximum benefits on the Plan Comparison chart as they vary between plans. There are no waiting periods under the Access PPO plans. Effective January, 204, most Americans must obtain pediatric dental coverage for dependents under the age of 9 that complies with the EHB provisions under the Patient Protection and Affordable Care Act (PPACA). If you do not have this coverage through your health insurance plan, you may enroll your dependent(s) in Dominion s pediatric dental plan to ensure that you are meeting the requirements of PPACA. If you choose to enroll in the Select Plan 705xa or Access PPO Adults, your dependents under the age of 9 will automatically be enrolled in the pediatric dental plan (The Discount 7000x provides discounted fees for children; however it does not include an EHB compliant pediatric plan). Please see the Plan Comparison chart for pediatric coverage details for the Select Plan 705xa and Access PPO plans. For full coverage details regarding Dominion s certified pediatric dental plans, please visit DominionDental.com/pediatric. 2 This is not an insurance plan. It is a reduced fee-for-service program designed specifically for individuals. Members pay a predetermined reduced fee for listed services provided by contracted providers. Dominion does not pay providers for services provided by contracted providers. 2 There is a $5 office visit copayment. You must use a participating dentist to receive access to discounted procedures. 3 Dental Services, Inc. - based on annual review of utilization data. 4 Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles and no pre-authorization paperwork or pre-treatment estimates.

3 Plan Comparison - Adults (Age 9 & Over) Discount Program Select Plan 705xa Access PPO (Plan ID 2347) Access PPO 2 (Plan ID 2348) Access PPO 3 (Plan ID 2349) Procedures and Covered Services In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Year 2 Year 2 2 Year 3 2 Year 2 Year 2 2 Year 3 2 Diagnostic and Preventive Care 45-00% 00% 00% 00% 00% 90% 90% 90% 00% 90% 00% 90% Oral exams 00% 00% 00% 00% 00% 90% 90% 90% 00% 90% 00% 90% Bitewing X-Rays 45% 00% 00% 00% 00% 90% 90% 90% 00% 90% 00% 90% Teeth cleanings (amount per year) 00% () 00% (2) 00% (2) 00% (2) 00% (2) 90% (2) 90% (2) 90% (2) 00% (2) 90% (2) 00% (2) 90% (2) Basic Care 45-50% 60-75% 40% 60% 80% 30% 50% 70% 50% 40% 50% 40% Full and panoramic X-rays 45% 75% 40% 60% 80% 30% 50% 70% 00% (Class I) 90% (Class I) 00% (Class I) 90% (Class I) Fillings Amalgam (silver) 50% 75% 40% 60% 80% 30% 50% 70% 50% 40% 50% 40% Composite (white) 50% 75% 40% 60% 80% 30% 50% 70% 50% 40% 50% 40% Extraction, erupted tooth 50% 75% 40% 60% 80% 30% 50% 70% 50% 40% 50% 40% Major Restorative Care 35-60% 55-70% 5% 25% 50% 0% 20% 40% 0% 0% 0% 0% Prosthetics Crowns and bridges 45% 60% 5% 25% 50% 0% 20% 40% 0% 0% 0% 0% Dentures 45% 60% 5% 25% 50% 0% 20% 40% 0% 0% 0% 0% Relining of dentures 35% 55% 5% 25% 50% 0% 20% 40% 0% 0% 0% 0% Periodontics (root planing and therapy) 50% 65% 5% 25% 50% 0% 20% 40% 50% (Class II) 40% (Class II) 50% (Class II) 40% (Class II) Endodontics (root canals) 60% 70% 5% 25% 50% 0% 20% 40% 0% 0% 50% (Class II) 40% (Class II) Oral Surgery (extraction of impacted teeth) 40% 40% 5% 25% 50% 0% 20% 40% 0% 0% 0% 0% Orthodontics (adults) 45% 45% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Benefit Features Office Visit $5 $0 None None None Deductibles None None $50 per adult (adult max $50) 3 $50 per adult (adult max $50) 3 $50 per adult (adult max $50) 3 Annual Maximums None None $,000 per insured person $750 per insured person $,000 per insured person Waiting Periods None None None None None Access PPO network dentist or any licensed dentist Access PPO network dentist or any licensed dentist Access PPO network dentist or any licensed dentist Select Plan Network Dentist Discount Network Dentist Receive Care From Approximate percentage of coverage for the Select Plan is based on the Captiva Context Fee Schedule s 80th percentile for zip codes beginning with 232. Coverage may vary by state. A specific fee schedule applies and will be mailed with your membership card. Please see the Summary of Member Fees (Discount) or the Description of Member Copayments (Select Plan 705xa) inside the brochure for a sample of member fees. To view copay schedules for the pediatric plans, please go to DominionDental.com/pediatric. 2 Year benefits apply during the subscriber s first 2 months of continuous coverage. Year 2 benefits apply during the subscriber s second 2 months of continuous coverage. Year 3 benefits apply during the subscriber s third 2 months of continuous coverage. 3 Deductibles apply to all services. 3 3

4 Plan Comparison - Kids (Under Age 9) 4 4 Select Plan Kids Access PPO Kids Procedures and Covered Services In-Network Out-of-Network Diagnostic and Preventive Care 75-00% 00% 80% Oral exams 00% 00% 80% Bitewing X-Rays 00% 00% 80% Full and panoramic X-rays 75% 00% 80% Semiannual teeth cleanings 00% 00% 80% Topical fluoride for children 00% 00% 80% Basic Care 55-70% 35% 20% Fillings Amalgam (silver) 70% 35% 20% Composite (white) 60% 35% 20% Extraction, erupted tooth 55% 35% 20% Major Restorative Care 35-55% 2 25% 0% Prosthetics Crowns 55% 25% 0% Bridges 45% 25% 0% Dentures 40% 25% 0% Periodontics (root planing and therapy) 50% 25% 0% Endodontics (root canals) 55% 25% 0% Oral Surgery (extraction of impacted teeth) 50% 25% 0% Implants* 0-30% 0% (DC, DE, PA, VA) 30% (MD) 50% 50% Medically-Necessary Orthodontics (child) (2- year waiting period) Discounted non-medically necessary orthodontics Yes N/A N/A Benefit Features Office Visit $0 None None Deductibles None $00 per child ($200 max) 3 $00 per child ($200 max) 3 Out-of-Pocket Maximums DE, PA & VA 4 $700 4 $700 4 N/A DC & MD 5 $,000 5 $,000 5 N/A Waiting Periods None 6 None 6 None 6 Receive Care From Select Plan Network Dentist Access PPO network dentist or any licensed dentist Access PPO network dentist or any licensed dentist * Implants are covered on Access PPO Kids and Select Plan Kids plans in the District of Columbia and Pennsylvania only. Delaware, Maryland and Virginia do not have implant coverage. Approximate percentage of coverage for the Select Plan is based on the Captiva Context Fee Schedule s 80th percentile for zip codes beginning with 232. Coverage may vary by state. A specific fee schedule applies and will be mailed with your membership card. Please see the Summary of Member Fees (Discount) or the Description of Member Copayments (Select Plan 703xa) inside the brochure for a sample of member fees. To view copay schedules for the pediatric plans, please go to DominionDental.com/pediatric. 2 Specialty care is provided at the listed copayment whether performed by a participating general dentist or a participating specialist. 3 Deductible is combined for all covered services for each calendar year per pediatric member - maximum $200 for pediatric members. Deductibles are waived for Diagnostic and Preventive Care (Class I) and Orthodontia (Class IV) when in-network; and waived for Diagnostic and Preventive Care (Class I) when out-of-network. 4 Applies to groups in Delaware, Pennsylvania and Virginia. The $700 annual out-of-pocket maximum applies to a single child. There is a $,400 annual out-of-pocket maximum for two or more children. 5 Applies to groups in the District of Columbia and Maryland. The $,000 annual out-of-pocket maximum applies to a single child. There is a $2,000 annual out-of-pocket maximum for two or more children. 6 There is a 24-month waiting period for medically necessary orthodontic benefits.

