MetLife Voluntary Dental. Summary of Benefits and Rate Guide

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1 Summary of Benefits and Rate Guide For plans effective January 1, 2016 MetLife Voluntary Dental Product Overview Plan Benefits Program Guidelines Rates Limitations and Exclusions Enrollment Checklist Part of the CoPower SELECT portfolio of dental plans underwritten by MetLife and made available through CoPower.

2 MetLife Voluntary Dental MetLife, through CoPower, is offering access to two great voluntary plan options a Dental Health Maintenance Organization (DHMO) and a Dental Preferred Provider Organization (DPPO). 1 Meet MetLife With than 140 years of experience in the insurance business and 90 years in the group benefits business, MetLife is positioned to meet its obligations to your clients and their employees both today and in the future. MetLife is the largest administrator of dental benefit plans among all single commercial carriers, i providing dental plan coverage for nearly 21 million people. ii Additional Benefits DHMO The DHMO plan offers a wide range of dental benefits through a network of participating dentists at a cost considerably lower than the fees typically charged. 2 Members must preselect a participating dentist who is responsible for day-to-day care and members are only responsible for the copayments listed in the Benefit Grid. There are no annual maximums, deductibles, or claims. The Voluntary DHMO Coverage Covered procedures include copays for services such as implants, veneers, white fillings, IV sedation, general anesthesia, nitrous oxide, and orthodontic treatment in progress at initial group enrollment 3 Defined fees for materials and procedures requiring multiple services such as root canals, crowns, and bridges minimize fee confusion The DPPO dental network includes over 304,823 participating dentist access points, including over 72,681 specialists ii The DHMO dental network includes over 9,416 participating network dentist access points in California iii DPPO The Preferred Dentist Program (PDP) provides both coverage for a broad range of services and the flexibility to visit any dentist, regardless of network status. PDP dentists have agreed to accept negotiated fees as payment in full, even for non-covered services. This means out-of-pocket costs are 15 45% less than the average fees charged by dentists in the same community! The DHMO plan offers than Easiest Way to Have The Voluntary Dental, DPPO Coverage Vision, and Life 400 covered services iv s can view and manage their dental benefits online Negotiated fees accepted by participating network dentists generally range from 15 45% below the average charges in a dentist s community MetLife s negotiated fees apply to all covered services provided by MetLife PDP dentists and may extend to non-covered services and services provided after the annual maximum has been exceeded 4 i LIMRA data, based on enrolled lives as of 12/31/13 ii MetLife data as of 1/15 iii MetLife data as of 1/1/15 iv Copayments apply for many covered procedures and vary by procedure 1 Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY Savings from enrolling in a dental benefits plan will depend on various factors, including how often participants visit the dentist and the cost of services covered. Negotiated fees for non-covered services may not apply in all states 3 Continuing orthodontic treatment applies to groups with 5 or eligible lives 4 Negotiated fees for non-covered services may not apply in all states 2

3 Plan Benefits VOLUNTARY DHMO DHMO Code Services Copay Office Visit Per visit (including all fees for sterilization and/or infection control) $0 Diagnostic Treatment D0120 Periodic Oral Evaluation Established Patient $0 D0150 Comprehensive Oral Evaluation New or Established Patient $0 D0210 Intra-oral Complete Series (including bite-wings) $0 D0274 Bite-wings Four Films $0 Preventive Services D1110/D1120 Prophylaxis Adult and child $0 D1351 Sealant Per tooth $0 Restorative Services D2140 Amalgam One surface, primary or permanent $0 D2330 Resin-based composite One surface, anterior $0 D2391 Resin-based composite One surface, posterior $30 Crowns (Additional fees for metal upgrades and/or porcelain apply) D2750 Crown Porcelain fused to high noble metal $185 D2751 Crown Porcelain fused to predominantly base metal $185 Endodontics D3220 Therapeutic pulpotomy (excluding final restoration) Removal of pulp coronal to dentinocemental junction and application of medicament $10 D3330 Endodontic therapy, molar tooth (excluding final restoration) $200 Periodontics D4260 Osseous surgery (including flap entry and closure) Four or contiguous teeth or tooth-bounded spaces per quadrant $295 D4341 Periodontal scaling and root planing Four or teeth per quadrant $40 D4910 Periodontal