Select Standard & High Dental Plans

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1 Select Standard & High Dental Plans FederalDentalPlans.com Featured Benefits at Dominion Great coverage at lower rates starting at $6.01 Prevention Rewards Program Discounts on Invisalign and teeth whitening procedures New mobile app Look Inside for Details! 2018

2 MyDOMINION MOBILE APP The MyDominion mobile app provides members with easy access to account and plan information. With MyDominion, you can: Find A Dentist View ID Cards View Plan Information The MyDominion app is compatible with iphone and Android and can be downloaded through our website at FederalDentalPlans.com/ mobile.

3 Select Standard & High Dental Benefit Options Plan Features NO Annual Maximums NO Deductibles NO Waiting Periods NO Claim Forms 1 NO Pre-authorization Paperwork Select Plans The Select Plans are Dental HMO benefits with fixed member copayments. Services must be provided by a participating dentist. Plan Highlights Quality care at predetermined fees Extensive coverage for over 250 procedures No charge for oral exams, cleanings, X-rays or topical fluoride for children (after a $10 office fee) Orthodontic benefits provided for adults and children 15% discount on Invisalign as an alternative to standard orthodontic braces from participating dentist s UCR fee Additional cleaning covered for diabetics and expecting mothers Specialist care is also provided at the listed copayment Choose any in-network dentist from one of the largest Dental HMO networks in the Mid-Atlantic 2 Family members may select different dentists All network dentists must meet Dominion s Quality Assurance Program standards Out-of-Area Emergency Care: You are covered up to $100 for palliative emergency dental treatment Prevention Rewards: Each family member enrolled with Dominion who receives two cleanings during the plan year will be reimbursed for their $10 office visit copayments made to the dentist at the time of service (a total reimbursement of $20 per family member). Dominion will submit a check for the reimbursement(s) to the primary subscriber at the end of the plan year. If you participate with FSAFEDS, Dominion may coordinate the reimbursement through your FSA. 1 Out-of-area emergency care reimbursement requires a receipt or other proof of loss. 2 Dominion Dental Services, Inc. Network Analysis Report, July Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change. Savings Comparison Select Standard Select High Procedure Area Charge * Your Fee ** Your Savings Your Fee ** Your Savings Office Visit Fee --- $ $ Comprehensive Oral Exam $85 No Charge 100% No Charge 100% Complete Series X-rays $161 No Charge 100% No Charge 100% Bitewing X-rays (4 Films) $74 No Charge 100% No Charge 100% Cleanings (Adults) $102 No Charge 100% No Charge 100% Cleanings (Children) $74 No Charge 100% No Charge 100% Fluoride Varnish $41 No Charge 100% No Charge 100% Sealant $58 No Charge 100% No Charge 100% Filling (3-Surface/Silver) $217 $76 65% No Charge 100% Crown (Porcelain/Metal) $1,299 $555 57% $380 71% Endoseal Implant (Surgical) $2,503 $1,292 48% $830 67% Complete Denture $1,785 $702 61% $455 74% Root Canal (Anterior Tooth) $747 $391 48% $260 65% Perio Scaling/Root Planing $247 $105 57% $31 87% Extraction, Erupted Tooth $170 $58 66% $47 72% Child Orthodontics $6,552 $3,422 48% $3,422 48% Adult Orthodontics $7,025 $3,658 48% $3,658 48% * Based on the Context4Healthcare s 80th percentile fee information. Based on zip 220. ** There is an additional $10 for the office visit fee (per visit, not per procedure). Refer to the exclusions and limitations.