5 Monthly Rates - Effective //4-2//4 (valid for 2-month contracts) Discount Program Member 7.50 Member + or More 0.00 ACCESS PPO PER ADULT [Age] PPO [9-29] PPO [30-45] PPO [46+] PPO2 [9-29] PPO2 [30-45] PPO2 [46+] PPO3 [9-29] PPO3 [30-45] PPO3 [46+] N/A N/A N/A N/A ACCESS PPO PER CHILD (Under Age 9) [Max Charge of 3 per family] SELECT PLAN PER ADULT (9+) N/A N/A N/A N/A N/A N/A N/A N/A SELECT PLAN PER CHILD (Under Age 9) [Max Charge of 3 per family] How to Calculate Your Monthly Rates. Determine your rating region based on your county or state of residence. See Region Legend on page Locate your monthly premium in the chart by referencing the rating region, your plan choice and your age band (range). This is your monthly rate if you are the only subscriber. 3. For each dependent, repeat step 2. (You will only be charged for up to three child dependents). 4. Add up each family member s rate to determine your total monthly premium. Example: A family of four living in Alexandria, VA, with two adults in the age band and two children under age 9 enrolling in the Access PPO plan:. Alexandria, VA is in Region Access PPO monthly rate in Region 2 in the age band = $ Primary Subscriber (Adult ) and Adult Dependent (Adult 2) = (2 x $29.64 = $59.28) Dependent and Dependent 2 = (2 x $24.95 = $49.90) 4. $ $49.90 = $09.8 *Maryland rates pending approval by insurance departments. 5 5

6 Rating Regions 6 Region Legend Region AR*, KY*, NE*, OH*, OK*, UT*, WV* Region 2 AL*, GA*, IL*, IN*, LA*, MO*, TN*, TX* AZ*, IA*, ID*, KS*, MI*, MS*, MT*, ND*, NM*, SD*, WI*, WY* VA counties: Accomack*, Albemarle*, Augusta*, Bedford*, Bedford City*, Botetourt*, Buckingham*, Buena Vista City*, Campbell*, Charlottesville City*, Craig*, Culpeper*, Danville City*, Emporia City*, Essex*, Fluvanna*, Franklin*, Franklin City*, Frederick, Giles*, Greene*, Greensville*, Harrisonburg City*, Henry*, King George, Lancaster, Madison*, Martinsville City*, Middlesex, Montgomery*, Nelson*, Northampton*, Norton City*, Nottoway*, Orange, Page*, Pittsylvania*, Pulaski*, Rappahannock, Richmond, Roanoke*, Roanoke City*, Rockingham*, Russell*, Salem*, Scott*, Shenandoah*, Southampton*, Staunton City*, Washington*, Waynesboro City*, Westmoreland*, Winchester City, Wise* Region 3 Region 4 MD counties: Allegany, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Kent, Queen Anne s, Somerset, St. Mary s, Talbot, Washington, Wicomico, Worcester PA counties: Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin*, Fulton*, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York Region 5 PA counties: Allegheny, Armstrong, Beaver, Bedford*, Blair, Bradford*, Butler, Cambria, Cameron, Carbon, Clarion, Clearfield, Clinton, Crawford*, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lackawanna, Lawrence, Luzerne, Lycoming, McKean*, Mercer, Monroe, Pike*, Somerset, Sullivan, Susquehanna*, Venango, Warren*, Washington, Wayne, Westmoreland, Wyoming Region 6 CO*, FL*, MN*, NH*, NV*, RI*, SC*, VT* VA counties: Amelia, Caroline, Charles City, Chesterfield, Colonial Heights City*, Cumberland*, Dinwiddie, Goochland, Hanover, Henrico, Hopewell City*, King and Queen, King William, Louisa*, New Kent, Petersburg City, Powhatan, Prince George, Richmond City, Sussex Region 7 Region 8 CA*, HI*, ME*, NC*, NJ* CT*, MA*, NY*, OR*, WA* MD counties: Anne Arundel, Baltimore City, Baltimore, Harford, Howard Region 9 Region0 DE Region PA counties: Bucks, Chester, Delaware, Montgomery, Philadelphia VA counties: Alexandria City, Arlington, Chesapeake City, Clarke, Fairfax, Fairfax City, Falls Church City, Fauquier, Fredericksburg City, Gloucester, Hampton City, Isle of Wight, James City, Loudoun, Manassas City, Manassas Park City*, Mathews, Newport News City, Norfolk City, Poquoson City, Portsmouth City, Prince William, Spotsylvania, Stafford, Suffolk City, Surry, Virginia Beach City, Warren, Williamsburg City, York Region 2 Region 3 AK* Region 4 MD counties: Montgomery and Prince George s Region 5 DC 6 * Select Plan is not available in the states or counties with an asterisk (*). Pediatric plans are available in DC, DE, PA & VA only.

7 Discount Program 7000x Description of Services & Member Fees ADA MEMBER CODE SERVICE FEE ($) ADA MEMBER CODE SERVICE FEE ($) DIAGNOSTIC/PREVENTIVE D9439 Office visit... 5 D020 Periodic oral eval - established patient... 0 D040 Limited oral eval - problem focused... 0 D045 Oral eval for a patient under 3 years of age... 0 D050 Comprehensive oral eval - new or established patient... 0 D060 Detailed and extensive oral eval - problem focused D070 Re-evaluation - limited, problem focused... 0 D020 Intraoral - complete series (including bitewings) D0220 Intraoral - periapical first film... 4 D0230 Intraoral - periapical each add. film... 2 D0240 Intraoral - occlusal film... 0 D0250/60 Extraoral - first film and each add. Film... 0 D0270 Bitewing - single film... 4 D0272 Bitewings - two films D0273 Bitewings - three films D0274 Bitewings - four films... 3 D0277 Vertical bitewings - 7 to 8 films D0330 Panoramic film D0340 Cephalometric Film... 0 D0350 Oral/facial photographic images... 0 D0460 Pulp vitality tests D0470 Diagnostic casts... 0 D0 Prophylaxis (cleaning) - adult... 0 D0* Additional cleaning (expecting mothers or Diabetics) D20 Prophylaxis (cleaning) - child... 0 D203 Topical application of fluoride - child... 0 D204 Topical application of fluoride - adult... 0 D206 Topical fluoride varnish for mod/high risk caries patients... 0 D30 Nutritional counseling for control of dental disease... 0 D320/30 Oral hygiene instructions... 0 D35 Sealant - per tooth D352 Prev resin rest. mod/high caries risk perm. tooth SPACE MAINTAINERS D50/20 Space maintainer - fixed/removable - unilateral D55/25 Space maintainer - fixed/removable - bilateral D550 Re-cementation of space maintainer RESTORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (SILVER) D240 Amalgam - one surface, prim. or perm D250 Amalgam - two surfaces, prim. or perm D260 Amalgam - three surfaces, prim. or perm D26 Amalgam - >=4 surfaces, prim. or perm RESIN/COMPOSITE RESTORATIONS (TOOTH COLORED). D2330 Resin-based composite - one surface, anterior D233 Resin-based composite - two surfaces, anterior... 0 D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - >=4 surfaces, anterior D239 Resin-based composite - one surface, posterior D2392 Resin-based composite - two surfaces, posterior... 8 D2393 Resin-based composite - three surfaces, posterior D2394 Resin-based composite - >=4 surfaces, posterior D2940 Sedative filling D295 Pin retention - per tooth, in addition to restoration D30/20 Pulp cap - direct/indirect (excl. final restoration) CROWN & BRIDGE D2390 Resin-based composite crown, anterior D250 Inlay - metallic - one surface D2520 Inlay - metallic - two surfaces D2530 Inlay - metallic - three or more surfaces D2542 Onlay - metallic-two surfaces D2543 Onlay - metallic-three surfaces D2544 Onlay - metallic-four or more surfaces D260 Inlay - porcelain/ceramic - one surface D2620 Inlay - porcelain/ceramic - two surfaces D2630 Inlay - porcelain/ceramic - >=3 surfaces D2642 Onlay - porcelain/ceramic - two surfaces D2643 Onlay - porcelain/ceramic - three surfaces D2644 Onlay - porcelain/ceramic - >=4 surfaces D2650 Inlay - resin-based composite - one surface D265 Inlay - resin-based composite - two surfaces D2652 Inlay - resin-based composite - >=3 surfaces D2662 Onlay - resin-based composite - two surfaces D2663 Onlay - resin-based composite - three surfaces D2664 Onlay - resin-based composite - >=4 surfaces D270 Crown - resin based composite (indirect) D272 Crown - 3/4 resin-based composite (indirect) D2720/2/22 Crown - resin with metal D2740 Crown - porcelain/ceramic substrate D2750/5/52 Crown - porcelain fused metal D2780/8/82 Crown - 3/4 cast with metal D2783 Crown - 3/4 porcelain/ceramic D2790/9/92 Crown - full cast metal... 6 D290/20 Recement inlay, onlay/crown or partial coverage rest... 6 D2930 Prefab. stainless steel crown - prim. tooth D293 Prefab. stainless steel crown - perm. tooth D2932 Prefabricated resin crown D2950 Core buildup, including any pins D2952 Cast post and core in addition to crown D2954 Prefab. post and core in addition to crown D2955 Post removal (not in conj. with endo. therapy) D2970 Temporary crown (fractured tooth)... 0 D2980 Crown repair, by report PROSTHETICS (DENTURES) D50/20 Complete denture - maxillary/mandibular D530/40 Immediate denture - maxillary/mandibular D52/2 Maxillary/mandibular partial denture - resin base D523/4 Maxillary/mandibular partial denture - cast metal D5225/25 Maxillary/mandibular partial denture - flexible base D528 Rem. unilateral partial denture - one piece cast metal D540/ Adjust complete denture - maxillary/mandibular... 5 D542/22 Adjust partial denture - maxillary/mandibular... 5 D550/560 Repair broken denture base (complete/resin)... 3 D5520 Replace missing or broken teeth - complete denture D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth - per tooth... 0 D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5670/7 Replace all teeth and acrylic on cast metal framework D570/ Rebase complete maxillary/mandibular denture D5720/2 Rebase maxillary/mandibular partial denture D5730/3 Reline complete maxillary/mandibular denture (chairside)...22 D5740/4 Reline maxillary/mandibular partial denture (chairside) D5750/5 Reline complete maxillary/mandibular denture (lab) D5760/6 Reline maxillary/mandibular partial denture (lab) D580/ Interim complete denture - maxillary/mandibular D5820/2 Interim partial denture - maxillary/mandibular D5850/5 Tissue conditioning - maxillary/mandibular BRIDGE/PONTICS D6000-D699 ALL IMPLANT SERVICES - 5% DISCOUNT (incl. D0360-D0363 cone beam imaging w/ implants) D620//2 Pontic - metal... 