DENTAL UNDERWRITING GUIDELINES SMALL GROUP

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1 SMALL GROUP AETNA DMO may be combined with any PPO. Freedom of Choice plans are only available standalone. 3 9 eligible: single plan option only eligible: DMO may be combined with any PPO. Freedom of Choice plans are only available standalone. Members enrolled in medical and dental will be enrolled in the Aetna Dental/Medical Integration program: The program focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. Preventive services are excluded from the calendar year maximum on plans 10B and 11B. These plans are only available to groups of eligible: Implants are included as a major service on the PPO in plan options 5B, 8B, 8C and 12B. Voluntary Plan Voluntary Plan Tooth Missing But Not Replaced Rule: Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that such removable dentures; fixed bridgework and other prosthetic services are (i) needed to replace one or more natural teeth that were removed while this policy was in force for the covered person; and (ii) are not abutments to a partial denture; removable bridge; or fixed bridge installed during the prior 8 years. Adult/Child ortho available for groups with 10+ eligible employees with a minimum of 5 enrolled. 2 9 eligible and voluntary 3-50 eligible: 12-month wait for Major and Ortho (excludes DMO). Can be waived with qualifying previous coverage eligible: No waiting period DE-9C required. Must be sole dental carrier offered. Groups of 2 must be sold alongside medical. Standalone available to groups with 3+ eligible; some industries must be sold alongside medical. Rates based on EMPLOYEE zip code. 50% of employee premium or 25% of the total cost. 2 3 eligible: 100% excluding valid waivers. A minimum of 2 must enroll eligible: 75% excluding valid waivers. A minimum of 2 and 50% of total eligible employees must enroll. For all group sizes: If 100% employer paid then 100% participation required. Plans where employer contribution is below 50% of employee premium or 25% of the total cost. 30% excluding valid waivers. A minimum of 3 must enroll. No more than 49%. Out of state enrollees will receive the same plan as CA enrollees; subject to network availability. Corporations: Eligible if there is at least one W-2 employee enrolling in medical. If the only employees are owners and/or spouses, and they are W-2, the group is eligible. All other types: Not allowed. Must have at least one non-spouse, common law employee on the DE-9C and enrolled in medical. Some industries ineligible if sold stand-alone; see California Plan Guide. Groups with 2 9 eligible or groups with 2-50 on voluntary plans: no open enrollment eligible: open enrollment included. Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 1 of 20

2 AMERITAS May offer Core PPO/Buy-up PPO or PPO Hi/PPO Low. Ameritas PPO plans may also be offered alongside another carrier s DHMO plan. May offer Core PPO/Buy-up PPO or PPO Hi/PPO Low. Ameritas PPO plans may also be offered alongside another carrier s DHMO plan. Ameritas can quote any of their plans with up to 4 cleanings per year. Groups with 3+ may request additional cleanings as part of the standard plan benefit; this should be requested with the RFP submission. Up to $5,000 available on MAC plans. Preventive Plus program. Plan payments for preventive services will not accumulate toward the annual maximum benefit. Riders are available to groups of 3+; Tooth-Color Composites on Molars rider and Cosmetic Tooth Bleaching rider Cosmetic Tooth Bleaching rider includes coverage toward 3 types of professional tooth whitening: Per arch bleaching (upper and lower) for ages 14 and over every two years Single tooth bleaching Internal bleaching to lighten a discolored tooth that has had root canal therapy Offered upon request for groups down to 3. Voluntary Plan Voluntary Plan A tooth must have been extracted within 12 months of the date the Ameritas plan goes into effect and that the group must have had prior coverage for takeover. For virgin groups, the takeover of the prior extraction will not be covered. Available for groups of 10 or more enrolled employees. Dental Rewards, optional feature. To qualify for rewards, member must submit at least 1 claim per year for a covered procedure and total paid claims must be under the plans annual threshold limit. A bonus is earned for utilizing PPO providers. Earned rewards are added to the next years calendar year maximum benefit and have a maximum accumulation amount based on the plan benefit. 