Aubrey ISD. Dental Select Plan Rates for: For the benefit period running 09/01/2017 through 08/31/2018

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1 Dental Select Plan Rates for: For the benefit period running 09/01/2017 through 08/31/2018 Indemnity Platinum Network Employee $37.54 Emp + 1 $70.88 Emp + Family $118.67

2 Summary of Benefits For: 80th R&C PREVENTIVE Indemnity Classic Plan MaxRewards Platinum Network Contracted Dentist Non-Contracted Dentist Routine exams, cleanings (2 per year), topical fluoride, x rays 100% 100% of R&C BASIC Composite fillings, extractions, oral surgery, sealants, space maintainers MAJOR Crowns, bridges, dentures, endodontics, periodontics ORTHODONTICS Children under 19 50% Waiting Period Lifetime Maximum 80% 80% of R&C 50% No Waiting Period 12 Month Waiting Period 12 Month Waiting Period $ % of R&C 50% MAXIMUM BENEFIT Applies to Preventive, Basic and Major Services Applies to Basic and Major Services Benefit Period is: Per Calendar Year DEDUCTIBLE Per Benefit Period Per Person: Family Maximum: $ $50.00 $

3 Dental Notes For: Network Access General Dentists Specialists (Include Pediatric, Endodontist, Prosthodontist, Oral Surgeon, Periodontist, Orthodontist*) UCR- No discount - including Orthodontists. The plan will pay based on Reasonable & Customary fees. The Member is responsible for the difference between the plan s payment and the Specialist s fee. Co-Pay Plans - See Schedule of co-payments for member responsibility Minnesota Plan Notes Dental Select participating general dentists accept the Platinum or Gold fee schedule as payment in full. Coinsurance Plans *Contracted Orthodontist: The member may receive a discount of up to 20% off of the contracted Orthodontist s fee. Contracted Specialists: The plan will pay based on a contracted fee schedule. Contracted specialist providers accept the fee schedule as payment in full with no balance billing. Non-Contracted Specialists: Dental Select participating general dentists utilize the Premier network. Services rendered will be reimbursed according to the Premier network fee schedule as payment in full. UCR CONTRACTED: General Dentists & Specialists: All payments made by the plan are based on the Platinum contracted fee schedule. NON-CONTRACTED: Dental Select will allow up to the reasonable and customary charge for the dental procedures and services after the required deductible amount, as shown. Charges above the plan payment are the member's responsibility. DISCOUNT: Discount only; no benefit will be paid. MaxRewards MAC- No discount - including Orthodontists. The plan will pay from our contracted fee schedule. The Member is responsible for the difference between the plan s payment and the Specialist s fee. For every consecutive year on the plan, each member will receive increased maximums by the schedule outlined below. The annual maximum benefit of each member will never exceed $2,000. Year 2 - $100 Year 3 - $200 Year 4 - $300 Year 5 - $400 This summary of benefits is current as of 09/01/2017. To verify up to date benefits, please contact Dental Select Member Services ( ) or refer to your current Certificate of Insurance.

4 Summary of Benefits For: Exam with Dilation as Necessary Access Discount Vision In Network Only Member Cost $5 off routine exam $10 off contact lense exam Complete pair of glasses (frame, lenses, and lens options) must be purchased in the same transaction to receive full discount. Items purchased separately will be discounted 20% off the retail price Standard Plastic Lenses Single Vision Bifocal Trifocal Progressive Frames Any frame at provider location Lens Options UV Coating Tint (Solid and Gradient) Standard Scratch Resistance Standard Polycarbonate Standard Anti Reflective Other Add ons and Services Contact Lenses $50 $70 $105 $135 35% off Retail Price $40 $45 20% Discount (Discount Applied to Materials Only) Conventional 15% off Retail Price Laser Correction (US Laser Network) Lasik or PRK 15% off retail price or 5% off promotional price

5 Discount Vision Notes For: Plan Notes Members will receive a 20% discount on items not covered by the plan at network providers. This discount may not be combined with any other discounts or promotional offers and does not apply to Eyemed Provider's professional services or contact lenses. Retail prices may vary by location. Discounts do not apply for benefits provided by other group benefit plans. Since Lasik or PRK vision correction is an elective procedure, performed by specially trained providers, this discount may not always be available from a provider in your immediate location. For a location near you and the discount authorization, please call LASER6 This summary of benefits is current as of 09/01/2017. To verify up to date benefits, please contact Dental Select Member Services ( ) or refer to your current Certificate of Insurance.

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