6 D6240/4/42 Pontic - porcelain fused metal D6245 Pontic - porc./ceramic D6250/5/52 Pontic - resin with metal D6545 Retainer - cast metal for resin bonded fixed prosthesis D6548 Ret. - porc./ceramic for resin bonded fixed prosthesis D6600 Inlay - porc./ceramic, two surfaces D660 Inlay - porc./ceramic, >=3 surfaces D6602 Inlay - cast high noble metal, two surfaces D6603 Inlay - cast high noble metal, >=3 surfaces D6604 Inlay - cast predominantly base metal, two surfaces D6605 Inlay - cast predominantly base metal, >=3 surfaces D6606 Inlay - cast noble metal, two surfaces D6607 Inlay - cast noble metal, >=3 surfaces D6608 Onlay -porc./ceramic, two surfaces D6609 Onlay - porc./ceramic, three or more surfaces D660 Onlay - cast high noble metal, two surfaces D66 Onlay - cast high noble metal, >=3 surfaces D662 Onlay - cast predominantly base metal, two surfaces D663 Onlay - cast predominantly base metal, >=3 surfaces D664 Onlay - cast noble metal, two surfaces D665 Onlay - cast noble metal, >=3 surfaces D6720/2/22 Crown - resin with metal D6740 Crown - porc./ceramic D6750/5/52 Crown - porcelain fused metal D6780 Crown - 3/4 cast high noble metal D678 Crown - 3/4 cast predominantly base metal D6782 Crown - 3/4 cast noble metal D6783 Crown - 3/4 porc./ceramic D6790/9/92 Crown - full cast metal... 6 All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used. 7

8 Discount Program 7000x 8 ADA MEMBER CODE SERVICE FEE ($) D6930 Recement fixed partial denture D6970 Post and core in addition to fixed part. dent. ret D6972 Prefab post and core in addition to fixed part. dent. ret D6973 Core build up for retainer, including any pins... 5 D6975 Coping - metal D6976 Each add. indirectly fabricated post - same tooth D6977 Each add. prefab post - same tooth D6980 Fixed partial denture repair, by report ADJUNCTIVE GENERAL SERVICES D90 Palliative (emergency) treatment of dental pain D920/5 Local anesthesia... 0 D92 Regional block anesthesia... 0 D922 Trigeminal division block anesthesia... 0 D9220 Deep sedation/general anesthesia - first 30 min D922 Deep sedation/general anesthesia - each add. 5 min D924 Intravenous conscious sedation/analgesia - first 30 min D9242 IV conscious sedation/analgesia - each add. 5 min D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D930 Consultation (diagnostic service by nontreating dentist)...63 D990 Application of desensitizing medicament... 3 D9930 Treatment of complications (post-surgical) D9990 Broken office appointment ENDODONTICS D3220 Therapeutic pulpotomy (excl. final restor.)... 2 D322 Pulpal debridement, prim. and perm. teeth... 2 D330 Endodontic therapy, anterior tooth D3320 Endodontic therapy, bicuspid tooth D3330 Endodontic therapy, molar D3333 Internal root repair of perforation defects D3346 Retreat of prev. root canal therapy, anterior D3347 Retreat of prev. root canal therapy, bicuspid D3348 Retreat of prev. root canal therapy, molar D340 Apicoectomy/periradicular surgery, anterior D342 Apicoectomy/periradicular surgery, bicuspid (first root) D3425 Apicoectomy/periradicular surgery, molar (first root) D3426 Apicoectomy/periradicular surgery (each add. root) D3430 Retrograde filling - per root D3450 Root amputation - per root D3920 Hemisection, not inc. root canal therapy D3950 Canal prep/fitting of preformed dowel or post PERIODONTICS D080 Comp. periodontal eval - new or established patient D420 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad D42 Gingivectomy or gingivoplasty - <=3 teeth, per quad D4240 Gingival flap proc., inc. root planing - >3 cont. teeth, per quad D424 Gingival flap proc, inc. root planing - <=3 cont. teeth, per quad... 3 D4260 Osseous surgery - >3 cont. teeth, per quad D426 Osseous surgery - <=3 cont. teeth, per quad D4268 Surgical revision proc., per tooth D4274 Distal or proximal wedge procedure D434 Perio scaling and root planing - >3 cont teeth, per quad...38 D4342 Perio scaling and root planing - <= 3 teeth, per quad D4355 Full mouth debridement D438 Localized delivery of chemotherapeutic agents D490 Periodontal maintenance D9940 Occlusal guard, by report D9950 Occlusion analysis - mounted case D995 Occlusal adjustment - limited D9952 Occlusal adjustment - complete ORAL SURGERY D7 Extraction, coronal remnants - deciduous tooth D740 Extraction, erupted tooth or exposed root D720 Surgical rem. of erupted tooth req. bone cut D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony... 3 D724 Removal of imp. tooth - completely bony, with unusual surg. complications D7250 Surgical removal of residual tooth roots... 8 D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth...35 D7280 Surgical access of an unerupted tooth D729 Transseptal fiberotomy/supra crestal fiberotomy, by report..59 D730 Alveoloplasty, in conj. with ext. - 4 or more teeth, per quad..75 D7320 Alveoloplasty not in conj. with extractions - 4 or more teeth, per quad D750 Incision and drainage of abscess - intraoral soft tissue D7960 Frenulectomy (frenectomy or frenotomy) - separate proc As performed by a participating General Dentist. See Plan Exclusion # 3. ADA MEMBER CODE SERVICE FEE ($) ORTHODONTICS 2 D8660 Pre-orthodontic treatment visit D8070 Comp. ortho. treatment - transitional dentition D8080 Comp. ortho. treatment - adolescent dentition D8090 Comp. ortho. treatment - adult dentition D8670 Periodic ortho. treatment visit (as part of contract)... 8 D8680 Orthodontic retention (rem. of appl. and placement of retainer(s)) Phase I Treatment (D800 - D8050) is provided at a 5% reduction from the orthodontist s UCR fees. See exclusion #5 for additional coverage exclusions. Program Exclusions. Services which are covered under Medicare, worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only). 2. Services which, in the opinion of the attending dentist, are not necessary for the patient s dental health. 3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth. 4. Oral surgery requiring the setting of fractures or dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or development malformations where, in the opinion of the Participating Dentist, such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation. 9. Replacement due to loss or theft of prosthetic appliance. 0. Procedures not listed as covered benefits under this Program.. Services obtained outside of the dental office in which enrolled and that are not preauthorizedby such office or Dominion Dental Services USA, Inc. (with the exception of out-of-area emergency dental services). 2. Services related to the treatment of TMD (Temporomandibular Disorder). 3. Services related to procedures that are of such a degree of complexity as to not be normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Participating Specialist (with the exception of orthodontics). Participating Specialists, if available, have entered into an agreement with Dominion Dental Services to provide dental services to members at a 25% reduction from their Usual, Customary, and Reasonable (UCR) fees. In Delaware, Participating Specialists will provide a reduction from their UCR that will vary between specialists. 4. Elective surgery including, but not limited to, extraction of nonpathologic, asymptomatic impacted teeth. 5. The Invisalign system and similar specialized braces are not a covered benefit. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient s responsibility. Program Limitations. Two (2) evaluations are covered per calendar year including a maximum of one () comprehensive evaluation. 2. One () problem focused exam is covered per calendar year. 3. One () teeth cleaning (prophylaxis) is covered per calendar year. 4. One () topical fluoride or fluoride varnish is covered per calendar year. 5. Two (2) bitewing x-rays are covered per calendar year. 6. One () set of full mouth x-rays or panoramic film is covered every three (3) years. 7. One () sealant or preventative resin restoration per tooth is covered per lifetime, up to age 6 (limited to permanent st and 2 nd molars). 8. Replacement of a filling is covered if it is more than two (2) years from the date of original placement. 9. Replacement of a bridge, crown or denture is covered if it is more than seven (7) years from the date of original placement. 0. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment program. Additional crown or bridge units, beginning with the sixth unit, are available at the provider s Usual, Customary, and Reasonable (UCR) fee, minus 25%.. Relining and rebasing of dentures is covered once every 24 months. 2. Retreatment of root canal is covered if it is more than two (2) years from the original treatment. 3. Root planing or scaling is covered once every 24 months per quadrant. 4. Full mouth debridement is covered once per lifetime. 5. Procedure Code D438 is limited to one () benefit per tooth for three teeth per quadrant or a total of 2 teeth for all four quadrants per twelve (2) months. Must have pocket depths of five (5) millimeters or greater. 6. Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgical site. 7. Periodontal maintenance after active therapy is covered twice per calendar year, within 24 months after definitive periodontal therapy. Only current ADA CDT codes are considered valid by Dominion Dental Services, Inc. Current Dental Terminology American Dental Association.