4 Summary of Benefits & Member Copayments This is only a summary of the over 250 procedures that are covered. For a complete listing of benefits and copays, please visit FederalDentalPlans.com. Copays are listed in USD. Benefit Description Standard High Office visit DIAGNOSTIC/PREVENTIVE Limited oral eval - problem focused Comp. oral eval - new or est. patient Complete series X-rays Periapical first film Periapical each add. film Bitewing x-rays Panoramic film Prophylaxis (cleaning) - adult/child Additional cleaning (expecting mothers/diabetics) Topical fluoride varnish Topical application of fluoride Sealant - per tooth Space maintainer - fixed/rem. - uni/bilateral RESTORATIVE DENTISTRY (FILLINGS) Amalgam - 1 surface, prim. or perm Amalgam - 2 surfaces, prim. or perm Amalgam - 3 surfaces, prim. or perm Amalgam - >=4 surfaces, prim. or perm Resin-based composite - 1 surf., anterior Resin-based composite - 2 surf., anterior Resin-based composite - >=3 surf., anterior Resin-based composite - 1 surf., posterior Resin-based composite - 2 surf., posterior Resin-based composite - 3 surf., posterior Resin-based composite - >=4 surf., post Pin retention - per tooth, in add. to rest Pulp cap - direct/indirect (excl. final rest.) CROWN & BRIDGE Inlay - metallic - one surface Inlay - metallic - two surfaces Inlay - metallic - three or more surfaces Onlay - metallic-two surfaces Crown - porcelain fused metal Crown - 3/4 cast with metal Crown - 3/4 porcelain/ceramic Crown - full cast high noble metal Prefab. stainless steel crown - prim./perm Core buildup, including any pins Prefab. post and core in addition to crown Crown, inlay, onlay or veneer repair PROSTHETICS (DENTURES) Complete denture - maxillary/mandibular Immediate denture - maxillary/mandibular Max./mand. partial denture - resin base Max./mand. partial denture - cast metal Adj. comp./partial denture - max./mand Repair broken denture base (comp./resin) Replace missing/broken teeth - comp Repair resin denture base/cast framework Repair or replace broken clasp Replace broken teeth - per tooth Rebase comp./part. max./mand. denture Reline comp./partial max./mand. denture (chair) Reline comp./partial max./mand. denture (lab) Tissue conditioning - maxillary/mandibular BRIDGE/PONTICS Endosteal implant - surgical placement Connecting bar - implant/abutment supp Prefab. abutment - incl. modi. and place Benefit Description Standard High Abutment porc/metal crown-pred. base metal Implant supp. metal crown - titanium/titanium alloy/high noble metal Abutment supp. ret. for porc./ceramic FPD Implant supp. retainer for cast titanium/titanium alloy/high noble metal FPD Implant maintenance procedures Repair implant prosthesis Replace. of semi-precision/precision attach Repair implant abutment Implant removal Pontic - cast metal Pontic - porcelain fused metal Pontic - porcelain/ceramic Retainer - cast metal for resin bond. fixed pros Retainer - porc./cer. for resin bond. fixed pros Inlay - cast predom. base metal, >=3 surf Onlay - cast predom. base metal, >=3 surf Crown - porcelain/ceramic Crown - porcelain fused metal Crown - 3/4 cast metal Crown - 3/4 porc./ceramic Crown - full cast metal Recement fixed partial denture Fixed partial denture repair, by report ADJUNCTIVE GENERAL SERVICES EXTERNAL BLEACHING - 15% DISCOUNT Palliative (emergency) treat. of dental pain Deep sed./general anes. - each 15 min Intra. consc. sed./analgesia - each 15 min Consultation (diag. by nontreating dentist) Office visit - after reg. scheduled hours Fabrication of athletic mouthguard Internal bleaching - per tooth Missed appointment ENDODONTICS Endodontic therapy, anterior tooth Endodontic therapy, bicuspid tooth Endodontic therapy, molar Retreat of prev. root canal therapy, anterior Retreat of prev. root canal therapy, bicuspid Retreat of prev. root canal therapy, molar Apexification/recalcification initial visit Apicoectomy, anterior Apicoectomy, bicuspid (first root) Apicoectomy, molar (first root) Retrograde filling - per root PERIODONTICS Gingivectomy or gingivoplasty - >3 cont. teeth, per quad Gingivectomy or gingivoplasty - <=3 teeth, per quad Gingival flap proc., inc. root planing - >3 cont. teeth, per quad Gingival flap proc, inc. root planing - <=3 cont. teeth, per quad Osseous surg. - >3 cont. teeth, per quad Osseous surg. - <=3 cont. teeth, per quad Perio scaling/root planing - >3 cont teeth, quad Perio scaling/root planing - <= 3 teeth, quad Full mouth debridement Periodontal maintenance Occlusal guard, by report

