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1 group dental & eye care For Cornell Employees and Their Families 2015 Coverage provided and underwritten by: Ameritas Life Insurance Corp. of New York GR 6685 NY Rev. 9-14

2 Plan A+ $3,000 calendar year maximum Preventive Plus Adult orthodontics Composites on molars Implants LASIK SoundCare Preserve the Annual Maximum with Preventive Plus With this option on Plans A+ and A, plan payments for covered Type 1 Preventive dental procedures are not deducted from the plan member s annual maximum benefit. Plan A+ Dental Plan In Network Out of Network Coinsurance: Type 1 (Preventive) 100% 90% 1 Cleanings (4/year) Exams (4/year) Space Maintainers Fluoride Applications Sealants (through age 16) X-rays Type 2 (Basic) 90% 70% 1 Simple Extractions and Fillings Full or Partial Denture Repair Complex Oral Surgery Anesthesia (with surgical procedures) Type 3 (Major) 50% 40% 1 Pontics (false tooth) and Bridges Implants Crown and Bridge Repair Dentures and Partial Dentures Crowns and Onlays Periodontics (Gum Diseases) Endodontics (Root Canals) Deductible $0 $50 per calendar year Type 2, 3 Waived Type 1 Maximum $3,000 per calendar year $3,000 per calendar year Preventive Plus SM Included Included Allowance Contracted fee 80th U&C Waiting Period None None Orthodontia Summary - Adult and Child Coverage Allowance Discounted fee U&C Coinsurance 50% 50% Lifetime Maximum $1,000 $1,000 (per person) Waiting Period 12 months New Enrolless only 12 months New Enrolless only also included with Plan A+: LASIK Advantage With LASIK Advantage, you can get benefits for a number of popular, well-established laser vision correction procedures. They are LASIK, LASIK with Wavefront Technology, LASIK with IntraLase Technology, Photorefractive Keratectomy (PRK), Advanced Surface Ablation (ASA) and LASEK. LASIK remains a popular procedure. More than 8 million Americans have had LASIK surgery. More than 95% of LASIK patients worldwide are satisfied with their new vision and approximately the same percentage would recommend LASIK to a friend. LASIK Advantage Year 1 Year 2 Year 3 Benefit for both eyes $ 700 $ 700 $ 1,400 The Plan benefit is $350 per eye for year 1 and 2, and $ 700 in year 3. LASIK benefits are a progressive annual amount. SoundCare With SoundCare, you can receive a wellness benefit that helps protect and preserve your ability to hear. Only 20 percent of people who could benefit from a hearing aid actually wear one; people with hearing loss wait an average of seven years before seeking help, often because of cost. Hearing aids generally cost anywhere between $800 and $3,500 per hearing aid. Your plan covers a comprehensive hearing exam and 50% of a hearing aid cost up to the maximum amount listed below. The benefit amount is progressive, rewarding members with an amount that increases over time based on the patient s effective date. SoundCare Year 1 Year 2 Year 3 Hearing exam benefit $ 75 $ 75 $ 75 Materials benefit for both ears Maintenance benefit Once plan members use their hearing aid coverage at any level, they become re-eligible for the benefit, at the $800 per ear benefit maximum, after five years as long as there is no break in coverage. A reduced benefit is available after three years if a member s hearing suffers deterioration the current aids can t correct, as long as there is no break in coverage. Hearing aid maintenance benefit: Members are eligible for up to a $40 allowance per benefit period. This benefit is designed to cover maintenance, batteries, service contracts, fittings, ear molds, and repairs. SoundCare members pay no copay for hearing exams, hearing aids, or hearing aid maintenance. 2

3 Plan A and Plan B Plan A Dental Plan In Network Out of Network Coinsurance: Type 1 (Preventive) 100% 90% 1 Cleanings (4/year) Exams (4/year) Space Maintainers Fluoride Applications Sealants (through age 16) X-rays Type 2 (Basic) 90% 70% 1 Simple Extractions and Fillings Full or Partial Denture Repair Complex Oral Surgery Anesthesia (with surgical procedures) Type 3 (Major) 50% 40% 1 Pontics (false tooth) and Bridges Crown and Bridge Repair Dentures and Partial Dentures Crowns and Onlays Periodontics (Gum Diseases) Endodontics (Root Canals) Deductible $0 per calendar year Type 2, 3 Waived Type 1 50$ per calendar year Type 2, 3 Waived Type 1 Maximum $1,250 per calendar year $1,250 per calendar year Preventive Plus SM Included Included Allowance Contracted fee 80th U&C Waiting Period None None Orthodontia Summary - Child Only Coverage Allowance Discounted fee U&C Coinsurance 50% 50% Lifetime Maximum $1,000 $1,000 (per person) Waiting Period 12 months New Enrolless only 12 months New Enrolless only Plan B Dental Plan Coinsurance: Type 1 (Preventive) Cleanings (2/year) Exams (2/year) Space Maintainers Fluoride Applications Type 2 (Basic) Simple Extractions and Fillings Full or Partial Denture Repair Sealants (through age 16) X-rays Type 3 (Major) Pontics (false tooth) and Bridges Crown and Bridge Repair Dentures and Partial Dentures Crowns and Onlays Periodontics (Gum Diseases) Endodontics (Root Canals) Complex Oral Surgery Anesthesia (with surgical procedures) See pages 9-13 for a list of Maximum Covered Procedures 100% U&C 2 Benefits based on the schedule for Plan B (see pages 9-13) Benefits based on the schedule for Plan B (see pages 9-13) Deductible $100 per calendar year Type 2, 3 Waived Type 1 Maximum $1,000 per calendar year Waiting Period None Orthodontia Summary - Child Only Coverage Allowance Discounted fee Coinsurance 50% Lifetime Maximum $1,000 (per person) Waiting Period 12 months New Enrolless only 1 Plan A+ and A procedures Out of Network based on the Usual and Customary charge. This plan utilizes the 80th percentile of U&C, which means 8 out of 10 dentists in a specific area charge at or below the plan allowance for a procedure. 2 Plan B is based on the Usual and Customary charge. This plan utilizes the 50th percentile of U&C, which means 5 out of 10 dentists in a specific area charge at or below the plan allowance for a procedure. more information about the plans A Brief Overview Employees can choose any of the options in the Group Dental Insurance Plan. The chart starting on page 2 of this brochure outlines each plan. If you enroll, premiums will be deducted from your paycheck before taxes. Regardless of which plan you choose, you have the freedom to visit the dentist of your choice. Our Dental Network The Ameritas Life Insurance Corp. of New York dental (Participating Provider Organization) network offers quality service at discounted dental fees to members. Members who choose to take advantage of the network when seeking dental treatment will often lower their out-of-pocket expenses. To join our dental network, a dentist must pass an extensive evaluation checklist encompassing such areas as sterilization and environmental safety, office administration, and emergency preparedness. Insurers provide and administer health insurance benefits and are not providers of health care. Treatment outcomes should be addressed by insureds directly with providers. Eligibility and Enrollment Who Can Enroll? Regular employees who work at least 20 hours per week and who are included in payroll/benefit classifications designated by Cornell as eligible to apply for coverage under the Group Dental Insurance Plan. Your spouse (or domestic partner) and children are eligible. Domestic Partners are required to complete the statement of Domestic Partnership as part of their enrollment. Refer to Cornell s website at hr.cornell.edu/benefits/ partnership_end_statement.pdf. Children may be covered through December 31 of the year in which their 26th birthday occurs. When to enroll? New employees have 60 days from the date of employment to decide whether or not they want to enroll in the Group Dental Insurance Plan. 3