9 Select Plan 705xa Description of Benefits & Member Copayments for Adult Services (age 9 and over) ADA MEMBER CODE BENEFIT COPAYMENT(S) DIAGNOSTIC/PREVENTIVE D9439 Office visit... 0 D020 Periodic oral eval - established patient... 0 D040 Limited oral eval - problem focused... 0 D050 Comprehensive oral eval - new or established patient... 0 D060 Detailed and extensive oral eval - problem focused... 0 D070 Re-evaluation - limited, problem focused... 0 D020 Intraoral - complete series (including bitewings) D0220 Intraoral - periapical first film... 0 D0230 Intraoral - periapical each add. film... 0 D0240 Intraoral - occlusal film... 0 D0250/60 Extraoral - first film and each add. film... 0 D Bitewing x-rays - to 4 films... 0 D0277 Vertical bitewings - 7 to 8 films... 0 D0330 Panoramic film D0340 Cephalometric Film... 0 D0350 Oral/facial photographic images... 0 D0460 Pulp vitality tests... 0 D0470 Diagnostic casts... 0 D0 Prophylaxis (cleaning) - adult... 0 D0* Additional cleaning (expecting mothers or Diabetics) D204 Topical application of fluoride - adult... 0 D206 Topical fluoride varnish for mod/high risk caries patients... 0 D30 Nutritional counseling for control of dental disease... 0 D320/30 Oral hygiene instructions... 0 RESORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (SILVER) D240 Amalgam - one surface D250 Amalgam - two surfaces D260 Amalgam - three surfaces D26 Amalgam - >=4 surfaces RESIN/COMPOSITE RESTORATIONS (TOOTH COLORED) D2330 Resin-based composite - one surface, anterior D233 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - >=4 surfaces, anterior D239 Resin-based composite - one surface, posterior D2392 Resin-based composite - two surfaces, posterior D2393 Resin-based composite - three surfaces, posterior D2394 Resin-based composite - >=4 surfaces, posterior... 2 D2940 Sedative filling D295 Pin retention - per tooth, in addition to restoration D30/20 Pulp cap - direct/indirect (excl. final restoration) CROWN & BRIDGE D2390 Resin-based composite crown, anterior D250 Inlay - metallic - one surface D2520 Inlay - metallic - two surfaces D2530 Inlay - metallic - three or more surfaces D2542 Onlay - metallic-two surfaces D2543 Onlay - metallic-three surfaces... 5 D2544 Onlay - metallic-four or more surfaces... 5 D260 Inlay - porcelain/ceramic - one surface D2620 Inlay - porcelain/ceramic - two surfaces D2630 Inlay - porcelain/ceramic - >=3 surfaces D2642 Onlay - porcelain/ceramic - two surfaces D2643 Onlay - porcelain/ceramic - three surfaces D2644 Onlay - porcelain/ceramic - >=4 surfaces D2650 Inlay - resin-based composite - one surface D265 Inlay - resin-based composite - two surfaces D2652 Inlay - resin-based composite - >=3 surfaces D2662 Onlay - resin-based composite - two surfaces D2663 Onlay - resin-based composite - three surfaces D2664 Onlay - resin-based composite - >=4 surfaces D270 Crown - resin based composite (indirect) D272 Crown - 3/4 resin-based composite (indirect) D2720/2/22 Crown - resin with metal D2740 Crown - porcelain/ceramic substrate D2750/5/52 Crown - porcelain fused metal D2780/8/82 Crown - 3/4 cast with metal D2783 Crown - 3/4 porcelain/ceramic D2790/9/92 Crown - full cast metal ADA MEMBER CODE BENEFIT COPAYMENT(S) D290/20 Recement inlay, onlay/crown or partial coverage rest... 4 D293 Prefab. stainless steel crown... 9 D2932 Prefabricated resin crown D2950 Core buildup, including any pins D2952 Cast post and core in addition to crown... 8 D2954 Prefab. post and core in addition to crown D2955 Post removal (not in conj. with endo. therapy)... 0 D2970 Temporary crown (fractured tooth)... 0 D2980 Crown repair, by report PROSTHETICS (DENTURES) D50/20 Complete denture - maxillary/mandibular D530/40 Immediate denture - maxillary/mandibular D52/2 Maxillary/mandibular partial denture - resin base D523/4 Maxillary/mandibular partial denture - cast metal D5225/26 Maxillary/mandibular partial denture - flexible base D528 Rem. unilateral partial denture - one piece cast metal D540/ Adjust complete denture - maxillary/mandibular D542/22 Adjust partial denture - maxillary/mandibular D550/560 Repair broken denture base (complete/resin) D5520 Replace missing or broken teeth - complete denture D5620 Repair cast framework D5630/60 Clasp repaired, replaced or added... 2 D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture... 2 D5670/7 Replace all teeth and acrylic on cast metal framework D570/ Rebase complete maxillary/mandibular denture D5720/2 Rebase maxillary/mandibular partial denture D5730/3 Reline complete maxillary/mandibular denture (chairside)...52 D5740/4 Reline maxillary/mandibular partial denture (chairside).. 52 D5750/5 Reline complete maxillary/mandibular denture (lab) D5760/6 Reline maxillary/mandibular partial denture (lab) D580/ Interim complete denture - maxillary/mandibular D5820/2 Interim partial denture - maxillary/mandibular D5850/5 Tissue conditioning - maxillary/mandibular BRIDGE & PONTICS D6000-D699 ALL IMPLANT SERVICES - 5% DISCOUNT (incl. D0360-D0363 cone beam imaging w/ implants) D620//2 Pontic - metal D6240/4/42 Pontic - porcelain fused metal D6245 Pontic - porcelain/ceramic D6250/5/52 Pontic - resin with metal D6545 Retainer - cast metal for resin bonded fixed prosthesis. 233 D6548 Ret. - porc./ceramic for resin bonded fixed prosthesis D6600 Inlay - porc./ceramic, two surfaces D660 Inlay - porc./ceramic, >=3 surfaces D6602 Inlay - cast high noble metal, two surfaces D6603 Inlay - cast high noble metal, >=3 surfaces D6604 Inlay - cast predominantly base metal, two surfaces D6605 Inlay - cast predominantly base metal, >=3 surfaces D6606 Inlay - cast noble metal, two surfaces D6607 Inlay - cast noble metal, >=3 surfaces D6608 Onlay -porc./ceramic, two surfaces D6609 Onlay - porc./ceramic, three or more surfaces D660 Onlay - cast high noble metal, two surfaces D66 Onlay - cast high noble metal, >=3 surfaces... 5 D662 Onlay - cast predominantly base metal, two surfaces D663 Onlay - cast predominantly base metal, >=3 surfaces... 5 D664 Onlay - cast noble metal, two surfaces D665 Onlay - cast noble metal, >=3 surfaces... 5 D6720/2/22 Crown - resin with metal D6740 Crown - porcelain/ceramic D6750/5/52 Crown - porcelain fused metal D6780 Crown - 3/4 cast high noble metal D678 Crown - 3/4 cast predominantly base metal D6782 Crown - 3/4 cast noble metal D6783 Crown - 3/4 porc./ceramic D6790/9/92 Crown - full cast metal D6930 Recement fixed partial denture D6970 Post and core in addition to fixed part. dent. ret D6972 Prefab post and core in addition to fixed part. dent. ret..48 D6973 Core build up for retainer, including any pins... 9 D6975 Coping - metal All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used. 9