5 Summary Continued, Exclusions & Limitations Benefit Description Standard High ORAL SURGERY Extraction, coronal rem. - deciduous tooth Extraction, erupted tooth or exposed root Erupted tooth req. bone cut Removal of impacted tooth - soft tissue Removal of impacted tooth - part. bony Removal of impacted tooth - comp. bony Removal of impacted tooth - comp. bony, with unusual surg. complications Alveoloplasty in conj. with ext. - >=4 teeth, quad ORTHODONTICS INVISALIGN - 15% DISCOUNT Limited ortho. treat. - primary dentition Limited ortho. treat. - transitional dentition Limited ortho. treat. - adolescent dentition Interceptive ortho. treat. - prim. dentition Interceptive ortho. treat. - trans. dentition Comp. ortho. treat. - trans. dentition Comp. ortho. treat. - adolescent dentition Comp. ortho. treatment - adult dentition Plan Exclusions 1. Services which are covered under Medicare, worker s compensation or employer s liability laws. 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. 4. Oral surgery requiring the setting of fractures or islocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, 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. 9. Replacement due to loss or theft of prosthetic appliance. 10. Procedures not listed as covered benefits under this Plan. 11. 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). 12. Services related to the treatment of TMD (Temporomandibular Disorder). 13. Services performed by a Participating Specialist without a referral from a Participating General Dentist (with the exception of orthodontics). 14. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. 15. Plaque control programs, oral hygiene instruction, and dietary instructions. 16. Nitrous oxide and oral sedation. Plan Limitations 1. Two (2) evaluations are covered per calendar year including a maximum of one (1) comprehensive evaluation. All oral evaluations will be considered integral when provided on the same date of service by the same dentist. 2. One (1) problem focused exam is covered per calendar year, per patient. 3. Two (2) teeth cleanings (prophylaxis) are covered per calendar year, per patient (one (1) additional cleaning is covered during pregnancy and for diabetic patients). Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and paid as such. 4. Two (2) topical fluorides or fluoride varnishes are covered per calendar year, per patient. 5. Two (2) bitewing x-rays are covered per calendar year, per patient. 6. One (1) set of full mouth x-rays or panoramic film is covered every three (3) years, per patient. 7. One (1) sealant per tooth is covered per 36 months, up to age 18 (limited to permanent 1st and 2nd molars). Sealants with a restoration on same date of service are considered integral. 8. Distal shoe space maintainer limited to once per lifetime. 9. Replacement of a filling is covered if it is more than two (2) years from the date of original placement. 10. Replacement of a bridge, crown or denture is covered if it is more than five (5) years from the date of original placement. 11. Crown, implant and bridge fees apply to treatment involving five (5) or fewer units when presented in a single treatment plan. Additional crown, implant or bridge units, beginning with the sixth unit, are available at the provider s Usual, Customary, and Reasonable (UCR) fee, minus 25%. 12. One (1) relining and rebasing of dentures is covered every 36 months, per patient. 13. Retreatment of root canal is covered if it is more than two (2) years from the original treatment. 14. Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of root canal therapy. 15. One (1) root planing or scaling is covered every 24 months per quadrant, per patient. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing, or periodontal surgical procedures, in the same area of the mouth is not covered. 16. Scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation and in lieu of a covered D1110/D1120, limited to once per two years. 17. One (1) full mouth debridement is covered per lifetime, per patient. 18. Procedure Code D4381 is limited to one (1) benefit per tooth for three (3) teeth per quadrant or a total of 12 teeth for all four (4) quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or greater. 19. One (1) periodontal surgery of any type, including any associated material, is covered every 36 months per quadrant or surgical site. 20. Periodontal maintenance after active therapy is covered two (2) times per calendar year, within 24 months after definitive periodontal therapy. 21. Stainless steel crowns (D2930, D2931) are covered through age 14, or when placed as a result of accidental injury and one per tooth, per lifetime. 22. Onlays, crowns, and posts and cores for members 12 years of age or younger are excluded from coverage, unless pre-approved by Plan. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core. Posts are eligible only when provided as part of a crown buildup or implant and are considered integral to the buildup or implant. 23. Fixed partial dentures, buildups and posts and cores for members under 16 years of age are not covered unless approved by Plan. 24. Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24 months of a gingival flap procedure are not covered. 25. Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of the mouth. 26. Surgical revision procedure (D4268) is considered integral to all other periodontal procedures. 27. One (1) scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure, per two (2) years. 28. Coronectomy, intentional partial tooth removal, once (1) per lifetime. Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless approved by the Plan. 29. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered procedure(s) when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions 30. Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMJD). Occlusal guards are limited to one (1) per 12 consecutive month period. 31. Athletic mouth guards are limited to one (1) per 12 consecutive month period. 32. One (1) internal bleaching of discolored teeth (D9974) is covered by report for endodontically treated anterior teeth per tooth per three (3) year period. 33. The Invisalign system is a discounted benefit that applies to D8070, D8080 and D8090. Additional costs incurred will become the patient s responsibility. 34. Teledentistry, synchronous (D9995) or asynchronous (D9996), limited to two (2) per calendar year (when available).

6 Rates & Rating Areas Great coverage at lower rates starting as low as $6.01 per bi-weekly pay period! Rating Area Self Only Self Plus One 2018 Rates - Select Standard Self and Family Self Only Self Plus One Self and Family 1 $6.01 $12.02 $18.03 $13.02 $26.04 $ $6.27 $12.54 $18.81 $13.59 $27.17 $ $6.99 $13.99 $20.98 $15.15 $30.31 $ $8.34 $16.68 $25.02 $18.07 $36.14 $ $8.89 $17.79 $26.68 $19.26 $38.55 $57.81 Rating Area Self Only Self Plus One 2018 Rates - Select High Self and Family Self Only Self Plus One Self and Family 1 $10.23 $20.46 $30.69 $22.17 $44.33 $ $10.60 $21.21 $31.81 $22.97 $45.96 $ $11.14 $22.29 $33.43 $24.14 $48.30 $ $12.96 $25.93 $38.89 $28.08 $56.18 $ $15.22 $30.45 $45.67 $32.98 $65.98 $98.95 Determine Your Rating Region State 3 Digit Zip Rating Area State 3 Digit Zip Rating Area DC Entire State 4 PA DE Entire State 5 PA MD , 214, 217 MD VA MD Rest of State 2 VA NJ PA Rest of State , , , Find a dentist at FederalDentalPlans.com.