12 months for ortho and major for virgin groups for Increasing Coverage plan only. Also for late entrant enrollment for in force groups. 3 2,000. DE-9C not required eligible: Minimum 25% of employee and dependent premium. 60% of eligible employees with a minimum of 3 must enroll. Core/buy-up and Hi/Low combinations require at least 10 eligible. PPO plans may be offered alongside another carriers DHMO plan: must have at least 50 eligible and 20% enrolled on the Ameritas plan eligible: None Minimum 20% of all eligible or 3 enrolled, whichever is greater. Core/buy-up and Hi/Low combinations require at least 10 eligible. PPO plans may be offered alongside another carriers DHMO plan: must have at least 50 eligible and 20% enrolled on the Ameritas plan. Out of State enrollees will be paid based on the out-of-network benefits. Allowed; 20% load applies. Allowed. Also, groups with more than 40% defined as Sales who receive compensation based on commission only will receive a 20% load. There is no open enrollment provision. Late Entrant Provision: Exams, Cleanings and Child Fluorides only allowed in the first 12-months if insured does not enroll in the initial eligibility period. Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 2 of 20

3 ANTHEM BLUE CROSS LEGACY (COPOWER) All plans may be offered; Metallic and Dental Blue plans may not be combined. Voluntary PPO may be combined with a Voluntary DHMO. ANTHEM BLUE CROSS PRIME & COMPLETE Single plan, HMO/PPO or PPO/PPO. PPO plans must have at least a 20% premium differential. Voluntary PPO may be combined with a Voluntary DHMO. Dental Blue only: Members can receive additional cleanings at Anthem s negotiated rate, Members who are pregnant or living with diabetes can receive one additional dental cleaning or periodontal maintenance procedure a year. $2,500 available. Available on specific plan designs. Not covered. Available on specific plan designs. Coverage is not available for the replacement of teeth missing prior to the effective date of coverage with partial dentures, complete dentures, or fixed bridges. Coverage is not available for the initial placement of prosthetics if teeth being replaced were missing before the member was covered by the plan (teeth extracted prior to this coverage). Built in for all plans except the Dental Blue Silver Plus , Standard PPO, and Basic PPO. Voluntary PPO includes child orthodontic coverage for groups with 10+ enrolling. See contract. 24 month waiting period for replacement of tooth missing prior to initial effective date. Available to groups of 10+ +or more enrolled employees. Not available on Value plans. Lifetime max must match annual max. Available on specific plan designs. Dental Net, Dental Blue & Enhanced plans: Voluntary: 12-month. Waived with proof of 12 consecutive months of prior group coverage with no lapse DE-9C required DE-9C required. Dental Prime & Complete: Voluntary: 12-month. Waived with proof of 12 consecutive months of prior comparable group coverage. 12 months, 24 month option available. If sold alongside medical, Medical Requirements will apply. Voluntary Plan Defined 15: $15 per employee. Defined Select: More than $15 per employee. Traditional : Minimum of 50% of EE premium. No minimum. 75% of eligible employees. 2 4 eligible: 100% 5 14 eligible: 70%. discounts apply with higher participation eligible: 50%. discounts apply with higher participation. Dual option HMO/PPO & PPO/PPO: eligible: 70% with minimum 2 enrolled in each plan eligible: 50% with minimum 2 enrolled in each plan. A minimum of 0% and a maximum of 49% of each covered employee s monthly voluntary dental premium. No minimum. Voluntary Plan Minimum 25% or 3 enrolled, whichever is greater. (CA only) A minimum of 5 employees must enroll (no % requirement). No more than 49%. No more than 49%. Minimum of 5 enrolled. Allowed. Not eligible. A sole proprietorship is ineligible without a common law employee. A spouse does not constitute a common law employee (refer to employee eligibility requirements). Owners, that are not spouses, may demonstrate that they meet the eligible employee criteria by providing W-2s or completing the Eligibility Statement. No. Yes, built into the rates. Dental offices not eligible for coverage Dependent Eligibility Dependent children are eligible until age 26. Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 3 of 20