10 Select Plan 705xa 0 ADA MEMBER CODE BENEFIT COPAYMENT(S) D6976 Each add. indirectly fabricated post - same tooth... 9 D6977 Each add. prefab post - same tooth D6980 Fixed partial denture repair, by report ADJUNCTIVE GENERAL SERVICES D90 Palliative (emergency) treatment of dental pain D920/5 Local anesthesia... 0 D92 Regional block anesthesia... 0 D922 Trigeminal division block anesthesia... 0 D9220 Deep sedation/general anesthesia - first 30 min D922 Deep sedation/general anesthesia - each add. 5 min.. 03 D924 Intravenous conscious sedation/analgesia - first 30 min D9242 IV conscious sedation/analgesia - each add. 5 min D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D930 Consultation (diagnostic service by nontreating dentist).. 42 D990 Application of desensitizing medicament... 3 D9930 Treatment of complications (post-surgical) D9990 Broken office appointment ENDODONTICS D3220 Therapeutic pulpotomy (excl. final restor.)... 8 D322 Pulpal debridement D330 Endodontic therapy, anterior tooth D3320 Endodontic therapy, bicuspid tooth D3330 Endodontic therapy, molar D3333 Internal root repair of perforation defects D3346 Retreat of prev. root canal therapy, anterior D3347 Retreat of prev. root canal therapy, bicuspid D3348 Retreat of prev. root canal therapy, molar D340 Apicoectomy/periradicular surgery, anterior D342 Apicoectomy/periradicular surgery, bicuspid (first root) D3425 Apicoectomy/periradicular surgery, molar (first root) D3426 Apicoectomy/periradicular surgery (each add. root) D3430 Retrograde filling - per root... 3 D3450 Root amputation - per root D3920 Hemisection, not inc. root canal therapy D3950 Canal prep/fitting of preformed dowel or post PERIODONTICS D080 Comp. periodontal eval - new or established patient D420 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad D42 Gingivectomy or gingivoplasty - <=3 teeth, per quad D4240 Gingival flap proc., inc. root planing - >3 cont. teeth, per quad D424 Gingival flap proc, inc. root planing - <=3 cont. teeth, per quad D4260 Osseous surgery - >3 cont. teeth, per quad D426 Osseous surgery - <=3 cont. teeth, per quad D4268 Surgical revision proc., per tooth D4274 Distal or proximal wedge procedure D434 Perio scaling and root planing - >3 cont teeth, per quad...05 D4342 Perio scaling and root planing - <= 3 teeth, per quad D4355 Full mouth debridement D438 Localized delivery of chemotherapeutic agents D490 Periodontal maintenance D9940 Occlusal guard, by report D9950 Occlusion analysis - mounted case... 8 D995 Occlusal adjustment - limited D9952 Occlusal adjustment - complete ORAL SURGERY D7 Extraction, coronal remnants - deciduous tooth D740 Extraction, erupted tooth or exposed root D720 Surgical rem. of erupted tooth req. bone cut D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony D724 Removal of imp. tooth - completely bony, with unusual surg. complications... 8 D7250 Surgical removal of residual tooth roots D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth...2 D7280 Surgical access of an unerupted tooth... D729 Transseptal fiberotomy/supra crestal fiberotomy, by report..4 D730/20 Alveoloplasty, per quad D750 Incision and drainage of abscess - intraoral soft tissue... 9 D7960 Frenulectomy (frenectomy/frenotomy) - separate proc As performed by a Participating General Dentist. See Plan Exclusion #3. ADA MEMBER CODE BENEFIT COPAYMENT(S) ORTHODONTICS 2 D8090 Comp. ortho. treatment - adult dentition D8660 Pre-orthodontic treatment visit D8670 Periodic ortho. treatment visit (as part of contract)... 8 D8680 Orthodontic retention (rem. of appl. and placement of retainer(s)) Phase I Treatment (D800 - D8050) is provided at a 5% reduction from the orthodontist s UCR fees. See exclusion #5 for additional coverage exclusions Plan Exclusions. Services which are covered under Medicare, worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only). 2. Services which are not necessary for the patient s dental health as determined by the Plan. 3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan. 4. Oral surgery requiring the setting of fractures or dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where, in the opinion of the Plan, such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation. 9. Replacement due to loss or theft of prosthetic appliance. 0. Procedures not listed as covered benefits under this Plan.. Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Plan (with the exception of outof-area emergency dental services). 2. Services related to the treatment of TMD (Temporomandibular Disorder). 3. Services related to procedures that are of such a degree of complexity as to not be normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Participating Specialist (with the exception of orthodontics). Participating Specialists, if available, have entered into an agreement with the Plan to provide dental services to members at a 25% reduction from their Usual, Customary, and Reasonable (UCR) fees. This means that Member will be responsible for 25% of the lesser of a Participating Specialist s UCR fee; of the amount the provider has agreed to accept. Members must directly contact the Participating Specialist to obtain fees, as the amount varies by provider. 4. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Plan. 5. The Invisalign system and similar appliances are not a covered benefit. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient s responsibility. Plan Limitations. Two (2) evaluations are covered per calendar year per patient including a maximum of one () comprehensive evaluation. 2. One () problem focused exam is covered per calendar year per patient. 3. Two (2) teeth cleanings (prophylaxis) are covered per calendar year per patient (one additional cleaning is covered during pregnancy and for diabetic patients). 4. One () topical fluoride or fluoride varnish is covered per calendar year per patient. 5. Two (2) bitewing x-rays are covered per calendar year per patient. 6. One () set of full mouth x-rays or panoramic film is covered every three (3) years per patient. 7. Replacement of a filling is covered if it is more than two (2) years from the date of original placement. 8. Replacement of a bridge, crown or denture is covered if it is more than seven (7) years from the date of original placement. 9. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider s Usual, Customary, and Reasonable (UCR) fee, minus 25%. 0. Relining and rebasing of dentures is covered once every 24 months per patient.. Retreatment of root canal is covered if it is more than two (2) years from the original treatment. 2. Root planing or scaling is covered once every 24 months per quadrant per patient. 3. Full mouth debridement is covered once per lifetime per patient. 4. Procedure Code D438 is limited to one () benefit per tooth for three teeth per quadrant or a total of 2 teeth for all four quadrants per twelve (2) months per patient. Must have pocket depths of five (5) millimeters or greater. 5. Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgical site per patient. 6. Periodontal maintenance after active therapy is covered twice per calendar year, within 24 months after definitive periodontal therapy, per patient. Only current ADA CDT codes are considered valid by Dominion Dental Services, Inc. Current Dental Terminology American Dental Association.