maintenance $30 Prosthodontics D5110/D5120 Complete Denture Maxillary or Mandibular $210 D5211/D5212 Partial Denture Resin Base Maxillary or Mandibular $240 Crowns/Fixed Bridges (Additional fees for metal upgrades and/or porcelain apply) D6241 Pontic Porcelain fused to predominantly base metal $185 D6750 Crown Porcelain fused to predominantly base metal $185 Oral Surgery D7140 Extraction Erupted tooth or exposed root (elevation and/or forceps removal) $0 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated $30 D7220 Removal of impacted tooth Soft tissue $45 D7240 Removal of impacted tooth Completely bony $80 Orthodontics D8070/D8080 Comprehensive orthodontic treatment of transitional or adolescent dentition (full treatment case up to 24 months) $1,695 Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain Minor procedure $0 D9310 Consultation Diagnostic service provided by dentist or physician other than requesting dentist or physician $0 The DHMO Plan Benefits description is only a summary of the DHMO plan being offered. A complete copy of all the terms and conditions of the DHMO plan being offered is set forth in the DHMO Schedule of Benefits and Evidence of Coverage and Disclosure Statement available from CoPower upon request. 3

4 Plan Benefits and Program Guidelines VOLUNTARY DPPO Dental Provider Reimbursement Basis DPPO without Ortho DPPO with Ortho In-network Out-of-network In-network Out-of-network Negotiated Fee Schedule Negotiated Fee Schedule (MAC) Negotiated Fee Schedule Negotiated Fee Schedule (MAC) Calendar Year Max $1,500 $1,500 $1,500 $1,500 Deductible Deductible Waived for Preventive Services Diagnostic and Preventive Services Cleaning, exam, bite-wing x-rays Basic Services Oral surgery, endodontics, periodontics, composite fillings, sealants, space maintainers, etc. Major Services Crowns, bridges, dentures, implants Orthodontics Lifetime maximum $50 Individual $150 Family $50 Individual $150 Family $50 Individual $150 Family $50 Individual $150 Family Yes Yes Yes Yes 100% 100% 100% 100% 80% 80% 80% 80% 50% 50% 50% 50% Not covered Child only to age 19, no deductible, 50% to max of $1,500 PROGRAM GUIDELINES MetLife Voluntary Dental Group Size and Eligibility Groups with 5 99 employees COBRA participants not to exceed 15% of enrolled employees Employer Contribution No than 50% of employee premium DPPO: Minimum 35% of total eligible employees not including waivers and no less than 5 enrolled Participation DHMO: Minimum 30% of total eligible employees and no less than 5 enrolled No than 75% of a group can be members of the same family (husband, wife, siblings, children, and parents) Dual Choice allowed for groups of 25+ eligible employees Product Combinations DHMO/DPPO product combination only Minimum 35% of total eligible employees not including waivers with no less than 5 enrolled on each plan Ineligible Industries SIC Codes: , 8070, 8072, Waiting Period for Services None, except for dental late entrants Dependents Dependent children are eligible until age 26 Ineligible s Retirees, part-time, temporary, seasonal, 1099 Voluntary Rate Guarantee Industry Loads Out-of-State Open Enrollment Yes 12 months None DPPO: No than 25% of primary enrollees may reside outside of California. There is no PPO coverage available in the following states: LA, MS, MT, TX. DHMO: Only available in CA Not Available. Qualifying event required. 4

5 Rates VOLUNTARY DENTAL (5-50 ELIGIBLE LIVES) DPPO without Ortho DPPO with Ortho DHMO Region 1 $46.52 $92.52 $ $46.52 $93.45 $ $16.55 $31.42 $43.86 Region 2 $47.92 $95.32 $ $47.92 $96.27 $ $16.55 $31.42 $43.86 Region 3 $52.04 $ $ $52.04 $ $ $16.55 $31.42 $43.86 Region 4 $54.81 $ $ $54.81 $ $ $16.55 $31.42 $43.86 Region 5 $56.88 $ $ $56.88 $ $ $16.55 $31.42 $43.86 Region 6 $63.30 $ $ $63.30 $ $ $16.55 $31.42 $43.86 VOLUNTARY DENTAL (51-99 ELIGIBLE LIVES) DPPO without Ortho DPPO with Ortho DHMO 185A Statewide Region 1 $40.94 $81.42 $ $40.94 $82.24 $ $15.64 $29.71 $41.43 Region 2 $42.17 $83.88 $ $42.17 $84.72 $ $15.64 $29.71 $41.43 Region 3 $45.80 $91.08 $ $45.80 $92.00 $ $15.64 $29.71 $41.43 Region 4 $48.23 $95.94 $ $48.23 $96.90 $ $15.64 $29.71 $41.43 Region 5 $50.05 $99.55 $ $50.05 $ $ $15.64 $29.71 $41.43 Region 6 $55.70 $ $ $55.70 $ $ $15.64 $29.71 $41.43 Note: All rates are effective January 1, Finding a MetLife Participating Dentist Visit and click on Find a Dentist on the right side of the home page. Enter your zip code and select your plan. For DPPO dentists, choose PDP Plus network. For DHMO dentists, choose Dental HMO/Managed Care, then select Plan Name MET185A. Dental Limitations for DHMO Plan GENERAL General anesthesia is a covered benefit only when administered by the treating dentist, in conjunction with oral and periodontal surgical procedures. PREVENTIVE Routine Cleanings (prophylaxis), periodontal