4 The plan allows employees and their dependents to enroll in any of the plans during the 2014 Annual Open Enrollment, without being considered late entrants. Coverage is effective January 1, After you select your plan, there are several types of coverage in which you may enroll: Employee Only Coverage (Individual) Employee and Spouse/Domestic Partner Employee and Child(ren) Family Please Note: Once you enroll in a particular type of coverage, you cannot stop or change your election until the next annual election period, unless you experience a change in family status. The election period of your plan will be communicated each year to employees. Changes in family status include, but are not limited to, birth, marriage, divorce, death of a spouse or child, or termination of employment. To participate, eligible dependents must enroll within 60 days of the qualifying event. A calendar year, January 1 through December 31, is the basis for your deductibles, maximums and coinsurance levels (see page 2). During the first year you are insured, your calendar year is from your effective date through December 31 of that year. Effective Date of Coverage for Group Dental & Vision Your benefits will become effective on the first day of the pay period after your date of hire. If your date of hire is the first day of a pay period, your effective date is the date of your hire. Coverage Coverage and deductibles vary according to the plan you choose and the procedures you receive. Please refer to the summary of Coverage and Limitations on page 2 for a broad overview of the available benefits. Also, please read the information about the coverage and deductibles under the Group Dental Plan Information for a more detailed explanation. Deductibles A deductible is the amount of covered expenses for which no benefits are paid. Benefits will be paid only for covered expenses which exceed the deductible. For Plan A+: There is no deductible if you see a provider within the network. There is a $50 deductible on Type 2 and 3 procedures when seeing a provider out of the network. Plan A: There is no deductible if you see a provider within the network. There is a $50 deductible on Type 2 and 3 procedures when seeing a provider out of the network. Plan B: There is no deductible for Type 1 procedures. Type 2 and Type 3 deductibles are combined to total a $100 deductible that applies to each patient each calendar year. Maximum Benefit The maximum benefit per calendar year is the most that will be paid for covered expenses incurred by each person covered during each calendar year. The calendar year is January 1 to December 31. The maximum dental benefit per calendar year is $3,000 (combined in and out of network) for Plan A+. The maximum dental benefit per calendar year is $1,250 (combined in and out of network) for Plan A. The maximum dental benefit per calendar year is $1,000 (combined in and out of network) for Plan B. For orthodontia, the lifetime maximum benefit for each person covered is $1,000 for all plans. Dental Rewards A benefit rewarding insured employees and dependents who visit the dentist yearly and use only a portion of their annual maximum in a benefit year, Dental Rewards helps you build your annual maximum to use for more costly covered dental procedures you may need in the future. To qualify, you need to: Plan A+: file a dental claim during the benefit year and not exceed the annual benefit threshold of $750. Preventive procedures apply toward the annual threshold. You are then rewarded the following benefit year with a $400 credit to add to your $3,000 annual maximum. The maximum amount that can be carried over is $1,200. Plan A: file a dental claim during the benefit year and not exceed the annual benefit threshold of $500. Preventive procedures apply toward the annual threshold. You are then rewarded the following benefit year with a $250 credit to add to your $1,250 annual maximum. The maximum amount that can be carried over is $1,000. Plan B: file a dental claim during the benefit year and not exceed the annual benefit threshold of $500. Preventive procedures apply toward the annual threshold. You are then rewarded the following benefit year with a $250 credit to add to your $1,000 annual maximum. The maximum amount that can be carried over is $1,000. A claim must be filed each benefit year or the annual maximum is reset to $3,000 for Plan A+, $1,250 for Plan A or $1,000 for Plan B, at which point you can start rebuilding your Dental Rewards. The Dental Rewards carries over between the plans if you change plans in the future. The maximum amount that can be carried over is $1,000. Covered Expenses For all procedures of Plan A+ and Plan A, covered expenses are negotiated fees or the usual and customary expenses, as determined by Ameritas of New York. For the Type 1 and orthodontic procedures of Plan B, covered expenses are negotiated fees or the usual and customary expenses, as determined by Ameritas of New York. Instructions are on your ID card. For the Type 2 and Type 3 procedures of Plan B, covered expenses will not exceed the scheduled amount shown for procedures listed in your plan certificate. These expenses will be covered only for procedures done by a dentist or dental hygienist. These expenses are subject to the Ineligible Dental Expenses listed on page 9. If two or more procedures can be used as an appropriate treatment to correct a certain condition, the amount of the covered expense will be the charge for the least expensive procedure. Expenses Incurred An expense is incurred at the time the service is rendered or a supply is furnished; the impression is made for an appliance or change to an appliance; the tooth or teeth are prepared for a crown, bridge or gold restoration; or the pulp chamber is opened for root canal therapy. 4