11 Benefit Coverage In-Network Out-of Network Year st 2nd 3rd st 2nd 3rd Class I 00% 00% 00% 90% 90% 90% Class II 40% 60% 80% 30% 50% 70% Class III 5% 25% 50% 0% 20% 40% Endo/Perio Class III Benefits Class III Benefits Annual Deductible In-Network Out-of-Network Amount $50 $50 Max for Adults $50 $50 Applies to all Yes Yes Benefits Maximums In-Network Out-of-Network Annual $,000 $,000 Lifetime Ortho N/A N/A * Annual Maximum applies to Class I, Class II and Class III Benefits. Waiting Periods In-Network Out-of-Network Class I NONE NONE Class II NONE NONE Class III NONE NONE Class IV N/A N/A Deductible is combined for all services for each Calendar Year per Member maximum $50 for adults. Services may be received from any licensed dentist. If course of treatment is to exceed $300, prior review is requested. Plan will pay either the Participating Dentist s negotiated fee or the Maximum Allowable Charge (subject to benefit coverage percentage) for dental procedures and services as shown below, after any required Annual Deductible. Class I. Diagnostic and Preventive Services Include:. Two evaluations per Calendar Year including a maximum of one comprehensive evaluation per 36 months 2. One emergency or problem focused exam (D040) per Calendar Year 3. Two prophylaxis (cleaning, scaling and polishing teeth) per Calendar Year 4. Bitewing x-rays, 2 per Calendar Year 5. Emergency palliative treatment (only if no services other than exam and x-rays were performed on the same date of service) Class II. Basic Services, Include:. Simple extraction of teeth 2. Amalgam and composite fillings (anterior restorations of mesiolingual, distolingual, mesiobuccal, and distobuccal surfaces considered single surface restorations), per tooth, per surface every 24 months 3. Periapical x-rays 4. One full mouth or panoramic x-ray per 60 months 5. Pin retention of fillings (multiple pins on the same tooth are allowable as one pin) 6. Antibiotic injections administered by a dentist Class III. Major Services:. Oral surgery, including postoperative care for: a. Removal of teeth, including impacted teeth b. Extraction of tooth root c. Alveolectomy, alveoplasty, and frenectomy d. Excision of periocoronal gingiva, exostosis, or hyper plastic tissue, and excision of oral tissue for biopsy e. Reimplantation or transplantation of a natural tooth f. Excision of a tumor or cyst and incision and drainage of an abscess or cyst 2. Endodontic treatment of disease of the tooth, pulp, root, and related tissue, limited to: a. Root canal therapy (not covered if pulp chamber was opened before effective date of coverage) b. Pulpotomy c. Apicoectomy d. Retrograde fillings, per root per lifetime 3. Periodontic services, limited to: a. Two periodontal maintenance visits following surgery per Calendar Year Access PPO (2347) b. One scaling and root planing per quadrant (D434 or D4342) of mouth per 24 months from age 2 c. Occlusal adjustment performed with covered surgery d. Gingivectomy e. Osseous surgery including flap entry and closure f. One pedicle or free soft tissue graft per site per lifetime g. One appliance (night guards) per 5 years h. One full mouth debridement per lifetime 4. One study model per 36 months 5. Crown build-up for non-vital teeth 6. Recementing bridges, inlays, onlays and crowns after 2 months of insertion and per 2 months per tooth thereafter 7. One repair of dentures or fixed bridgework per 24 months 8. General anesthesia and analgesia, including intravenous sedation, in conjunction with covered oral surgery or periodontal surgery 9. Restoration services, limited to: a. Gold or porcelain inlay, onlay, and crown for tooth with extensive caries or fracture that is unable to be restored with an amalgam or composite filling b. Replacement of existing inlay, onlay, or crown, after 7 years of the restoration initially placed or last replaced c. Post and core in addition to crown when separate from crown for endodontically treated teeth, with a good prognosis endodontically and periodontally 0. Prosthetic services, limited to: a. Initial placement of removable dentures or fixed bridges (including acid etch metal bridges) b. Replacement of removable dentures or fixed bridges that cannot be repaired after 7 years from the date of last placement c. Addition of teeth to existing partial denture d. One relining or rebasing of existing removable dentures per 24 months Class IV. Orthodontia Services: Not Covered Diagnostic services, active and retention treatment to include removable fixed appliance therapy and limited and comprehensive therapy Plan Exclusions:. Services which are covered under worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only). 2. Services which are not necessary for the patient s dental health. 3. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry. 4. Oral surgery requiring the setting of fractures and dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared. 9. Implant removal or the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. 0. Diagnosis or treatment of Temporomandibular Disorder (TMD) and/or occlusal disharmony.. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. 2. Services not listed as covered. 3. Implants and related services; replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semi-precision attachments; denture duplication; periodontal splinting of teeth. 4. Services for increasing vertical dimension, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions. 5. Procedures that in the opinion of the Plan are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member s condition. 6. Treatment of cleft palate, malignancies or neoplasms. 7. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36 months of Member s continuous coverage under the plan. 8. Maryland policyholders only: Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. Prohibited referral means a referral prohibited by Section -302 of the Maryland Health Occupations Article.

12 Benefit Coverage In-Network Out-of-Network Class I 00% 90% Class II 50% 40% Class III 0% 0% Class IV 0% 0% Endo/Perio Class III & II/III Class III & II/III Benefits Benefits Annual Deductible In-Network Out-of-Network Amount $50 $50 Max for adults $50 $50 Applies to all Yes Yes Benefits Maximums In-Network Out-of-Network Annual $750 $750 Lifetime Ortho N/A N/A * Annual Maximum applies to Class I, Class II and Class III Benefits. Waiting Periods In-Network Out-of-Network Class I NONE NONE Class II NONE NONE Class III NONE NONE Class IV N/A N/A Deductible is combined for all services for each Calendar Year per Member maximum $50 for adults. Services may be received from any licensed dentist. If course of treatment is to exceed $300, prior review is requested. Plan will pay either the Participating Dentist s negotiated fee or the Maximum Allowable Charge (subject to benefit coverage percentage) for dental procedures and services as shown below, after any required Annual Deductible. Class I. Diagnostic and Preventive Services:. Two evaluations per Calendar Year including a maximum of one comprehensive evaluation per 36 months 2. One emergency or problem focused exam (D040) per Calendar Year 3. Two prophylaxis (cleaning, scaling and polishing teeth) per Calendar Year 4. Bitewing x-rays, 2 per Calendar Year 5. Periapical x-rays 6. One full mouth or panoramic x-ray per 60 months 7. Emergency palliative treatment (only if no services other than exam and x-rays were performed on the same date of service) Class II. Basic Services:. Simple extraction of teeth 2. Amalgam and composite fillings (anterior restorations of mesiolingual, distolingual, mesiobuccal, and distobuccal surfaces considered single surface restorations), per tooth, per surface every 24 months 3. Pin retention of fillings (multiple pins on the same tooth are allowable as one pin) 4. Antibiotic injections administered by a dentist 5. Periodontic services, limited to: a. Two periodontal maintenance visits following surgery per Calendar Year b. One scaling and root planing per quadrant (D434 or D4342) of mouth per 24 months from age 2 c. Occlusal adjustment performed with covered surgery d. One appliance (night guards) per 5 years within 6 months of osseous surgery e. One full mouth debridement per lifetime Class III. Major Services: Not Covered. Oral surgery, including postoperative care for: a. Removal of teeth, including impacted teeth b. Extraction of tooth root c. Alveolectomy, alveoplasty, and frenectomy d. Excision of periocoronal gingiva, exostosis, or hyper plastic tissue, and excision of oral tissue for biopsy e. Reimplantation or transplantation of a natural tooth f. Excision of a tumor or cyst and incision and drainage of an abscess or cyst 2. Periodontic services, limited to: a. Gingivectomy b. Osseous surgery including flap entry and closure c. One pedicle or free soft tissue graft per site per lifetme 2 Access PPO 2 (2348) 3. Endodontic treatment of disease of the tooth, pulp, root, and related tissue, limited to: a. Root canal therapy (not covered if pulp chamber was opened before effective date of coverage) b. Pulpotomy c. Apicoectomy d. Retrograde fillings, per root per lifetime 4. One study model per 36 months 5. Crown build-up for non-vital teeth 6. Recementing bridges, inlays, onlays and crowns after 2 months of insertion and per 2 months per tooth thereafter 7. One repair of dentures or fixed bridgework per 24 months 8. General anesthesia and analgesia, including intravenous sedation, in conjunction with covered oral surgery or periodontal surgery 9. Restoration services, limited to: a. Gold or porcelain inlay, onlay, and crown for tooth with extensive caries or fracture that is unable to be restored with an amalgam or composite filling b. Replacement of existing inlay, onlay, or crown, after 7 years of the restoration initially placed or last replaced c. Post and core in addition to crown when separate from crown for endodontically treated teeth, with a good prognosis endodontically and periodontally 0. Prosthetic services, limited to: a. Initial placement of removable dentures or fixed bridges (including acid etch metal bridges) b. Replacement of removable dentures or fixed bridges that cannot be repaired after 7 years from the date of last placement c. Addition of teeth to existing partial denture d. One relining or rebasing of existing removable dentures per 24 months Class IV. Orthodontia Services: Not Covered Diagnostic services, active and retention treatment to include removable fixed appliance therapy and limited and comprehensive therapy Plan Exclusions:. Services which are covered under worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only). 2. Services which are not necessary for the patient s dental health. 3. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry. 4. Oral surgery requiring the setting of fractures and dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared. 9. Implant removal or the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. 0. Diagnosis or treatment of Temporomandibular Disorder (TMD) and/or occlusal disharmony.. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. 2. Services not listed as covered. 3. Implants and related services; replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semi-precision attachments; denture duplication; periodontal splinting of teeth. 4. Services for increasing vertical dimension, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions. 5. Procedures that in the opinion of the Plan are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member s condition. 6. Treatment of cleft palate, malignancies or neoplasms. 7. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36 months of Member s continuous coverage under the plan. 8. Maryland policyholders only: Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. Prohibited referral means a referral prohibited by Section -302 of the Maryland Health Occupations Article.