4 CALCPA Voluntary Plan Single plan option For pregnant enrollees, Delta Dental will pay for the following additional services per calendar year: 1 additional oral evaluation and either 1 additional routine cleaning or 1 additional periodontal scaling and root planing per quadrant. Written confirmation of the pregnancy must be provided by the enrollee or the dentist when the claim is submitted. Direct composite restorations are benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite restorations are optional & Delta s payment is limited to the cost of the equivalent amalgam restorations. Covered under Major services. Delta Dental will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials. Excluded: Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). Child only ortho included for groups of 5+ enrolled. Not available to groups of 1-4 enrolled eligible and enrolled. DE-9C required. Must be headquartered in California. Available to accounting firms in public practice or firms offering general financial services (SIC 8721). To be eligible, more than 50% of all of the firm s owners (principals, proprietors, partners, shareholders, or other owners) must be CPA members of CalCPA, or Associate members of CalCPA. All CPA owners must be members of CalCPA in good standing. Must be written alongside medical. Minimum 100% of employee premium. 100% of eligible employees must enroll. Dependents may participate in the coverage provided at least 50% of the individuals at the firm who have eligible dependents enroll them. If an employee chooses to enroll dependents, all of his/her eligible dependents must enroll. Voluntary Plan No more than 49% may reside outside California Not allowed. Dependent Eligibility Allowed, includes husband/wife groups. occurs once a year through November and December, and all changes are effective January 1. This is the only period, regardless of when the group joined the plan. Up to age 19, or age 25 if full-time student in an accredited school, college or university). Rev. Date 1/7/16 Page 4 of 20

5 CALIFORNIA DENTAL NETWORK (CDN) CALIFORNIACHOICE Single DHMO. Dual DHMO available with carrier approval. DHMO may be combined with PPO an approved carrier partner. Approved CDN partners: Ameritas & Principal. All plans are available on a voluntary basis. All plans may be offered. Covered at a higher copay. N/A N/A One voluntary plan available. Cosmetic benefits included in plan as standard. Not covered. Not covered. N/A A tooth must have been extracted within 12 months of the date the Ameritas plan goes into effect and that the group must have had prior coverage for takeover. For virgin groups, takeover of prior extraction will not be covered. Included on all plans. Available to groups of 5 or more. N/A Dental Rewards By Ameritas Group. Included on EPO 3500 & PPO plans. Members who visit the dentist & use only a portion of their annual maximum benefit in a year are rewarded with additional benefits for the following year based on the plan selected, members can earn additional money toward their next year s annual max benefit if they use less than half of the annual maximum, they can increase next year s coverage by $250 & additional $100-$150 if they visit a network provider. PPO 3500, 4000 & 5000: 12 months for Major, 24 months for Ortho. Can be waived at enrollment groups of 10+ with proof of prior similar coverage for preceding 12 months with no break in coverage. Credit given for time on prior plan. 2+. DE-9C not required. Groups with no prior coverage must be custom quoted. Yes No 24 month option available for groups of 25+; custom quote required. Rev. Date 1/7/16 Page 5 of alongside medical only. DE-9C required. $10 per month for groups with less than 25 employees. Not specific to dental Minimum 50% of employee or 50% of the employee and dependent combined premium. 75% with a minimum of 2 enrolled. Dual Choice with a CDN PPO partner: Min 1 CDN enrollee Voluntary Plan Minimum 0 49% of premium regardless of family tier. No minimum Minimum of 50% of lowest available rate. Voluntary Plan Minimum 2 enrolled. Voluntary enrollment. Minimum of 70%. No minimum participation for dependents. None allowed. PPO dental plans 3500 (EPO), 4000 and Minimum 2 enrolled. Mgmt, Owner, Key EE allowed. Not allowed Employees Allowed on voluntary only. Not eligible. Allowed. Not allowed. Must have at least one non-spouse, common law employee on the DE-9C. Included on all DHMO plans. Dependent Eligibility Dependent children are eligible until age 26. Dependent children are eligible until age 26.