5 comparison of covered procedures Plan A+ Plan A Plan B Topic/Service In Network Out of Network In Network Out of Network Deductible $0 $50 calendar year for Type 2 or 3 $0 $50 calendar year for Type 2 or 3 Maximum $3,000 $1,250 $1,000 Orthodontics Preventive Plus $1000; adult and child; 12 month waiting period for new enrollees Yes, Type 1 services will not reduce available maximum $1000; child only; 12 month waiting period for new enrollees Yes, Type 1 services will not reduce available maximum Type 1 Procedures In Network Out of Network In Network Out of Network $100 annual Type 2 and 3 combined $1000; child only; 12 month waiting period for new enrollees No, Type 1 services will reduce the maximum Coinsurance 100% of Network Fee 90% of U&C 1 100% of Network Fee 90% of U&C 1 100% U&C 2 Exams 4 per benefit period 4 per benefit period 2 per benefit period Bitewings 2 per benefit period 2 per benefit period 2 per benefit period (Type 2) Full Mouth/ Panoramic Xray 1 per 3 years 1 per 3 years 1 per 3 years (Type 2) Cleanings 4 per benefit period 4 per benefit period 2 per benefit period Fluoride 2 per benefit period; through age 18 2 per benefit period; through age 18 1 per benefit period; through age 18 Sealants through age 16 through age 16 through age 16 (Type 2) Space Maintainers fixed and removable fixed and removable fixed and removable Type 2 Procedures In Network Out of Network In Network Out of Network Coinsurance 90% of Network Fee 70% of U&C 1 90% of Network Fee 70% of U&C 1 full list of allowances on pages 9-13 Fillings resin considered on all teeth resin considered on anterior teeth only, molar teeth have benefit for silver filling Surgical Extractions extractions, impacted teeth, alveolar or gingival reconstruction, cysts, and neoplasms extractions, impacted teeth, alveolar or gingival reconstruction, cysts, and neoplasms full list of allowances on pages 9-13 extractions, impacted teeth, alveolar or gingival reconstruction, cysts, and neoplasms (Type 3) Anesthesia not available without a cutting procedure not available without a cutting procedure not available without a cutting procedure (Type 3) Type 3 Procedures In Network Out of Network In Network Out of Network Coinsurance 50% of Network Fee 40% of U&C 1 50% of Network Fee 40% of U&C 1 full list of allowances on pages 9-13 Endodontics root canal root canal root canal Periodontics root planing, gingivectomy root planing, gingivectomy root planing, gingivectomy Crowns 1 per 5 years 1 per 5 years 1 per 5 years Bridges; Dentures 1 per 5 years 1 per 5 years 1 per 5 years Implants 1 per 5 years not covered not covered Additional Benefits Dental Rewards threshold: $750; annual carryover: $400; max carryover: $1200 threshold: $500; annual carryover: $250; max carryover: $1000 threshold: $500; annual carryover: $250; max carryover: $1000 Vision Benefits included with Dental Benefits included with Dental Benefits included with Dental Benefits SoundCare Benefits included with Plan A+ not covered not covered LASIK included with Plan A+ not covered not covered 1 Plan A+ and A procedures Out of Network based on the Usual and Customary charge. This plan utilizes the 80th percentile of U&C, which means 8 out of 10 dentists in a specific area charge at or below the plan allowance for a procedure. 2 Plan B is based on the Usual and Customary charge. This plan utilizes the 50th percentile of U&C, which means 5 out of 10 dentists in a specific area charge at or below the plan allowance for a procedure. 5

6 covered procedures orthodontic expense benefits Orthodontic Treatment Orthodontic treatment means the movement of teeth by means of active appliances to correct the position of maloccluded or malpositioned teeth. Treatment Program Treatment program means an interdependent series of orthodontic services prescribed by a physician to correct a specific dental condition. A program will start when the active appliances are inserted. A program will end when the services are done, or after eight calendar quarters starting with the day the appliances were inserted, whichever is earlier. Expenses Incurred An expense is incurred: a. at the end of every quarter (three month period) of a treatment for a person who pursues an orthodontic program, but not beyond the date the treatment ends, or b. at the time the service is rendered for a person who incurs covered expenses but does not pursue a treatment program. Benefit Calculation Benefits will be payable when a covered expense is incurred. The covered expenses are based on the estimated cost of the patient s treatment program. Payments are pro-rated by quarter (three month periods) over the estimated length of the program, but not for more than eight quarters, and multiplied by the orthodontic benefit percentage (50%). The last quarterly payment for a treatment may be changed if the estimated and actual cost of the treatment differs. Ineligible Orthodontia Expenses Covered expenses exclude and no benefits will be paid for expenses incurred: 1. for an orthodontic treatment program which began on or after an insured s 17th birthday. Not applicable to Plan A+. 2. for a treatment program which began before the insured became covered for Orthodontic Expense Benefits. 3. after the individual s insurance for orthodontic benefits terminates. Claim Procedure Ameritas of New York provides each employee with instructions to view a Certificate of Insurance explaining the plan benefits and limitations in complete detail. For answers to your claims questions, call toll free, Dental claim forms are available on the Ameritas of New York website just go to www. ameritas.com, click on individual/families, dental, vision/hearing to find Ameritas of New York claim form. how to submit a claim 1. Upon enrollment, you will receive ID cards with instructions to view your Certificate of Insurance and to obtain claim forms. Additional claim forms can be obtained from your Benefits/ Human Resources office, Ameritas Life of New York, or 2. Take the claim form with you to the dentist performing your service. 3. You complete Parts 1 and 3 of the claim form. Part 1 is information about you and your employer. Part 3 allows you to have benefits paid directly to your dentist. 4. Your dentist completes Parts 2 and 4. Part 2 identifies the services that were performed. Part 4 certifies that the dentist performed the services. 5. Deadline to file a claim, also referred to as Proof of Loss. Written proof of loss must be given to us within 120 days after the incurred date of the services provided for which benefits are payable. If it is impossible to give written proof within the 120 day period, we will not reduce or deny a claim for this reason if the proof is filed as soon as is reasonably possible. 6. You or your dentist can send the claim form to: Ameritas Life Insurance Corp. of New York Group Dental Claims P.O. Box Lincoln, NE FAX: Unencrypted is susceptible to viewing by unauthorized parties. To ensure your confidentiality, it is important that you do not provide any information you consider confidential and/or personal in nature (i.e. Social Security Number, claim number, etc.) estimate of payment If your dentist thinks charges for the proposed work will be $200 or more, you and your dentist can complete a claim form for pre-statement of benefits. Your dentist shows the work to be done and what the charges will be. The claim form is then sent to Ameritas of New York. Ameritas of New York will estimate your benefits and send a report to your dentist. Coordination of Benefits If you or any of your dependents incur charges which are covered by any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the charges incurred. 6

7 Ineligible Dental Expenses Covered expenses exclude and no benefits will be paid for expenses incurred: 1. for Plans A+, A and B, Orthodontics in the first 12 months that the insured is covered. 2. for any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the second bicuspid are considered cosmetic, alternate of metal equivalent. 3. to replace any crown, bridge, inlay, onlay, partial denture, or full denture which was originally placed less than five years ago, regardless if the original prosthetic was covered under the plan. However, if the replacement is due to an accidental injury sustained while covered under this plan, it will be a Covered Expense. 4. if the extraction(s) occurred while the insured person is covered under this contract, then this limitation does not apply. The extraction of a third molar (wisdom tooth) will not qualify under the above. Any such prosthetic crown, appliance or fixed partial denture must include the replacement of the extracted tooth or teeth. 5. for any procedure begun before a person becomes insured. 6. for any procedure begun after a person s insurance terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after a person s insurance terminates. 7. to replace lost or stolen appliances. 8. for appliances, restorations, or procedures to alter vertical dimension, restore or maintain occlusion, splint or replace tooth structure lost as a result of abrasion or attrition. 9. for any procedure which is not shown on the Table of Dental Procedures in your Certificate of Insurance. 10. for education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. 11. for the completion of claim forms. 12. for sealants which are: a. not applied to a permanent molar, b. applied after attaining age 17, c. reapplied to a molar within three years from the date of a previous sealant application. 13. because of an injury or sickness arising out of, or in the course of, work for wage or profit or that is eligible for benefits under any Worker s Compensation act or similar law. 14. for charges for which a person is not liable or which would not have been made had no insurance been in force. 15. for services which are not recommended by a dentist or which are not required for necessary care and treatment. 16. because of war or any act of war, declared or not. 7