13 Benefit Coverage In-Network Out-of-Network Class I 00% 90% Class II 50% 40% Class III 0% 0% Class IV 0% 0% Endo/Perio Class II Benefits Class II Benefits Annual Deductible In-Network Out-of-Network Amount $50 $50 Max for Adults $50 $50 Applies to all No, Waived on No, Waived on Benefits Class I Benefits Class I Benefits Maximums In-Network Out-of-Network Annual $,000 $,000 Lifetime Ortho N/A N/A * Annual Maximum applies to Class I, Class II and Class III Benefits. Waiting Periods In-Network Out-of-Network Class I NONE NONE Class II NONE NONE Class III NONE NONE Class IV N/A N/A Deductible is combined for all services for each Calendar Year per Member maximum $50 for adults. Services may be received from any licensed dentist. If course of treatment is to exceed $300, prior review is requested. Plan will pay either the Participating Dentist s negotiated fee or the Maximum Allowable Charge (subject to benefit coverage percentage) for dental procedures and services as shown below, after any required Annual Deductible. Class I. Diagnostic and Preventive Services:. Two evaluations per Calendar Year including a maximum of one comprehensive evaluation per 36 months 2. One emergency or problem focused exam (D040) per Calendar Year 3. Two prophylaxis (cleaning, scaling and polishing teeth) per Calendar Year 4. Bitewing x-rays, 2 per Calendar Year 5. Periapical x-rays 6. One full mouth or panoramic x-ray per 60 months 7. Emergency palliative treatment (only if no services other than exam and x-rays were performed on the same date of service) Class II. Basic Services:. Simple extraction of teeth 2. Amalgam and composite fillings excluding posterior composite fillings (anterior restorations of mesiolingual, distolingual, mesiobuccal, and distobuccal surfaces considered single surface restorations), per tooth, per surface every 24 months 3. Pin retention of fillings (multiple pins on the same tooth are allowable as one pin) 4. Antibiotic injections administered by a dentist 5. Endodontic treatment of disease of the tooth, pulp, root, and related tissue, limited to: a. Root canal therapy (not covered if pulp chamber was opened before effective date of coverage) b. Pulpotomy c. Apicoectomy d. Retrograde fillings, per root per lifetime 6. Periodontic services, limited to: a. Two periodontal maintenance visits following surgery per Calendar Year b. One scaling and root planing per quadrant (D434 or D4342) of mouth per 24 months from age 2 c. Occlusal adjustment performed with covered surgery d. Gingivectomy e. Osseous surgery including flap entry and closure f. One pedicle or free soft tissue graft per site per lifetme g. One appliance (night guards) per 5 years within 6 months of osseous surgery h. One full mouth debridement per lifetime Class III. Major Services: Not Covered. Oral surgery, including postoperative care for: Access PPO 3 (2349) a. Removal of teeth, including impacted teeth b. Extraction of tooth root c. Alveolectomy, alveoplasty, and frenectomy d. Excision of periocoronal gingiva, exostosis, or hyper plastic tissue, and excision of oral tissue for biopsy e. Reimplantation or transplantation of a natural tooth f. Excision of a tumor or cyst and incision and drainage of an abscess or cyst 2. One study model per 36 months 3. Crown build-up for non-vital teeth 4. Recementing bridges, inlays, onlays and crowns after 2 months of insertion and per 2 months per tooth thereafter 5. One repair of dentures or fixed bridgework per 24 months 6. General anesthesia and analgesia, including intravenous sedation, in conjunction with covered oral surgery or periodontal surgery 7. Restoration services, limited to: a. Gold or porcelain inlay, onlay, and crown for tooth with extensive caries or fracture that is unable to be restored with an amalgam or composite filling b. Replacement of existing inlay, onlay, or crown, after 7 years of the restoration initially placed or last replaced c. Post and core in addition to crown when separate from crown for endodontically treated teeth, with a good prognosis endodontically and periodontally 8. Prosthetic services, limited to: a. Initial placement of removable dentures or fixed bridges (including acid etch metal bridges) b. Replacement of removable dentures or fixed bridges that cannot be repaired after 7 years from the date of last placement c. Addition of teeth to existing partial denture d. One relining or rebasing of existing removable dentures per 24 months Class IV. Orthodontia Services: Not Covered Diagnostic services, active and retention treatment to include removable fixed appliance therapy and limited and comprehensive therapy Plan Exclusions:. Services which are covered under worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only). 2. Services which are not necessary for the patient s dental health. 3. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry. 4. Oral surgery requiring the setting of fractures and dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared. 9. Implant removal or the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. 0. Diagnosis or treatment of Temporomandibular Disorder (TMD) and/or occlusal disharmony.. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. 2. Services not listed as covered. 3. Implants and related services; replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semi-precision attachments; denture duplication; periodontal splinting of teeth. 4. Services for increasing vertical dimension, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions. 5. Procedures that in the opinion of the Plan are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member s condition. 6. Treatment of cleft palate, malignancies or neoplasms. 7. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36 months of Member s continuous coverage under the plan. 8. Maryland policyholders only: Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. Prohibited referral means a referral prohibited by Section -302 of the Maryland Health Occupations Article. 3

14 Vision Plan 6030 You may use any licensed vision provider or choose from over 42,000 participating providers nationwide including Wal-Mart, Pearle Vision, Sears Optical, J.C. Penney, For Eyes Optical, Hour Eyes and Target Optical, along with independent optometrists, ophthalmologists and opticians. 2 In-Network Benefits Include: Eye Examination: Covered 00% after a $0 copay. Eyeglass Lenses: Covered 00% after a $0 copay per pair. Lens options purchased from a participating provider will be provided to the member at a fixed price (does not apply to Wal-Mart locations). Please refer to your coverage schedule for specific pricing. Frames: Any frame up to a retail price of $20. The member is responsible for frame costs exceeding $20, less a 30% discount (for example, if the frame costs $220, the plan covers $20 and the member is responsible for the remaining balance of $00. Instead of paying the full $00, the member gets a 30% discount and pays only $70). Contact Lenses 3 : Any pair of contact lenses up to a retail price of $00 (member cannot have eyeglass lenses and contact lenses covered under the plan in the same 2-month period). The member is responsible for contact lens costs exceeding $00, less a 25% discount (for example, if the contact lenses cost $200, the plan covers $00 and the member is responsible for the remaining balance of $00. Instead of paying the full $00, the member gets a 25% discount and pays only $75). 4 Dental Subscribers Can Also Enroll in our Vision Plan! Vision Plan 6030 At a Glance Rates Vision 6030 Monthly Premium Member $8.42 Member + $4.58 Member + 2 or More $2.0 Benefit Summary Copayments Frequency Exam $0 2 Months Lenses $0 2 Months Frames None 2 Months Contact Lenses (instead of glasses) None 2 Months Lenses Benefit Options (in-network) (in addition to lenses copayment above) UV Coating $2 Tint $0 Scratch Resistance $0 Polycarbonate $25 Anti-Reflective $40 Standard Progressive $50 Other Add Ons Retail Discount Maximum Allowances Preferred Provider Frame $20 Contact Lenses (instead of glasses) $00 Non-Preferred Provider Exam $32 Frames $60 Single Vision Lenses $24 Bifocal Lenses $36 Trifocal Lenses $46 Contact Lenses $75 The scheduled amounts shown are the maximum allowable amount. The actual amount to be paid for any service or material will be the lesser of the scheduled amount for such service rendered and/or materials purchased, or the actual amount charged. There is no assurance that the scheduled amount will be sufficient to pay the full cost of the service rendered or the materials selected. A mail order discount program is also available by ordering online through Contact Fill at contactfill.com or toll-free at LASIK - Non-Insured Discount Benefit: Members will receive a 5% discount off of standard prices or a 5% discount off of promotional prices. Out-of-Network Benefits Include: While Dominion offers access to a leading national network through National Vision Administrators (NVA), members may choose to go outside the network using any licensed vision provider. Please refer to the description of benefits on the next page, which will outline coverage if a non-participating provider is utilized. * Please note the benefits are licensed vision products, but 2 All other brand names, product names or trademarks belongs to their respective holders. they are not pediatric vision essential health benefits 3 Instead of glasses offered by a stand-alone vision plan under the Affordable Care Act.

