PRODUCT SPECIFICATIONS AIG Group Scheduled Reimbursement Dental SM Insurance Under the AIG Group Scheduled Reimbursement Dental SM plan, we combine choice and affordability to create long-term satisfaction. Benefits and plan costs are more predictable from year to year compared with plans based on R&C charges. The scheduled reimbursement design of the program controls cost by assigning specific dental fees to specific procedures. For example, for each dental procedure performed, an insured is reimbursed the dollar amount listed on the schedule for that procedure. If the dentist s fee is greater than the schedule amount, the insured is responsible for the balance and the deductible. For more information on AIG Group Scheduled Reimbursement Dental insurance, contact your Agent, Broker or AIG Employee Benefit Solutions Representative, or visit www.aigebs.com. Schedules can be adjusted or maintained as desired. This means lower group premiums and plan satisfaction for employees. When you compare costs, you will see significant savings with our scheduled reimbursement plans. Best of all, the AIG Group Scheduled Reimbursement Dental plan is brought to you by your single source for exceptional products designed specifically for today s workforce: AIG Employee Benefit Solutions SM. Plan Highlights Employees have their choice of dental professionals no restrictions Coverage for up to 100 of the top most often used dental procedures Eleven benefit levels to meet various budget levels Options to choose Preventive care covered at 100 percent of the R&C charges and the deductible waived (for 10-plus groups) Deductible is waived for charges due to accidents 06675006-1665 R05/07
Group Employer-Funded Plans AIG Group Scheduled Reimbursement Dental SM Employer-Funded Plan Provisions* Group Eligibility Participation Requirements Employer Contribution Number of Hours Worked Child(ren) Eligibility Benefit Waiting Periods Conversion Factors Preventive Covered 100% of R&C Limit Annual Maximum Benefit Deductible Rate Guarantee Pretreatment Review Threshold Orthodontia Continuation of Coverage When Employment Terminates 2 or more enrolled employees If selected, child-only orthodontia is available for 25 or more eligible employees or 10 enrolled dependent units; the 10 dependent units must consist of employee/child and/or family units Noncontributory (100% employer-funded) plans: 100% Contributory plans (2 9 eligible lives): At least 75% Contributory plans (10+ eligible lives): 75% or at least 40% if reduced participation Noncontributory plans: 100% Contributory plans: At least 35% of premium paid Actively work 20 30 or more hours per week on a full-time basis (state variations may apply) Over age 3 and under age 19 (state variations may apply) To age 25 if full-time student (state variations may apply) None except orthodontia For late entrants, maximum benefit during the first 12 months of coverage is $100 10 to 20 Option available for 10+ employees R&C percentile for Preventive at 80% $750 $1,000 (standard) $1,500 $0, $25, $50 (standard), $75 or $100 per calendar year $100 lifetime (option for 10+ employees only) Deductible waived for accidents Deductible waiver for Preventive at R&C if selected (option for 10+ employees only) 12 months 24 months (option for 10+ employees only) $300 Child only $0 deductible 50% coinsurance $750 maximum $1,000 maximum (standard) $1,500 maximum (option for 51+ employees only) 24-month waiting period Continuation privilege available for groups of 20+ lives only Coverage continuation ceases upon nonpayment of premium or when group policy terminates * Plan provisions may vary by group size and are subject to state insurance law, and may vary due to such law. AIG Group Scheduled Reimbursement Dental SM Insurance 06675006-1665 R05/07
Schedule of Covered Dental Services To determine the maximum amount to be paid for a dental service, multiply the dental conversion factor by the dental value shown for that service. P=Preventive / B=Basic / M=Major Schedule of Covered Dental Services Procedure P, B, M Description Dental Value Preventive P Prophylaxis adult $1.65 P Prophylaxis child 1.20 P Topical application of fluoride (including prophylaxis) child 0.86 P Topical application of fluoride (prophylaxis not included) child 0.33 P Sealant per tooth 0.49 P Space maintainer fixed unilateral 2.99 P Space maintainer fixed bilateral 4.66 Diagnostic P Comprehensive oral evaluation new or established patient $1.35 B Detailed and extensive oral evaluation problem-focused, by report 2.33 B Comprehensive periodontal evaluation 1.73 P Intraoral complete series (including bitewings) 2.45 B Intraoral periapical first film 0.48 B Intraoral periapical each additional film 0.38 P Bitewings two films 0.75 P Bitewings four films 1.13 P Panoramic film 1.98 B Pulp vitality tests 0.74 B Limited oral evaluation problem focused (emergency exam) 1.04 P Periodic oral evaluation 0.85 Minor Restorative B Amalgam one surface, primary or permanent $1.88 B Amalgam two surfaces, primary or permanent 2.30 B Amalgam three surfaces, primary or permanent 2.76 B Amalgam four or more surfaces, primary or permanent 3.24 B Resin-based composite one surface, anterior 2.16 B Resin-based composite two surfaces, anterior 2.64 B Resin-based composite three surfaces, anterior 3.20 B Resin-based composite four or more surfaces or incisal angle (anterior) 3.64 B Resin-based composite one surface, posterior 1.88 B Resin-based composite two surfaces, posterior 2.30 B Resin-based composite three surfaces, posterior 2.76 B Resin-based composite four or more surfaces, posterior 3.24 Oral Surgery B Extraction erupted or exposed root $2.04 B Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 3.86 B Removal of impacted tooth soft tissue 2.94 B Removal of impacted tooth partially bony 3.76 B Removal of impacted tooth completely bony 4.38 B Surgical removal of residual tooth roots (cutting procedure) 2.51 B Surgical access of an unerupted tooth 4.91 B Alveoloplasty in conjunction with extractions per quadrant 2.18 Endodontics B Pulp cap indirect (excluding final restoration) $0.88 B Therapeutic pulpotomy (excluding final restoration) 2.44 B Root canal therapy anterior (excluding final restoration) 10.94 B Root canal therapy bicuspid (excluding final restoration) 12.84 B Root canal therapy molar (excluding final restoration) 16.34 Periodontics B Clinical crown lengthening hard tissue $12.26 B Osseous surgery, including flap entry and closure four or more contiguous teeth or bounded teeth per quadrant 17.66 AIG Group Scheduled Reimbursement Dental SM Insurance 06675006-1665 R05/07
Schedule of Covered Dental Services Schedule of Covered Dental Services (continued) Procedure P, B, M Description Dental Value Periodontics (cont d.) B Osseous surgery, including flap entry and closure one to three teeth, per quadrant 13.40 B Bone replacement graft first site in quadrant 6.42 B Free soft tissue graft procedure (including donor site surgery) 13.70 B Subepithelial connective tissue graft procedure (including donor site surgery) 12.06 B Periodontal scaling and root planning, four or more contiguous teeth or bounded teeth per quadrant 3.58 B Periodontal scaling and root planning one to three teeth, per quadrant 2.24 B Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis 2.24 B Periodontal maintenance procedures (following active therapy) 2.10 Miscellaneous B Palliative (emergency) treatment of dental pain minor procedure $1.50 B Deep sedation/general anesthesia first 30 minutes 3.45 B Deep sedation/general anesthesia each additional 15 minutes 1.46 Crowns & Fixed Bridges M Onlay porcelain/ceramic three surfaces $10.51 M Onlay porcelain/ceramic four or more surfaces 10.89 M Crown porcelain/ceramic substrate 10.99 M Crown porcelain fused to high noble metal 10.30 M Crown porcelain fused to predominantly base metal 9.19 M Crown porcelain fused to noble metal 9.70 M Crown porcelain/ceramic 10.96 M Crown full cast high noble metal 10.03 M Crown full cast predominantly base metal 9.44 M Crown full cast noble metal 10.16 B Recement crown 0.86 B Prefabricated stainless steel crown primary tooth 3.68 B Prefabricated stainless steel crown permanent tooth 4.14 M Core buildup, including any pins 2.30 M Cast post and core in addition to crown 3.63 M Prefabricated post and core in addition to crown 2.96 M Pontic porcelain fused to high noble metal 10.15 M Pontic porcelain fused to predominantly base metal 9.04 M Pontic porcelain fused to noble metal 9.56 M Crown porcelain/ceramic 10.93 M Crown porcelain fused to high noble metal 10.26 M Crown porcelain fused to predominantly base metal 9.21 M Crown porcelain fused to noble metal 9.73 Dentures M Complete denture maxillary $12.06 M Complete denture mandibular 11.64 M Immediate denture maxillary 12.84 M Immediate denture mandibular 12.46 M Maxillary partial denture resin base (including any conventional clasps, rests and teeth) 8.84 M Mandibular partial denture resin base (including any conventional clasps, rests and teeth) 9.90 M Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps and rests) 13.86 M Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps and rests) 13.85 B Add tooth to existing partial denture 2.62 Labial Veneers M Labial veneer (porcelain laminate) laboratory $10.76 AIG Group Scheduled Reimbursement Dental SM Insurance 06675006-1665 R05/07
Group Employee-Paid Plans AIG Group Scheduled Reimbursement Dental SM Employee-Paid Plan Provisions* Group Eligibility Participation Requirements Number of Hours Worked Child(ren) Eligibility Benefit Waiting Periods Conversion Factors Preventive Covered 100% of R&C Limit Annual Maximum Benefit Deductible Rate Guarantee Pretreatment Review Threshold Orthodontia Continuation of Coverage When Employment Terminates 10 enrolled and 20% of eligible lives If selected, child-only orthodontia is available for 25 or more enrolled employees or 10 enrolled dependent units; the 10 dependent units must consist of employee/child and/or family units (state variations may apply) 20% participation with a minimum of 10 enrolled employees Actively work 20 30 or more hours per week on a full-time basis (state variations may apply) Over age 3 and under age 19 (state variations may apply) To age 25 if full-time student (state variations may apply) None except orthodontia For late entrants, maximum benefit during the first 12 months of coverage is $100 10 to 20 R&C percentile for Preventive at 80% $750 $1,000 (standard) $1,500 $0, $25, $50 (standard), $75 or $100 per calendar year $100 lifetime Deductible waived for accidents Deductible waiver for Preventive at R&C if selected 12 months 24 months $300 Child only $0 deductible 50% coinsurance $750 maximum $1,000 maximum (standard) $1,500 maximum (option for 51+ employees only) 24-month waiting period Continuation privilege available for groups of 20+ lives only Coverage continuation ceases upon nonpayment of premium or when group policy terminates * Plan provisions may vary by group size and are subject to state insurance law, and may vary due to such law. AIG Group Scheduled Reimbursement Dental SM Insurance 06675006-1665 R05/07