8 sample comparisons of Plan A+, Plan A and Plan B coverage The hypothetical examples below summarize the benefit you can expect to receive, depending on the plan you choose. In these three examples it is assumed that the deductible, if applicable, has been satisfied. Example 1 If Ellen elected Plan A+ or Plan A, the reimbursement from Ameritas of New York would be calculated like this: If Ellen elected Plan B, the reimbursement from Ameritas of New York would be calculated like this: Example 2 If Joe elected Plan A+ or Plan A, the reimbursement from Ameritas of New York would be calculated like this: If Joe elected Plan B, this procedure is considered a Type 2 procedure. The reimbursement from Ameritas of New York would be calculated like this: Example 3 If Susan elected Plan A+ or Plan A, the reimbursement from Ameritas of New York would be calculated like this: If Susan elected Plan B, this procedure is considered a Type 3 procedure. The reimbursement from Ameritas of New York would be calculated like this: Ellen visited a dentist for a periodic exam (Procedure Code D 0120*) and cleaning (procedure code D 1110*). Assuming this is Ellen s first visit to the dentist in the new calendar year. In Network Out of Network Dentist Charge $83.00 Dentist Charge $83.00 Dentist Negotiated Fee $77.00 Dentist Allowable Charge $ (80% U&C Allowance) Dentist Allowable Charge $77.00 Amount Paid by Plan $77.00 Amount Paid by Plan $83.00 Amount Due Dentist $ 0.00 Amount Due Dentist $0.00 Dentist Charge $83.00 Dentist Charge $83.00 Dentist Negotiated Fee $77.00 Dentist Negotiated Fee Not Applicable Dentist Allowable Charge $77.00 Dentist Allowable Charge $ (50% U&C Allowance) Coinsurance Level 100% Coinsurance Level 100% Amount Paid by Plan $77.00 Amount Paid by Plan $83.00 Amount Due Dentist $0.00 Amount Due Dentist $0.00 Joe visited the dentist to have a tooth filled (procedure code D 2330*). Joe has already obtained $300 in dental benefits in this calendar year. In Network Out of Network Dentist Charge $87.00 Dentist Charge $87.00 Dentist Negotiated Fee $73.00 Dentist Allowable Charge $ (70% U&C Allowance) Dentist Allowable Charge $73.00 Coinsurance Level 90% Coinsurance Level 70% Amount Paid by Plan $65.70 Amount Paid by Plan $60.90 Amount Due Dentist $7.30 Amount Due Dentist $26.10 Dentist Charge $87.00 Dentist Charge $87.00 Dentist Negotiated Fee $73.00 Dentist Negotiated Fee Not Applicable Dentist Allowable Charge $73.00 Dentist Allowable Charge $ (50% U&C Allowance) Coinsurance Level Not Applicable Coinsurance Level Not applicable Amount Allowed by Schedule $52.00 Amount Allowed by Schedule $52.00 Amount Paid by Plan $52.00 Amount Paid by Plan $52.00 Amount Due Dentist $21.00 Amount Due Dentist $35.00 Susan visited the dentist for a crown (procedure code D 2792*). The dentist recommended a full cast noble metal crown. She has already obtained $800 in dental benefits this calendar year. In Network Out of Network Dentist Charge $ Dentist Charge $ Dentist Negotiated Fee $ Dentist Allowable Charge $ (40% U&C Allowance) Dentist Allowable Charge $ Coinsurance Level 50% Coinsurance Level 40% Amount Paid by Plan $ Amount Paid by Plan $ Amount Due Dentist $ Amount Due Dentist $ Dentist Charge $ Dentist Charge $ Dentist Negotiated Fee $ Dentist Negotiated Fee Not Applicable Dentist Allowable Charge $ Dentist Allowable Charge $ (50% U&C Allowance) Coinsurance Level Not Applicable Coinsurance Level Not applicable Amount Allowed by Schedule $ Amount Allowed by Schedule $ Amount Paid by Plan $ Amount Paid by Plan $ Amount Due Dentist $ Amount Due Dentist $ * Current Dental Terminology American Dental Association ** The dental charges shown above are based on the average cost for zip code 148 and are for illustrative purposes only. The Plan s reimbursement is based on the 80th percentile. Amounts will differ by zip code and year to reflect changes in the dental costs. 8