15 Vision Plan 6030 Plan will pay for eligible expenses (subject to benefit coverage) incurred by or on behalf of Subscriber and/or their Dependents while covered under the Policy including: A. Services: Include, but are not limited to:. Vision Examinations - Each Subscriber and eligible Dependent(s) is entitled to a complete analysis of the eyes and related structures to determine vision problems and other abnormalities. Plan will cover such service once every 2 months. Where the vision examination shows new lenses or frames or both are necessary for proper visual health, such materials will be covered, together with certain services as necessary. 2. Prescribing and ordering proper lenses. 3. Assisting with selection of frames. 4. Verifying accuracy of finished lenses. 5. Proper fitting and adjustments. B. Materials:. Lenses: Plan will pay for lenses on a new prescription for standard lenses once every 2 months. The lens allowance equals two (2) lenses. If only one () lens is needed the allowance will be half (/2) the lens allowance. 2. Frames: Plan will pay for frames once every 2 months. 3. Contact Lenses: Plan will pay for contact lenses once every 2 months. C. Benefits: Copayments Freguency Exam $0 2 months Lenses $0 2 months Frames None 2 months Contact Lenses None 2 months Lenses Benefit Options (in-network) (in addition to lenses copayment above) UV Coating $2 Tint $0 Scratch Resistance $0 Polycarbonate $25 Anti-Reflective $40 Anti-Reflective $40 Other Add Ons Retail Discount Maximum Allowances Preferred Provider: Frame $20 Contact Lenses $00 (instead of glasses) Non-Preferred Provider: Exam $32 Frames $60 Single Vision Lenses $24 Bifocal Lenses $36 Trifocal Lenses $46 Contact Lenses $75 The scheduled amounts shown are the maximum allowable amount. The actual amount to be paid for any service or material will be the lesser of the scheduled amount for such service rendered and/or materials purchased, or the actual amount charged. There is no assurance that the scheduled amount will be sufficient to pay the full cost of the service rendered or the materials selected. Use of a Participating Provider does not guarantee that all expenses will be covered under the Policy. Participating Provider locations are identified by contacting the Plan s Member Services Department or the website. Services and materials will be covered at the benefit levels for a Non- Participating Provider when: a) the provider rendering the service or furnishing the materials is no longer a Participating Provider; or b) the Member elects not to use the services or materials of the Participating Provider. Non-Participating Provider shall mean a licensed provider NOT under contract with Plan. After the applicable copayment, Plan will pay the reasonable and customary charge for services and materials, up to the scheduled amount shown in this document. Benefits will be payable the same as for a Participating Provider when: a) a Participating Provider refers the Member to a Non- Participating Provider because the Participating Provider is unable to render the necessary service or furnish the necessary materials; or b) a Non- Participating Provider is on call in the absence of the Participating Provider. Plan may not prohibit the assignment of benefits to a Provider by a Member or refuse to directly insure a Non-Participating Provider under an assignment of benefits. Plan Limitations: In no event will payment exceed the lesser of:. The actual cost of covered services or materials; or 2. The limits of the Policy, shown in this schedule. Plan Exclusions:. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared. 2. Services which are covered under Medicare, worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law (Pennsylvania policyholders only). 3. Services and treatment provided without charge or for which there would be no charge in the absence of insurance. DOES NOT APPLY TO MEDICAID. 4. Services not listed as covered. 5. Hospitalization for any vision procedure. 6. Services and treatment for which Member is eligible for coverage under his or her hospital, medical/surgical or major medical plan. 7. Orthoptic or vision training and any associated supplemental testing. 8. Plano lenses. 9. Two pair of glasses, in lieu of bifocals or trifocals. 0. Medical or surgical treatment of the eyes.. Any eye examination, or any corrective eyewear, required by an employer as a condition of employment. 2. Customization of bifocal lenses to a progressive or no-line lens. 3. Photo-chromatic lenses. 4. Sub-normal vision aids or non-prescription lenses. 5. Services rendered or materials purchased outside the U.S. or Canada, unless: a) the Member resides in the U.S. or Canada; and b) the charges are incurred while on a business or pleasure trip. 6. Charges in excess of the usual and customary charge for the service or materials. 7. Charges incurred after: a) the Policy ends; or b) the Member s coverage under the Policy ends, except as stated in the Policy. Maryland policyholders only: Also subject to the Extension of Benefits provision. 8. Experimental or non-conventional treatment or device as determined by treating provider. 9. Spectacle lens treatments or add-ons, except solid tints (# & #2), and oversize lenses. 20. High Index lenses of any material type. 2. Lost or broken materials, except when replaced at normal intervals when services are available. 22. Maryland policyholders only: Any bill, or demand for payment, for a vision service that the appropriate regulatory board determines was provided as a result of a prohibited referral. Prohibited referral means a referral prohibited by Section -302 of the Maryland Health Occupations Article. Participating Provider shall mean a licensed provider who has contracted to accept, as full payment, Member s copayment and the contracted payment from Plan. Plan will pay benefits if the services are rendered or materials are furnished by a Participating Provider. 5

16 Who is Eligible for the Dental & Vision Plan? You and your dependents are eligible. Dependents include your spouse and unmarried children up to age 26. How do I Join the Dental & Vision Plan?. To pay annually by check, complete the Enrollment Card and submit it with a check for 2 months of premium. Go to Step To pay by debit to your checking account or credit card account, please fill out the Payment Authorization Card. Be sure to select either the automatic monthly debit option or annual payment option. When you choose the monthly payment option future monthly installments will be debited directly from your account. You will not receive monthly bills. Please attach a voided check to Payment Authorization Card when selecting this option. When you choose the annual payment option you will be charged (debited) one time for 2 months of premium. There is a minimum participation requirement of one year. 3. Fill out the Enrollment Card. Be sure to list all dependents you want covered. Additional dependents can be listed on the back of the Enrollment Card, if necessary. Select either the Discount Program, Select Plan or Access PPO Plan. You do not have to enroll in a dental benefit to enroll in the vision plan. If you choose either the Discount Program or the Select Plan, please select a dentist and fill in the Dental Office Name & Code # box. Sign and date the appropriate section of the Enrollment Card. 4. Return the completed Enrollment Card, Payment Authorization Card (if applicable) or payment (if applicable) to: Dominion Dental Services, Inc. P.O. Box 7534 Charlotte, NC A Membership Card and coverage information will be mailed to you on or before your first day of eligibility. The following explanation as required by the Maryland Insurance Administration. Access PPO & Select Plan Premium Dollar Distribution 26% 3% Dentist Compensation Administration Costs Other Dominion is licensed as a Dental Plan Organization (DPO) in the State of Maryland. Providers are paid through a combination of member copayments and capitation dollars (predetermined monthly payments per member). This chart shows how premium dollars were distributed in 202 between dentist compensation and administration costs. 7% Vision Premium Dollar Distribution 3% 9% 60% Provider Compensation Administration Costs Other This chart shows how premium dollars were distributed in 202 between provider compensation and administration costs. 5 South Union Street, Suite 300 Alexandria, VA (Phone) (Fax) DominionDental.com DominionDental.com/eDental/picpa 6