6 CHOICE BUILDER DeltaCare USA HMO will be combined with one EPO/PPO carrier. All plans offered by the selected EPO/PPO dental carrier will be available. Same as above. Pending. Pending. Pending. Ameritas: Available for child only, requires 5+ eligible. DeltaCare HMO: Included for adult and child. Delta Dental: Available for child only, requires 10+ enrolled for employer sponsored plans, and 25+ eligible for voluntary plans. Madison: Available for child only, requires 2+ enrolled. Ameritas: Silver and Gold plans offer Dental Rewards program. Members can earn additional benefit for the following year. DeltaCare, Delta Dental & Madison: Ameritas DeltaCare USA Delta Dental Madison Employer Sponsored Major None None None None Ortho 12 months None None 12 months Takeover Credit Available* None None Available* Voluntary Major 6 months None 12 months 12 months Ortho 12 months None None 12 months Takeover Credit None None None Available* * At initial enrollment, takeover credit is available to groups of 10+ eligible with proof of prior ortho coverage for the preceding 12 consecutive months. For Ameritas, 12 months will be waived if 12 months proof is provided, no partial credit. For Madison, up to 12 months will be waived in accordance with the proof provided DE-9C not required. DeltaCare HMO rated by employee home zip code. EPO/PPO rated by employer zip code. Per group, per billing location, per month: (If group is enrolling alongside CalChoice, the CalChoice admin fee will be waived.) 2-8 employees: $ employees: $ employees: $30 Minimum 50% of the lowest cost plan available. 70% of eligible employees with a minimum of 2 enrolled. Voluntary Plan 0-49% Voluntary Plan Must have 10+ eligible employees. A minimum of 5 must enroll. No maximum. Group must be domiciled in California. Out of state employees will receive the same plan as a California enrollee; subject to network availability. Allowed, including Husband/Wife groups. Ameritas & DeltaCare: No. Delta Dental & Madison: Loads apply by SIC code. Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 6 of 20

7 Voluntary Plan Voluntary Plan COPOWER ONE Dual choice Delta Dental PPO and DeltaCare USA within CoPower ONE portfolio: If Less than 10 eligible and/or enrolled employees: minimum 2 enrolled in one plan and the remainder in the other plan. When enrolling less than 5 in PPO, use CoPower ONE Good 2-4 rates. If 5+ enrolled on PPO and a minimum of 2 enrolled on HMO, all CoPower ONE plans are available except Voluntary plans. CoPower ONE Voluntary is not allowed for dual choice. Dental and Vision bundle only. For pregnant enrollees, Delta Dental will pay for the following additional services per calendar year: 1 additional oral evaluation and either 1 additional routine cleaning or 1 additional periodontal scaling and root planing per quadrant. All CoPower ONE D&P services are waived for in-network benefits. CoPower ONE Best waives D&P for both in and out of network services. Direct composite restorations are benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite restorations are optional services and Delta s payment is limited to the cost of the equivalent amalgam restorations. Covered under Major services for PPO. Not covered on HMO. Delta Dental will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials. Excluded: Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). Child only available with CoPower ONE Better, Better Plus, and Best. Good, Better, Better Plus, Best PPOs: Voluntary PPO: 12-months for all covered services except D&P, sealants, simple restorations, simple extractions and dental accident. Waiting period can be waived for initial enrollees at takeover with proof of coverage in a comprehensive dental plan with no break in coverage (copy of group s prior carrier s EOC and last bill) 2-99 eligible employees for Good-PPO and DeltaCare USA plans eligible employees for Better-PPO, Better Plus-PPO+Premier, Best-PPO+Premier and Voluntary plans. DE-9C required for all groups under 10 enrolled and any group with PPO enrollment. DE-9C not required for groups 10+ with DHMO-only enrollment. Groups currently enrolled with Delta Dental are allowed if they are converting to CoPower ONE. Groups currently enrolled with Unum Life are not eligible. 24 months. Minimum 75% employee, no minimum for dependents. Minimum 75% of eligible employees must enroll with no less than 2 in Good-PPO and DeltaCare USA plans and 5 in remaining PPO plans. If employer contributes 100% then 100% participation is required. Less than 75% for employees. Minimum enrollment of 5 eligible employees. 2-3 eligible: No out-of-state employees allowed. 