9 schedule for Plan B Type 1 procedures are considered 100% based on the average fee in the area. These procedures include: oral exams, prophylaxis (cleaning), fluoride, and space maintainers, fixed and removable. The following is a list of Type 2 (Basic) and Type 3 (Major) dental procedures for which benefits are payable under Plan B. Please read the page entitled INELIGIBLE EXPENSES for additional limitation information. Always refer to your certificate for the most complete, current list of covered procedures. Current Dental Terminology American Dental Association. Type 2 (Basic) Procedures Maximum Covered Limited Oral Evaluation Expense D0140 Limited oral evalu ation - problem focused $25.00 D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) $25.00 Limited Oral Evaluation: D0140, D0170 Coverage is allowed for accidental injury only. If not due to an accident, will be considered at an alternate benefit of a D0120 and count towards this frequency. Complete Series or Panoramic Film D0210 Intraoral - complete series (including bitewings) $51.00 D0330 Panoramic film $41.00 Complete Series/Panoramic Films: D0210, D0330 Coverage is limited to 1 of any of these procedures per 3 year(s). Other X-rays D0220 Intraoral - periapical first film $9.00 D0230 Intraoral - periapical each additional film $7.00 D0240 Intraoral - occlusal film $13.00 D0250 Extraoral - first film $16.00 D0260 Extraoral - each additional film $13.00 Periapical Films: D0220, D0230 The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. Bitewing Films D0270 Bitewing - single film $8.00 D0272 Bitewings - two films $14.00 D0274 Bitewings - four films $22.00 D0277 Vertical bitewings - 7 to 8 films $34.00 Bitewing Films: D0270, D0272, D0274 Coverage is limited to 2 of any of these procedures per 1 benefit period. D0277 also contribute(s) to this limitation. The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. Vertical Bitewing Film: D0277 Coverage is limited to 1 of any of these procedures per 3 year(s). The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. Oral Pathology/Laboratory D0472 Accession of tissue, gross examination, preparation and transmission of written report $30.00 D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report $59.00 D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report $59.00 Oral Pathology Laboratory: D0472, D0473, D0474 Coverage is limited to 1 of any of these procedures per 12 month(s). Coverage is limited to 1 examination per biopsy/excision. Sealant D1351 Sealant - per tooth $19.00 Sealant: D1351 Coverage is limited to 1 of any of these procedures per 3 year(s). Benefits are considered for persons age 16 and under. Benefits are considered on permanent molars only. Coverage is allowed on the occlusal surface only. Amalgam Restorations (Fillings) D2140 Amalgam - one surface, primary or permanent $43.00 D2150 Amalgam - two surfaces, primary or permanent $54.00 D2160 Amalgam - three surfaces, primary or permanent $66.00 D2161 Amalgam - four or more surfaces, primary or permanent $79.00 Amalgam Restorations: D2140, D2150, D2160, D2161 Coverage is limited to 1 of any of these procedures per 6 month(s). D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394,.D9911 also contribute(s) to this limitation. Resin Restorations (Fillings) D2330 Resin-based composite - one surface, anterior $52.00 D2331 Resin-based composite - two surfaces, anterior $66.00 D2332 Resin-based composite - three surfaces, anterior $82.00 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) $91.00 D2391 Resin-based composite - one surface, posterior $57.00 D2392 Resin-based composite - two surfaces, posterior $72.00 D2393 Resin-based composite - three surfaces, posterior $91.00 D2394 Resin-based composite - four or more surfaces, posterior.... $ D2410 Gold foil - one surface $43.00 D2420 Gold foil - two surfaces $54.00 D2430 Gold foil - three surfaces $66.00 Composite Restorations: D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394 Coverage is limited to 1 of any of these procedures per 6 month(s). D2140, D2150, D2160, D2161, D9911 also contribute(s) to this limitation. Gold Foil Restorations: D2410, D2420, D2430 Gold foils are considered at an alternate benefit of an amalgam/composite restoration. Stainless Steel Crown (Prefabricated Crown) D2390 Resin-based composite crown, anterior $ D2930 Prefabricated stainless steel crown - primary tooth $93.00 D2931 Prefabricated stainless steel crown - permanent tooth $99.00 D2932 Prefabricated resin crown $ D2933 Prefabricated stainless steel crown with resin window $ D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $ Stainless Steel Crown: D2390, D2930, D2931, D2932, D2933, D2934 Benefits are considered for persons age 18 and under. For persons age 19 and over, these procedures are subject to the coinsurance,deductible, maximums, limitations, and frequencies of Crowns Single Restorations, if applicable. Recement D2910 Recement inlay, onlay, or partial coverage restoration $34.00 D2915 Recement cast or prefabricated post and core $17.00 D2920 Recement crown $34.00 D6930 Recement fixed partial denture $47.00 Sedative Filling D2940 Sedative filling $32.00 Full Mouth Debridement D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $53.00 Full Mouth Debridement: D4355 Coverage is limited to 1 of any of these procedures per 5 year(s). Periodontal Maintenance D4910 Periodontal maintenance $54.00 Periodontal Maintenance: D4910 Coverage is limited to 2 of any of these procedures per 1 benefit period. D1110, D1120, D1201, D1205 also contribute(s) to this limitation. Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if performed on the same date as any other periodontal procedure. Denture Repair D5510 Repair broken complete denture base $54.00 D5520 Replace missing or broken teeth - complete denture ( each tooth) $45.00 D5610 Repair resin denture base $54.00 D5620 Repair cast framework $64.00 D5630 Repair or replace broken clasp $67.00 D5640 Replace broken teeth - per tooth $

10 Type 2 (Basic) Procedures (continued) Denture Relines D5730 Reline complete maxillary denture (chairside) $ D5731 Reline complete mandibular denture (chairside) $ D5740 Reline maxillary partial denture (chairside) $90.00 D5741 Reline mandibular partial denture (chairside) $90.00 D5750 Reline complete maxillary denture (laboratory) $ D5751 Reline complete mandibular denture (laboratory) $ D5760 Reline maxillary partial denture (laboratory) $ D5761 Reline mandibular partial denture (laboratory) $ Denture Reline: D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761 Coverage is limited to service dates more than 6 months after placement date. Non-Surgical Extractions D7111 Extraction, coronal remnants - deciduous tooth $48.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $48.00 Biopsy of Oral Tissue D7285 Biopsy of oral tissue - hard (bone, tooth) $ D7286 Biopsy of oral tissue - soft $ D7287 Exfoliative cytological sample collection $52.00 D7288 Brush biopsy - transepithelial sample collection $52.00 Palliative D9110 Palliative (emergency) treatment of dental pain - minor procedure $36.00 Palliative Treatment: D9110 Not covered in conjunction with other procedures, except diagnostic x-ray films. Professional Consult/Visit/Services D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) $37.00 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed $25.00 D9440 Office visit - after regularly scheduled hours $44.00 D9930 Treatment of complications (post-surgical) - unusual circumstances, by report $27.00 Consultation: D9310 Coverage is limited to 1 of any of these procedures per 1 provider. Office Visit: D9430, D9440 Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services rendered or visit, whichever is greater. Occlusal Adjustment D9951 Occlusal adjustment - limited $24.00 D9952 Occlusal adjustment - complete $ Occlusal Adjustment: D9951, D9952 Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of periodontal disease. Miscellaneous D2951 Pin retention - per tooth, in addition to restoration $16.00 D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth $52.00 Desensitization: D9911 Coverage is limited to 1 of any of these procedures per 6 month(s). D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394 also contribute(s) to this limitation. Type 3 (Major) Procedures Maximum Covered Inlay Restorations Expense D2510 Inlay - metallic - one surface $ D2520 Inlay - metallic - two surfaces $ D2530 Inlay - metallic - three or more surfaces $ D2610 Inlay - porcelain/ceramic - one surface $ D2620 Inlay - porcelain/ceramic - two surfaces $ D2630 Inlay - porcelain/ceramic - three or more surfaces $ D2650 Inlay - resin-based composite - one surface $ D2651 Inlay - resin-based composite - two surfaces $ D2652 Inlay - resin-based composite - three or more surfaces..... $ Inlay: D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652 Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from caries (tooth decay) or traumatic injury. Onlay Restorations D2542 Onlay - metallic - two surfaces $ D2543 Onlay - metallic - three surfaces $ D2544 Onlay - metallic - four or more surfaces $ D2642 Onlay - porcelain/ceramic - two surfaces $ D2643 Onlay - porcelain/ceramic - three surfaces $ D2644 Onlay - porcelain/ceramic - four or more surfaces $ D2662 Onlay - resin-based composite - two surfaces $ D2663 Onlay - resin-based composite - three surfaces $ D2664 Onlay - resin-based composite - four or more surfaces..... $ Onlay: D2542, D2543, D2544, D2642, D2643, D2644, D2662, D2663, D2664 D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. Coverage is limited to necessary placement resulting from caries (tooth decay or traumatic injury. Benefits will not be considered if procedure D2390, D2930, D2931 D2932, D2933 or D2934 has been performed within 12 months. Crowns Single Restorations D2710 Crown - resin-based composite (indirect) $86.00 D2712 Crown - 3/4 resin-based composite (indirect) $ D2720 Crown - resin with high noble metal $ D2721 Crown - resin with predominantly base metal $ D2722 Crown - resin with noble metal $ D2740 Crown - porcelain/ceramic substrate $ D2750 Crown - porcelain fused to high noble metal $ D2751 Crown - porcelain fused to predominantly base metal $ D2752 Crown - porcelain fused to noble metal $ D2780 Crown - 3/4 cast high noble metal $ D2781 Crown - 3/4 cast predominantly base metal $ D2782 Crown - 3/4 cast noble metal $ D2783 Crown - 3/4 porcelain/ceramic $ D2790 Crown - full cast high noble metal $ D2791 Crown - full cast predominantly base metal $ D2792 Crown - full cast noble metal $ D2794 Crown - titanium $ Crown: D2710, D2712, D2720, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794 D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. Core Build-Up D2950 Core buildup, including any pins $48.00 D6973 Core build up for retainer, including any pins $