7 Why Dominion? The only Dental HMO offered in the FEDVIP program Rates starting as low as $6.01 per bi-weekly pay period Extensive coverage at predictable, pre-determined fees One of the largest Dental HMO networks in the Mid-Atlantic 1 Significant savings when your dentist already participates in our Dental HMO network (must use a participating dentist for services) World-class service with over 875,000 members 2 Headquartered in Arlington, VA What is the Prevention Rewards Program? Each family member enrolled with Dominion who receives two cleanings during the plan year will be reimbursed for their $10 office visit copayments made to the dentist at the time of service (a total reimbursement of $20 per family member). Dominion will submit a check for the reimbursement(s) to the primary subscriber at the end of the plan year. If you participate with FSAFEDS, Dominion may coordinate the reimbursement through your FSA. For more information, please go online to FederalDentalPlans.com/PreventionRewards. Is this a FEDVIP benefit? Yes. This benefit is part of the FEDVIP program and is endorsed by the U.S. Office of Personnel Management (OPM). Who is eligible? Federal and U.S. Postal Service employees and annuitants, including dependents, are eligible. Dependents include your spouse and unmarried children under age 22. How do I enroll? There are two ways for you to enroll. 1. Go to BENEFEDS.com, which contains extensive support and FAQs to assist you through the enrollment process. If you don t already have an online BENEFEDS account, you will be prompted to create one prior to enrolling. 2. Call BENEFEDS Call Center toll-free at ; TTY How do I choose my dentist? You must choose a primary care dentist before you utilize the plan. Prior to your effective date, you will receive a notification prompting you to select a dentist. You can find a current list of dentists, or nominate your dentist, online at FederalDentalPlans.com or by calling Dominion tollfree at After your effective date, simply call the dental office you selected to make an appointment. Except for out-of-area emergency care, you must receive treatment at the dental office you selected. When should I contact BENEFEDS? Enrollment, including Qualifying Life Events Eligibility Billing and payment Updates to contact information You may go online to BENEFEDS.com or call BENEFEDS Call Center toll-free at ; TTY When should I contact Dominion? Plan information ID card requests Dentist search and selection Dental office transfers You may go online to FederalDentalPlans.com or call our Member Services Department toll-free at ; TTY 711. Summary of Benefits Standard 3 High 3 Basic Care 100% 100% Comprehensive oral exam Complete series X-rays Bitewing X-rays Semiannual cleaning Fluoride varnish Sealant Intermediate Care 45-65% % Fillings Oral surgery Endodontics Periodontics Major Restorative Care 45-60% 65-85% Crown (porcelain/metal) Implant (surgical) Bridges Dentures Orthodontics Children Adults 48% 48% 1 Dominion Dental Services, Inc. Network Analysis Report, July Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change. 2 Dominion National Internal Performance Report, July Participating providers are subject to change. 3 Approximate percentage of coverage based on the Context4Healthcare s 80th percentile. Based on zip code 220.

8 TOP REASONS TO CHOOSE DOMINION Find Out More at FederalDentalPlans.com Rates starting as low as $6.01 per bi-weekly pay period Extensive coverage at predictable, pre-determined fees No annual maximums, deductibles or waiting periods One of the largest Dental HMO networks in the Mid-Atlantic 1 Orthodontic coverage for children and adults Discounts on Invisalign and teeth whitening procedures Access to ID card, dentist search and more via the MyDominion mobile app Prevention Rewards Program: $20 copay reimbursement for each family member that receives two cleanings during the plan year FederalDentalPlans.com th Street South, Suite 900 Arlington, VA P: (Member Services) P: TTY 711 F: Dominion Dental Services, Inc. Network Analysis Report, July Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating dentists are subject to change. Dominion is licensed as a Dental Plan Organization in Delaware, Maryland and Virginia, Risk Assuming PPO in Pennsylvania and Accident & Health Insurer in D.C. The Dominion group of companies includes Dominion Dental Services, Inc., a licensed issuer of dental plans, and Dominion Dental Services USA, Inc., a licensed administrator of dental and vision benefits. t

Select Plan Basic 703xa (DC)

Select Plan Basic 703xa (DC) Description of Benefits & Member Copayments for Adult Services (age 19 and over) Coverage begins the first day of the month following the month in which the Member turns 19.