4 eligible: 1 eligible EE may be located out of state eligible & Voluntary plans: No more than 50% of may reside out-of-state. DeltaCare: Service must be rendered in California. Can consist of union/non-union, mgmt/non-mgmt, and hourly/salaried EEs. PPO can be offered to one population and DeltaCare USA to the other; mulitple PPO plans are not allowed. Delta must be the sole dental carrier for both populations. Employers must provide a DE- 9C identifying the carve-out EEs; if the carve-out is all owners, a letter from the group confirming this is needed. Level 2 rating applies to carve-out groups regardless of industry. Underwriting guidelines apply to each carve-out plan. Allowed if all owners appear on the DE-9C. If owners are not on the DE-9C they are considered ineligible for coverage and do not count in calculating group size or participation. Yes, also some ineligible industries. Available only to groups with a POP/Section 125 plan in place. Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 7 of 20

8 COPOWER SUITE Available to groups with 10+ enrolling and a minimum of 3 enrolled on each plan: DHMO may be offered alongside the Standard Dental PPO Option 1 or the Preferred Dental PPO Option 2. Covered under Basic services. Covered under Major services. Coverage for initial installation of fixed & permanent Denture; initial installation of full or removable Dentures; implants and implant supported prosthetics (time period restrictions apply): when needed to replace congenitally missing teeth; or when needed to replace natural teeth that are lost while the person receiving such benefits was insured for Dental Insurance under this certificate. Coverage for Addition of teeth to fixed and permanent Denture or partial removable denture to replace natural teeth removed while this Dental Insurance was in effect for the person receiving such services. Excluded: Initial installation of a Denture to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Preferred Dental PPO Option 2: Child only available for groups Dental HMO: Child and Adult available for groups Voluntary Plan Voluntary Plan DE-9C not required. 2 4 employees: Package consists of Dental PPO, Vision, and Basic Term Life and AD&D employees: Package consists of 2 Dental PPOs, Dental HMO, Vision, and Basic Term Life and AD&D. Dental, vision and life must be purchased as an employer package. 12 months Dental/Vision, 24 months Life. Dental/Vision: 50% employee Basic Term Life: 99% employee Supplemental Life: 0% for employee and dependent 2 4: 75% with minimum 2 enrolled. 5 99: 75% with minimum 5 enrolled. CoPower SUITE plan requirements do not count valid wavers towards participation. Supplemental Life: 25% with minimum 5 enrolled. Supplemental Life is available for employees and eligible dependents. Waivers included in the calculation. Dental PPO: Up to 25% allowed. Dental HMO: None allowed. Union/Non-union and Management carve-outs will be allowed. Allowed if owners are not related and also appear on the DE-9C. No, but some ineligible industries. No for groups 2 4. Yes for groups Dependent Eligibility Dental/Vision: Dependent children are eligible until age 26. Supplemental Life: Dependent children are eligible until age 19 or age 25 if full time student. Rev. Date 1/7/16 Page 8 of 20

9 If ER contributes 100% then 100% participation is required. Voluntary Plan Voluntary Plan DELTA DENTAL/DELTACARE THROUGH COPOWER Dual Choice available for groups of 4+ employees enrolled. Must have a minimum of 2 in one plan and the remainder of employees in the other plan. Delta must be the sole carrier offered, and non-voluntary plans may not be paired with voluntary plans. Employer contribution percentage for employee and dependent coverage must be identical for both plans. PPO can only be paired with DeltaCare HMO plans 10A, 11A, 12A, 15B-Options A or B, or 48N. When enrolling less than 5 in PPO, use the 2-4 PPO rates. When using the 2-4 PPO rates, only PPO Value and PPO Plus Premier Enhanced plans are available. Dual Choice Voluntary PPO/HMO available for groups of 10+ enrolling, with a minimum of 5 enrolled in one plan and remainder in the other. Voluntary PPO can only be paired with Voluntary DeltaCare HMO plans 10A, 11A, 12A, 15B-Option C, or 48N. For pregnant enrollees, Delta Dental will pay for the following additional services per calendar year: 1 additional oral evaluation and either 1 additional routine cleaning or 1 additional periodontal scaling and root planing per quadrant.written confirmation of the pregnancy must be provided by the enrollee or the dentist when the