11 Type 3 (Major) Procedures (continued) Post and Core D2952 Cast post and core in addition to crown $76.00 D2954 Prefabricated post and core in addition to crown $64.00 Fixed Crown and Partial Denture Repair D2980 Crown repair, by report $39.00 D6980 Fixed partial denture repair, by report $43.00 D9120 Fixed partial denture sectioning $43.00 Endodontics Miscellaneous D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $30.00 D3221 Pulpal debridement, primary and permanent teeth $30.00 D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $40.00 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $35.00 D3333 Internal root repair of perforation defects $50.00 D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $50.00 D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resporption, etc.) $34.00 D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) $98.00 D3430 Retrograde filling - per root $39.00 D3450 Root amputation - per root $92.00 D3920 Hemisection (including any root removal), not including root canal therapy $78.00 Endodontics Miscellaneous: D3333, D3430, D3450, D3920 Procedure D3333 is limited to permanent teeth only. Pulpotomy/Pulpal Debridement/Pulpal Therapy: D3220, D3221, D3230, D3240 Procedure D3220 is limited to primary teeth. Endodontic Therapy (Root Canals) D3310 Anterior (excluding final restoration) $ D3320 Bicuspid (excluding final restoration) $ D3330 Molar (excluding final restoration) $ D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $81.00 D3346 Retreatment of previous root canal therapy - anterior $ D3347 Retreatment of previous root canal therapy - bicuspid $ D3348 Retreatment of previous root canal therapy - molar $ Root Canals: D3310, D3320, D3330, D3332 Benefits are considered on permanent teeth only. Allowances include intraoperative films and cultures but exclude final restoration. Retreatment of Root Canal: D3346, D3347, D3348 Coverage is limited to 1 of any of these procedures per 12 month(s). D3310, D3320, D3330 also contribute(s) to this limitation. Benefits are considered on permanent teeth only. Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative films and cultures but exclude final restoration. Surgical Endodontics D3410 Apicoectomy/periradicular surgery - anterior $ D3421 Apicoectomy/periradicular surgery - bicuspid (first root)..... $ D3425 Apicoectomy/periradicular surgery - molar (first root) $ D3426 Apicoectomy/periradicular surgery (each additional root)..... $64.00 Surgical Periodontics D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant $90.00 D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant $45.00 D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant.... $ D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant $62.00 D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant.... $ D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant.... $ D4263 Bone replacement graft - first site in quadrant $74.00 D4264 Bone replacement graft - each additional site in quadrant.... $56.00 D4265 Biologic materials to aid in soft and osseous tissue regeneration $37.00 D4270 Pedicle soft tissue graft procedure $ D4271 Free soft tissue graft procedure (including donor site surgery) $ D4273 Subepithelial connective tissue graft procedures, per tooth.. $ D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $99.00 D4275 Soft tissue allograft $ D4276 Combined connective tissue and double pedicle graft, per tooth $ Bone Grafts: D4263, D4264, D4265 Each quadrant is limited to 1 of each of these procedures per 3 year(s). Coverage is limited to treatment of periodontal disease. Gingivectomy: D4210, D4211 Each quadrant is limited to 1 of each of these procedures per 3 year(s). Coverage is limited to treatment of periodontal disease. Osseous Surgery: D4240, D4241, D4260, D4261 Each quadrant is limited to 1 of each of these procedures per 3 year(s). Coverage Is Limited To Treatment Of Periodontal Disease. Tissue Grafts: D4270, D4271, D4273, D4275, D4276 Each quadrant is limited to 2 of any of these procedures per 3 year(s). Coverage is limited to treatment of periodontal disease. Crown Lengthening D4249 Clinical crown lengthening - hard tissue $ Non-Surgical Periodontics D4341 Periodontal scaling and root planing - four or more teeth per quadrant $46.00 D4342 Periodontal scaling and root planing - one to three teeth, per quadrant $23.00 D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report..... $34.00 Chemotherapeutic Agents: D4381 Each quadrant is limited to 2 of any of these procedures per 2 year(s). A scaling and root planing must be performed in this quadrant within.2 years prior to the date of service for this procedure. Periodontal Scaling & Root Planing: D4341, D4342 Each quadrant is limited to 1 of each of these procedures per 2 year(s). Prosthodontics - Fixed/Removable (Dentures) D5110 Complete denture - maxillary $ D5120 Complete denture - mandibular $ D5130 Immediate denture - maxillary $ D5140 Immediate denture - mandibular $ D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $ D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $ D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) $ D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) $ D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) $ D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $ D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $ D5810 Interim complete denture (maxillary) $ D5811 Interim complete denture (mandibular) $ D5820 Interim partial denture (maxillary) $96.00 D5821 Interim partial denture (mandibular) $ D5860 Overdenture - complete, by report $ D5861 Overdenture - partial, by report $ D6053 Implant/abutment supported removable denture for completely edentulous arch $ D6054 Implant/abutment supported removable denture for partially edentulous arch $ D6078 Implant/abutment supported fixed denture for completely edentulous arch $ D6079 Implant/abutment supported fixed denture for partially edentulous arch $ Complete Denture: D5110, D5120, D5130, D5140, D5860, D6053, D6078 Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053, and D6078 are considered at an alternate benefit of a D5110/D