Limitation of Benefits (state variations may apply) If two or more procedures are adequate and appropriate treatment for a certain condition, the least costly will be used to determine benefits If a tooth is lost or extracted prior to coverage under this policy, a prosthetic device to replace such tooth will not be covered, unless the device also replaces at least one other tooth lost or extracted while the insured is covered under this policy Charges must be incurred while insured to be eligible. The incurred date of the charges is the date on which the service is performed, except for: Crowns, bridges and cast restorations, which is the date the tooth is prepared Other prosthetic devices, which is the date the master impression is taken Root canal therapy, which is the date the pulp chamber is opened Charges Not Covered (state variations may apply) Services not specifically listed in the Schedule of Covered Dental Services Oral hygiene, plaque control, diet instruction Precision attachments Treatment that does not meet accepted standards of dental practice or is experimental in nature Treatment that is due to an on-the-job related injury; or a condition for which benefits are payable under workers compensation or similar laws Orthodontic treatment, unless the Schedule of Covered Dental Services lists orthodontia benefits Orthodontic class 1 malocclusions Appliance or prosthetic device used to change vertical dimension; to restore or maintain occlusion, except to the extent that orthodontic benefits are covered; to splint or stabilize teeth for periodontic reasons; to replace tooth structure lost as a result of abrasion or attrition; or to treat disturbances of the temporomandibular (TMJ) joint, except to the extent that supplemental bundled benefits, including TMJ services, are covered Cosmetic services, including but not limited to bleaching (except to the extent that supplemental bundled benefits, including bleaching is covered), making facings on prosthetic devices for any tooth posterior to the second bicuspid, and characterizing and personalizing prosthetic devices Replacement of (1) an appliance or prosthetic device unless the appliance or device is at least 10 years old and cannot be made usable, or is damaged while in the insured person s mouth in an injury that occurs while insured, and it cannot be repaired; (2) crowns within 5 years of initial placement; or (3) a lost, stolen or missing appliance or prosthetic device Making a spare appliance or device Services or devices for which no charge is made, including, but not limited to services provided by the covered person s employer, labor union or similar group, in its dental or medical department or clinic; a facility owned or run by any government body; or any public program except Medicaid, paid for or sponsored by any government body For surgery, periodontic and endodontic treatment, separate payment will not be made for X-rays, local anesthetics, treatment plan or follow-up care (included in payment for the procedure) Charges for IV sedation and other analgesics, excepting general anesthesia Diagnostic casts, models and study models Implants and all related services, except to the extent that supplemental bundled benefits including implants are covered; then, only limited implant procedures as set forth in the Schedule of Covered Dental Services are covered Radical resection of mandible with bone graft Interim crowns and dentures Treatment given after insurance ends, regardless of when the injury or sickness occurred Procedures and services that are not essential for the necessary care and treatment of the dental condition Treatment that would be given free of charge if the person were not insured Any expense that results from a war or act of war Any expense incurred while the insured person is on active duty or training in the armed forces, National Guard or reserves of any state or country, and for which any governmental body or its agencies are liable Any expense resulting from an intentionally self-inflicted injury Treatment given by a person s immediate family member, employer or an employee of such employer Any expense for services or supplies which are provided or paid for by the federal government or its agencies for: The Veterans Administration, when services are provided to a veteran for a disability which is not service-connected A military hospital or facility, when services are provided to a retiree (or dependent of a retiree) from the armed services A group plan established by the government for its own civilian employees and their dependents, or Medicaid, if required by Medicaid assignment of benefits AIG Employee Benefit Solutions insurance products underwritten by: AIG Life Insurance Company Wilmington, Delaware American International Life Assurance Company of New York New York, New York Member companies of American International Group, Inc. www.aigebs.com This is a summary only of products and services offered. Actual offerings may vary by group size and are subject to state insurance law, and the benefits/provisions as described may vary due to such law. All products are subject to the terms, conditions, limitations and exclusions of the policy. Please see policy and certificate for details. Policy form series numbers: G-DEN-32000 and G-DEN-42000. An employer-funded program may be funded 100 percent by the employer or a combination of both employer and employee funding. The underwriting risks, financial obligations and support functions associated with the products issued by the above-listed companies are the responsibility of each individual issuing company. Each of the above-listed companies is responsible for its own financial condition and contractual obligations. AIG Life Insurance Company does not solicit business in the state of New York. 2007 American International Group, Inc. All rights reserved. 06675006-1665 R05/07