claim is submitted. Optional benefit available. Not available on the Voluntary PPO. Direct composite restorations are benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite restorations are optional & Delta s payment is limited to the cost of the equivalent amalgam restorations. PPO: Covered under Major services. HMO: Not covered. Delta Dental will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials. Excluded: Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). DPPO: Available for groups with 10+ enrolled in the PPO plan. Dependent children only. Voluntary PPO requires 25+ enrolled. DeltaCare: Included Adult and dependent child for groups with 5+ enrolled. Dual Choice Voluntary: Available for groups with a minimum of 25 on PPO and 5 on HMO. None, except on Voluntary PPO: 12-month wait for many services. Can be waived at initial enrollment with a copy of the group s most recent bill showing no break in coverage, and a copy of the group s prior carrier s EOC in Indemnity, PPO or comprehensive DHMO. New hires subject to 12-month wait DE-9C required for DPPO Plans. Groups of 2 may not be comprised of related individuals (ex: Husband/wife not allowed. Parent/tax-dependent and/or cohabitant child not allowed.) Voluntary PPO: 24 months unless waiting period waived for major benefits, then DPPO & DeltaCare Option B: Minimum 75% for employee. No minimum for dependents. DeltaCare Option A: 100% for employee & dependent premium. DPPO: 75% of all eligible employees. Groups 2-4 must have a minimum of 2 eligible enrolled, Groups of 5-99 must have a minimum of 5 eligible enrolled. DHMO: Minimum 2 eligible employees. Voluntary PPO & DeltaCare Option C: Less than 75% of employee premium. 2-4 Voluntary PPO: Voluntary enrollment. Minimum of 2 enrolled Voluntary PPO: Voluntary enrollment. Minimum of 5 enrolled. DeltaCare Option C: Voluntary enrollment. Minimum of 2 enrolled. All Delta Dental PPO plans: Up to 50%. DeltaCare: No out of state enrollees. 2-4 PPO: Groups of 4 may have 1 member may be out of state. No out of state enrollees for groups of 2-3. Employee class carve-outs allowed; management/non-management, union/non-union and hourly/salaried employees (excludes Voluntary PPO). The following will apply: Delta PPO can be offered to one population, DeltaCare USA to another (multiple PPOs not allowed). Not allowed with another carrier; union/non-union population must be through Delta. Level 2 rating applies regardless of industry. DE-9C must identify the carve-out EEs. Underwriting guideline apply to each of the carve-out groups. Allowed if all owners appear on the DE-9C. If owners are not, they may ineligible for coverage; contact CoPower for exceptions. DPPO: Yes, Some industries are ineligible. DeltaCare: No, however some industries are ineligible. Voluntary DPPO: Employees who contribute towards the cost of coverage for themselves and/or their dependents using pretax dollars may add or delete coverage for themselves and/or their dependents during the group s open enrollment. Children may be enrolled at the group s anniversary up to or immediately following the child s 4th birthday Rev. Dependent Date 1/7/16 Eligibility Dependent children are eligible until age 26. Page 9 of 20

10 Voluntary Plan Voluntary Plan DELTA CHOICE THROUGH COPOWER PPO+Premier/HMO, or PPO/HMO: Available for groups of 10+ enrolling with a minimum of 3 enrolled in one plan. DeltaCare Option A is available if the employer contributes 50% or more of dependent premium. Note: Delta Care Choice HMO 10B pairs with Choice PPOs only. For pregnant enrollees, Delta Dental will pay for the following additional services per calendar year: 1 additional oral evaluation and either 1 additional routine cleaning or 1 additional periodontal scaling and root planing per quadrant.written confirmation of the pregnancy must be provided by the enrollee or the dentist when the claim is submitted. Optional benefit available. Not available on the Voluntary PPO. Direct composite restorations are benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite restorations are optional & Delta s payment is limited to the cost of the equivalent amalgam restorations. PPO: Covered under Major services. HMO: Not covered. Delta Dental will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials. Excluded: Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). Choice DPPO Plans: Available for groups with 10+ enrolled. Dependent children only. Choice 10B: Included Adult and dependent child DE-9C required for DPPO plans. Minimum of 6 months. 