12 Type 3 (Major) Procedures (continued) Partial Denture: D5211, D5212, D5213, D5214, D5225, D5226, D5281, D5670, D5671, D5861, D6054, D6079 Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054, and D6079 are considered at an alternate benefit of a D5213/D5214. Denture Adjustments D5410 Adjust complete denture - maxillary $14.00 D5411 Adjust complete denture - mandibular $13.00 D5421 Adjust partial denture - maxillary $15.00 D5422 Adjust partial denture - mandibular $14.00 Denture Adjustment: D5410, D5411, D5421, D5422 Coverage is limited to dates of service more than 6 months after placement date. Add Tooth/Clasp To Existing Partial D5650 Add tooth to existing partial denture $32.00 D5660 Add clasp to existing partial denture $37.00 Denture Rebases D5710 Rebase complete maxillary denture $90.00 D5711 Rebase complete mandibular denture $95.00 D5720 Rebase maxillary partial denture $86.00 D5721 Rebase mandibular partial denture $90.00 Tissue Conditioning D5850 Tissue conditioning, maxillary $25.00 D5851 Tissue conditioning, mandibular $27.00 Prosthodontics - Fixed D6058 Abutment supported porcelain/ceramic crown $ D6059 Abutment supported porcelain fused to metal crown (high noble metal) $ D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $ D6061 Abutment supported porcelain fused to metal crown (noble metal).... $ D6062 Abutment supported cast metal crown (high noble metal)... $ D6063 Abutment supported cast metal crown (predominantly base metal) $ D6064 Abutment supported cast metal crown (noble metal) $ D6065 Implant supported porcelain/ceramic crown $ D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $ D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) $ D6068 Abutment supported retainer for porcelain/ceramic FPD.... $ D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $ D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $ D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) $ D6072 Abutment supported retainer for cast metal FPD (high noble metal) $ D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) $ D6074 Abutment supported retainer for cast metal FPD (noble metal) $ D6075 Implant supported retainer for ceramic FPD $ D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)... $ D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal) $ D6094 Abutment supported crown - (titanium) $ D6194 Abutment supported retainer crown for FPD - (titanium)..... $ D6205 Pontic - indirect resin based composite $ D6210 Pontic - cast high noble metal $ D6211 Pontic - cast predominantly base metal $ D6212 Pontic - cast noble metal $ D6214 Pontic - titanium $ D6240 Pontic - porcelain fused to high noble metal $ D6241 Pontic - porcelain fused to predominantly base metal $ D6242 Pontic - porcelain fused to noble metal $ D6245 Pontic - porcelain/ceramic $ D6250 Pontic - resin with high noble metal $ D6251 Pontic - resin with predominantly base metal $ D6252 Pontic - resin with noble metal $ D6545 Retainer - cast metal for resin bonded fixed prosthesis $75.00 D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis. $75.00 D6600 Inlay - porcelain/ceramic, two surfaces $ D6601 Inlay - porcelain/ceramic, three or more surfaces $ D6602 Inlay - cast high noble metal, two surfaces $ D6603 Inlay - cast high noble metal, three or more surfaces $ D6604 Inlay - cast predominantly base metal, two surfaces $ D6605 Inlay - cast predominantly base metal, three or more surfaces $ D6606 Inlay - cast noble metal, two surfaces $ D6607 Inlay - cast noble metal, three or more surfaces $ D6608 Onlay - porcelain/ceramic, two surfaces $ D6609 Onlay - porcelain/ceramic, three or more surfaces $ D6610 Onlay - cast high noble metal, two surfaces $ D6611 Onlay - cast high noble metal, three or more surfaces $ D6612 Onlay - cast predominantly base metal, two surfaces $ D6613 Onlay - cast predominantly base metal, three or more surfaces $ D6614 Onlay - cast noble metal, two surfaces $ D6615 Onlay - cast noble metal, three or more surfaces $ D6624 Inlay - titanium $ D6634 Onlay - titanium $ D6710 Crown - indirect resin based composite $ D6720 Crown - resin with high noble metal $ D6721 Crown - resin with predominantly base metal $ D6722 Crown - resin with noble metal $ D6740 Crown - porcelain/ceramic $ D6750 Crown - porcelain fused to high noble metal $ D6751 Crown - porcelain fused to predominantly base metal $ D6752 Crown - porcelain fused to noble metal $ D6780 Crown - 3/4 cast high noble metal $ D6781 Crown - 3/4 cast predominantly base metal $ D6782 Crown - 3/4 cast noble metal $ D6783 Crown - 3/4 porcelain/ceramic $ D6790 Crown - full cast high noble metal $ D6791 Crown - full cast predominantly base metal $ D6792 Crown - full cast noble metal $ D6794 Crown - titanium $ D6940 Stress breaker $62.00 Fixed Partial Crown: D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 D2390, D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2930, D2931, D2932, D2933, D2934, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. Fixed Partial Inlay: D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624 D2390, D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2930, D2931, D2932, D2933, D2934, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. Fixed Partial Onlay: D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634 D2390, D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2930, D2931, D2932, D2933, D2934, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. 12

13 Type 3 (Major) Procedures (continued) Fixed Partial Pontic: D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6094, D6194 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. Implant Supported Crown: D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094 D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6194, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. Implant Supported Retainer: D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6194 D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 also contribute(s) to this limitation. Procedures that contain titanium or high noble metal (gold) will be considered at the corresponding semi-precious metal allowance. Cast Post and Core for Partials D6970 Cast post and core in addition to fixed partial denture retainer. $67.00 D6972 Prefabricated post and core in addition to fixed partial denture retainer $67.00 Surgical Extractions D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $48.00 D7220 Removal of impacted tooth - soft tissue $60.00 D7230 Removal of impacted tooth - partially bony $80.00 D7240 Removal of impacted tooth - completely bony $93.00 D7241 Removal of impacted tooth - completely bony, with unusual surgical complications $ D7250 Surgical removal of residual tooth roots (cutting procedure)... $50.00 D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $97.00 D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $76.00 D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $97.00 D7465 Destruction of lesion(s) by physical or chemical method, by report $23.00 D7471 Removal of lateral exostosis (maxilla or mandible) $67.00 D7472 Removal of torus palatinus $67.00 D7473 Removal of torus mandibularis $67.00 D7485 Surgical reduction of osseous tuberosity $ D7490 Radical resection of maxilla or mandible $ D7510 Incision and drainage of abscess - intraoral soft tissue $34.00 D7520 Incision and drainage of abscess - extraoral soft tissue $39.00 D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $31.00 D7540 Removal of reaction producing foreign bodies, musculoskeletal system $85.00 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $85.00 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $ D7910 Suture of recent small wounds up to 5 cm $15.00 D7911 Complicated suture - up to 5 cm $17.00 D7912 Complicated suture - greater than 5 cm $24.00 D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure. $81.00 D7963 Frenuloplasty $ D7970 Excision of hyperplastic tissue - per arch $62.00 D7972 Surgical reduction of fibrous tuberosity $99.00 D7980 Sialolithotomy $93.00 D7983 Closure of salivary fistula $30.00 Removal of Bone Tissue: D7471, D7472, D7473 Coverage is limited to 5 of any of these procedures per 1 lifetime. Anesthesia-General/IV D9220 Deep sedation/general anesthesia - first 30 minutes $72.00 D9221 Deep sedation/general anesthesia - each additional 15 minutes $24.00 D9241 Intravenous conscious sedation/analgesia - first 30 minutes.. $47.00 D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes... $12.00 General Anesthesia: D9220, D9221, D9241, D9242 Coverage is only available with a cutting procedure. Verification of the dentist s anesthesia permit and a copy of the anesthesia report is required. A maximum of two additional units (D9221 or D9242) will be considered. Other Oral Surgery D7260 Oroantral fistula closure $ D7261 Primary closure of a sinus perforation $ D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $71.00 D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $71.00 D7280 Surgical access of an unerupted tooth $ D7282 Mobilization of erupted or malpositioned tooth to aid eruption. $80.00 D7283 Placement of device to facilitate eruption of impacted tooth... $33.00 D7310 Alveoloplasty in conjunction with extractions - per quadrant.. $41.00 D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $21.00 D7320 Alveoloplasty not in conjunction with extractions - per quadrant $53.00 D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $27.00 D7340 Vestibuloplasty - ridge extension (secondary epithelialization). $76.00 D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue).. $ D7410 Excision of benign lesion up to 1.25 cm $76.00 D7411 Excision of benign lesion greater than 1.25 cm $97.00 D7412 Excision of benign lesion, complicated $ D7413 Excision of malignant lesion up to 1.25 cm $ D7414 Excision of malignant lesion greater than 1.25 cm $75.00 D7415 Excision of malignant lesion, complicated $82.00 D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm. $ D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm $75.00 D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $

14 vision benefit Who Can Enroll? All employees participating in any of the Group Dental Insurance Plans (Plan A+, Plan A, Plan B) may receive the vision benefit at no additional cost. The benefit pays specified expenses for frames and lenses or for contact lenses for the employee and his or her eligible dependents. An employee must enroll in the Group Dental Insurance Plan to receive the vision benefit. No Late Entrant penalty is imposed for the vision benefit. Ameritas of New York provides each employee with a Certificate of Insurance explaining the plan benefits and limitations in complete detail. For answers to your claims questions, call toll free, For claim forms, call toll free, Vision claim forms also are available on the Ameritas website just go to www. ameritas.com, click on individual/families, dental, vision/hearing to find Ameritas of New York claim form. Vision Perfect Plan Summary Maximum Benefit (per calendar year) $ Annual Eye Exam N/A Lenses (per pair) Single Subject to Maximum Bifocal Subject to Maximum Trifocal Subject to Maximum Lenticular Subject to Maximum Contact Lenses - elective/medically necessary Subject to Maximum Frames Subject to Maximum Frequencies (months) - Lens/Frame N/A EyeMed Discount Overlay (Additional discounts only if seen by an EyeMed participating provider.) Exam: with dilation as necessary contact lense exam $ 5.00 off routine exam $ off Standard Plastic Lenses Single $ Bifocal $ Trifocal $ Frame 35% off retail price with a complete pair of glasses (Items purchased separately - 20% off retail price) Standard Progressive Lenses Premium Progressive Lenses $65 + Standard Plastic Lens cost 20% discount Standard Polycarbonate $ Tint (Solid and Gradient) $ Scratch Resistant Coating $ Anti-Reflective Coating $ Ultraviolet Coating $ Other Add-Ons Contact Lenses - Conventional 20% discount To find an EyeMed provider, go to eyemedvisioncare.cm. 15% off retail price (does not apply to fitting). After initial purchase, replacements by mail are offered at substantial savings via eyemedvisioncare.com. 14

15 What if your Provider is Not in the EyeMed Network? That s ok, you may choose any vision provider for your vision services. You can get as many pairs of prescription glasses and contacts as you want, and be reimbursed up to your annual vision dollar amount of $150. Pay the provider at the time of services. Ask your doctor/optical provider to complete Ameritas Vision Claim Form FA325 (available on our website). Submit the form, along with a copy of an itemized bill from your provider, to Ameritas of New York for reimbursement. Proof of Loss Written proof of loss must be given to us within 120 days after the incurred date of the services provided for which benefits are payable. If it is impossible to give written proof within the 120 day period, we will not reduce or deny a claim for this reason if the proof is filed as soon as reasonably possible. How do I get the EyeMed Network Provider Discount? When your vision provider participates in the EyeMed network, you are entitled to additional discounts, also referred to as member costs. Make sure that the EyeMed provider looks at both sides of your ID card the front shows that Vision Perfect is the insurance plan, and the back shows that you are eligible for EyeMed network discounts. Be sure to reference code As noted above, you can get as many pairs of prescription glasses and contacts as you want, and be reimbursed up to your annual vision dollar amount of $150. Pay the provider at the time of services. Ask your doctor/optical provider to complete Ameritas of New York Vision Claim Form FA325 (available on our website). Submit the form, along with a copy of an itemized bill from your provider, to Ameritas of New York for reimbursement. Ameritas Life Insurance Corp. of New York Group Eye Care Claims P.O. Box Lincoln, NE FAX: Website: ameritas.com Coordination of Benefits If you or any of your dependents incur charges which are covered by any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the charges incurred. Limitations and Exclusions Also known as a discount overlay, the EyeMed Access Network provider discounts are only available to groups who have a specific schedule/defined benefit vision plan in place. The discount program may not be combined with any other discounts or promotional offers. Retail prices may vary by location. Discounts are not available for the following procedures, material or services: Orthoptic or vision training, subnormal vision aids, and any associated supplement testing. Medical and/or surgical treatment of the eye, eyes, or supporting structures. Corrective eye wear required by an employer as a condition of employment, and safety eye wear unless specifically covered under the plan. Services provided as a result of any Worker s Compensation law. Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount). EyeMed s providers professional services or disposable contact lenses. Two pairs of glasses in lieu of bifocal. 15

16 about this brochure This brochure provides a description of plan benefits. Cornell is not the publisher and makes no representations about its content. Your certificate booklet from Ameritas Life Insurance Corp. of New York is your legal plan coverage document. Please refer to that for full plan details. about this brochure This employee handout is a benefit highlight, not a Certificate of Insurance. The coverage outlined here highlights the dental benefits available through Ameritas Life Insurance Corp. of New York. Ameritas Life Insurance Corp. of New York 1350 Broadway, Suite 2201 New York, NY For Administrative information call: For Claims information call: Insured by: Ameritas Life Insurance Corp. of New York In New York, dental, vision and hearing care products are offered through Ameritas Life Insurance Corp. of New York [Ameritas of New York]. Certain plan designs may not be available in all areas. To become appointed with Ameritas of New York, call Ameritas of New York s group dental, vision and hearing care products [9000 Rev ] and individual dental and vision products [Indiv NY Ed ] are issued by Ameritas of New York Ameritas of New York. Ameritas, the bison symbol, Ameritas Life Insurance Corp. of New York and company product names designated with SM or are service marks or registered service marks of Ameritas of New York, Ameritas Life Insurance Corp. or Ameritas Mutual Holding Company. Ameritas, the bison symbol, fulfilling life and product names designated with SM or are service marks or registered service marks of Ameritas Life or Ameritas Mutual Holding Company. All other brands are property of their respective owners Ameritas Mutual Holding Company ameritas.com recycled paper

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