maintenance services, and fluoride treatments are limited to twice a year. Two (2) additional cleanings (routine and periodontal) are available at the copayment listed on this Plan s Schedule of Benefits. Additional prophylaxis is available, if medically necessary. Sealants and/or preventive resin restorations: Plan benefit applies to primary and permanent molar teeth, within four (4) years of eruption, unless medically necessary. DIAGNOSTIC Panoramic or full-mouth X-rays: Once every three (3) years, unless medically necessary. Dental ZIP Code Regions Region 1 ZIP Codes: , 936, 937 Region 2 ZIP Codes: , Region 3 ZIP Codes: 917, 930, 931, 935, 952, 953, 959 Region 4 ZIP Codes: 902, 905, 907, 908, , 916, , , 946, 947, 949, 954, 960, 961 Region 5 ZIP Codes: 900, 901, 903, 904, 906, , 918, 945, 948, 950, 951, 955 Region 6 ZIP Codes: Please note: Regions have been updated in Dental Plan Limitations and Exclusions RESTORATIVE TREATMENT An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble, or titanium metal. Replacement of any crowns or fixed bridges (per unit) are limited to once every five (5) years. Cases involving seven (7) or crowns and/or fixed bridge units in the same treatment plan require an additional $125 copayment per unit in addition to the specified copayment for each crown/bridge unit. There is a $75 copayment per crown/bridge unit in addition to the specified copayment for porcelain on molars. Provisional crowns/restorations are to be used for an interim of at least six (6) months duration. Interim crowns/restorations are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. 5

6 Dental Plan Limitations and Exclusions PROSTHODONTICS Relines are limited to one (1) every twelve (12) months. Dentures (full or partial): Replacement only after five (5) years have elapsed following any prior provision of such dentures under a SafeGuard Plan, unless due to the loss of a natural functioning tooth. Replacements will be a benefit under this Plan only if the existing denture is unsatisfactory and cannot be made satisfactory as determined by the treating SafeGuard selected general dentist. Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. Provisional prostheses are to be used for an interim of at least six (6) months duration. Interim prostheses are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. ENDODONTICS The copayments listed for endodontic procedures do not include the cost of the final restoration. ORAL SURGERY The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists. Dental Exclusions for DHMO Plan Any procedures not specifically listed as a covered benefit in this Plan s Schedule of Benefits are not covered. Services performed by any dentist not contracted with SafeGuard, without prior approval by SafeGuard (except for out-of-area emergency services). This includes services performed by a general dentist or specialty care dentist. Dental procedures started prior to the member s eligibility under this Plan or started after the member s termination from the Plan. Examples include teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken. Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or improving the member s dental health, as determined by the SafeGuard selected general dentist. Orthognathic surgery. In-patient/out-patient hospital charges of any kind including dentist and/or physician charges, prescriptions or medications. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen or damaged due to abuse, misuse, or neglect. Treatment of malignancies, cysts, or neoplasms, unless specifically listed as a covered benefit on this Plan s Schedule of Benefits. Any services related to pathology laboratory fees. Procedures, appliances, or restorations whose primary main purpose is to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specifically listed as a covered benefit on this Plan s Schedule of Benefits. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. Dental services required while serving in the Armed Forces of any country or international authority. Dental services considered experimental in nature. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member. ORTHODONTICS If you require the services of an orthodontist, a referral must first be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment. If you terminate coverage from the SafeGuard Plan after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment. Orthodontic treatment must be provided by a SafeGuard selected general dentist or SafeGuard contracted orthodontist in order for the copayments listed in this Plan s Schedule of Benefits to apply. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a charge of $25 per visit. The following are not included as orthodontic benefits: repair or replacement of lost or broken appliances; retreatment of orthodontic cases; treatment involving maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; hormonal imbalances or other factors affecting growth or developmental abnormalities; treatment related to temporomandibular joint disorders; composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. Active orthodontic treatment in progress on your effective date of coverage is not covered. Active orthodontic treatment means tooth movement has begun. Dental Frequency & Allocations for DPPO Plan Benefits are payable immediately from the start date of an individual s benefits. TYPE A: Examinations: 1 time in 6 months Prophylaxis Cleanings: 1 time in 6 months Sealants: 1 per molar in 36 months for a child under age 16 Space Maintainers: 1 per lifetime for a child under age 14 Flouride: 1 time in 12 months for a dependent child under age 16 Full Mouth X-Rays: Once in 36 months Bitewing X-Rays For a child under 14: 2 times in 1 calendar year Bitewing X-Rays Adult: 1 time in 1 calendar year Emergency Palliative Treatment Periapical X-Rays Other X-Rays TYPE B: Amalgam Fillings: 1 replacement per surface in 24 months Consultations: 1 in 12 months Examinations Problem Focused: 1 time in 12 months Root Canal: 1 in 24 months Periodontal Maintenance: 2 periodontal treatments in 1 calendar year, includes 2 cleanings (total combination: 2) Periodontal Surgery: 1 per quadrant in any 36 month period Scaling and Root Planing: 1 per quadrant in any 24 month period Resin Composite Fillings: Includes Coverage for Composite Fillings on Molars Labs and Other Tests Pulpotomy Pulp Capping Pulp Therapy Apexification and Recalcification Periodontal Surgery Soft and Connective Tissue Grafts Periodontics Non-Surgical Oral Surgery Simple Extractions Oral Surgery Surgical Extractions Other Oral Surgery General Anesthesia General Services TYPE C: Prefabricated Crowns: 1 per tooth in 24 months Crown Buildups/Post Core: 1 per tooth in 10 Calendar years Repairs: 1 in 12 months Recementations: 1 in 12 months Dentures: 1 in 5 calendar years Immediate Temporary Dentures Complete/Partial: 1 replacement in 12 months Dentures Rebases/Relines: 1 in 36 months Denture Adjustments: 1 in 12 months Fixed Bridges: 1 in 5 calendar years Inlays/Onlays/Crowns: 1 replacement per tooth in 10 calendar years Implant Services: 1 per tooth position in 60 months Implant Repairs: 1 per tooth in 12 months Implant Supported Prosthetic: 1 per tooth in 60 months Tissue Conditioning: 1 in 36 months Occlusal Adjustments: 1 in 12 months 6

7 Dental Plan Limitations and Exclusions ORTHODONTICS: Orthodontic Diagnostics Orthodontic Treatment Dental Exclusions for DPPO without Orthodontia LATE ENTRANTS s who do not elect coverage during their 31-day application period may still elect coverage later. Dental coverage would be subject to the following waiting periods: Type A Services: No waiting period Type B Services Fillings: 6-month waiting period Type B Services All Other Services: 12-month waiting period Type C Services: 12-month waiting period Orthodontic Services (if applicable): 12-month waiting period Services which are not dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deems experimental in nature. Services for which a covered person would not be required to pay in the absence of dental insurance. Services or supplies received by a covered person before the insurance starts for that person. Services which are neither performed nor prescribed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling or polishing of teeth or fluoride treatment. Services which are primarily cosmetic. (For residents of Texas: Services which are primarily cosmetic unless required for the treatment or correction of a congenital defect of a newborn child). Services or appliances which restore or alter occlusion or vertical dimension. Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease. Restorations or appliances used for the purpose of periodontal splinting. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. Personal supplies or devices including, but not limited to water picks, toothbrushes, or dental floss. Initial installation of a denture to replace one or teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Decoration or inscription of any tooth, device, appliance, crown or other dental work. Missed appointments. Services covered under any workers compensation or occupational disease law. Services covered under any employer liability law. Services for which the employer of the person receiving such services is not required to pay. Services received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital. Services covered under other coverage provided by the Policyholder. Temporary or provisional restorations. Temporary or provisional appliances. Prescription drugs. Services for which the submitted documentation indicates a poor prognosis. Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. MetLife will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first. The following when charged by the dentist on a separate basis Claim form completion; infection control such as gloves, masks, and sterilization of supplies; or local anesthesia, nonintravenous conscious sedation or analgesia such as nitrous oxide. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing and biting of food. Caries susceptibility tests. Precision attachments associated with fixed and removable prostheses. Adjustment of a denture made within 6 months after installation by the same dentist who installed it. Duplicate prosthetic devices or appliances. Replacement of a lost or stolen appliance, cast restoration or denture. Intra- and extra-oral photographic images. Fixed and removable appliances for correction of harmful habits. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards. Treatment of temporomandibular joint disorder. This exclusion does not apply to residents of Minnesota. Dental Exclusions for DPPO with Orthodontia All of the exclusions above, plus: Orthodontia services or appliances. Repair or a replacement of an orthodontic appliance. Additional Information About MetLife Dental Plans Benefits for DPPO Plans Your dental plan provides that where two or professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is costly than the treatment upon which the plan benefit is based, your actual out-of-pocket expense will be the procedure charge for the treatment upon which the plan benefit is based, plus the full difference in cost between the scheduled PDP fee or, if non PDP, the actual charge, for the service actually rendered and the scheduled PDP fee or R&C fee (if non-pdp) for the service upon which the plan benefit is based. R&C fee refers to the Reasonable and Customary R&C charge, which is based on the lowest of 1.the dentist s actual charge, 2.the dentist s usual charge for the same or similar services or 3.the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife. To avoid any misunderstandings, MetLife suggests you discuss treatment options with your dentist before services are rendered, and obtain a pre-treatment estimate of benefits prior to receiving certain high-cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plans reimbursement for those services, and your out-of-pocket expense. Procedure charge schedules are subject to change each plan year. You can obtain an updated procedure charge schedule for your area via fax by calling and using the MetLife Dental Automated Information Service. DPPO Plans PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY Cancellation/Termination of Benefits Coverage is provided under a group insurance policy (Policy form GPNP99 issued by MetLife). Coverage terminates when your membership ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. The group policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: completion of a prosthetic device, crown or root canal therapy. DHMO Plans Dental Managed Care Plan benefits are provided by Metropolitan Life Insurance Company, a New York corporation in NY. Dental HMO plan benefits are provided by: SafeGuard Health Plans, Inc., a California corporation in CA. The Dental HMO/Managed Care companies are part of the MetLife family of companies. 7

8 Enrollment Checklist CoPower SELECT through MetLife Employer Application Packet Packet combines all of the necessary employer applications for coverage Completed enrollment (choose one): CoPower SELECT Census Enrollment form Enrolling employees may also complete the CoPower Enrollment/Change Form All Plans. DHMO enrollees must select a primary care dental facility CoPower SELECT MetLife broker non-standard commission agreement completed & signed A company check for the first month s premium made payable to CoPower Brokers not yet appointed with MetLife will need to submit the CoPower SELECT Broker Appointment Inquiry Form Brokers not yet appointed with CoPower will need to submit a completed CoPower Producer Agreement with a copy of their current insurance license, proof of E&O insurance, and W-9 form Plan Administration: CoPower 1600 W. Hillsdale Blvd. San Mateo, California T: E: sales@copower.com Carrier Contact Information: MetLife Metropolitan Life Insurance Company, New York, NY L [exp0217][CA] While the information provided in this guide is believed to be accurate as of the print date, it is subject to change without notice. For the most up-to-date information, contact CoPower. The benefit information contained in this booklet is summary in nature. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions of benefits, limitations and terms for keeping them in force. Please contact CoPower for complete details. CPE /16