100% for employee and 50% for dependents. If offering dual choice, contribution must be identical for both plans. Choice DPPO Plans: 100% of all eligible employees; no minimum for dependents. Minimum of 5 enrolled. Choice 10B Plan: 100% of eligible employees & minimum of 50% of dependents. Minimum of 5 enrolled. All Delta Dental Choice PPO plans: Up to 50%. Choice 10B Plan: No OOS enrollees. Allowed if all owners appear on the DE-9C. If owners are not on the DE-9C they are considered ineligible for coverage and do not count in calculating group size or participation. Industry loads on PPO & Premier Plans. Ineligible Industries on DeltaCare: law firms, associations, groups with seasonal employment, groups without an employee/employer relationship, and businesses with a high turnover. Available for groups with employee contributions made on a pre-tax basis. Applicable for dependent enrollment only Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 10 of 20

11 Voluntary Plan Voluntary Plan DELTA OPTIONS THROUGH COPOWER Dual Choice PPO/HMO available for groups of 50+ enrolling with a minimum of 10 enrolled in one plan. Employer contribution percentage for employee and dependent coverage must be identical for both plans. For pregnant enrollees, Delta Dental will pay for the following additional services per calendar year: 1 additional oral evaluation and either 1 additional routine cleaning or 1 additional periodontal scaling and root planing per quadrant.written confirmation of the pregnancy must be provided by the enrollee or the dentist when the claim is submitted. Optional benefit available. Not available on the Voluntary PPO. Direct composite restorations are benefits on anterior teeth and the facial surface of bicuspids. Any other posterior direct composite restorations are optional & Delta s payment is limited to the cost of the equivalent amalgam restorations. PPO: Covered under Major services. HMO: Not covered. Delta Dental will pay the applicable percentage of the Dentist s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. A standard complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using accepted and conventional procedures and materials. Excluded: Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). Available for adult and child or child only DE-9C required. Minimum of 75% for employee & no minimum for dependents. Minimum 75% of eligible employees and 35 enrolled. Dual Option requires a minimum of 50 enrolled employees. Maximum of 50%. Employee class carve-outs are allowed and can consist of management/non-management, union/non-union and hourly/salaried employees. The following will apply: Delta Dental PPO can be offered to one population, DeltaCare USA can be offered to another (multiple PPOs not allowed). Carve-outs are not allowed with another carrier; union and non-union population must be through Delta. Level 2 rating applies to carve-out groups regardless of industry. Employer must provide DE-9C identifying the carve-out employees. Underwriting guideline apply to each of the carve-out groups. Allowed if all owners appear on the DE-9C. If owners are not on the DE-9C they are considered ineligible for coverage and do not count in calculating group size or participation. Also some ineligible industries. Yes for groups when the employee contribution towards dental benefits is being made on a pre-tax basis. Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 11 of 20

12 HEALTH NET HMO/PPO, HMO/PPO, or PPO/PPO combination available. HMO/PPO, HMO/PPO, or PPO/PPO combination available. HMO plans offer up to 2 additional cleanings per year at a copay. PPO plans offer pregnant woman additional cleanings and periodontal maintenance when medical necessary; not subject to deductible and does not apply to annual max. Posterior: Yes, however plans have a least expensive procedure alternate provision. Dental services are covered at the least costly, clinically accepted treatment. Coverage excludes replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been covered under the policy for 12 continuous months. DHMO: Ortho included on all plans. Classic PPO: included with 10+ enrolled. Included on groups of 2 9 only with prior indemnity Ortho coverage. If Voluntary, included only if 10+ enrolled regardless of prior ortho coverage Must have 2 enrolled. DE-9C required. Effective January 2016: eligible and enrolled, based on FTE count (full-time equivalents). DE-9C required. Minimum 50% for employee. Proof of prior group coverage is required for employer paid rates. DHMO: Minimum 50% and 2 enrolled. PPO: Minimum 75% and 2 enrolled. DHMO/PPO: Minimum 75% participation with a minimum of 4 enrolled; must have a minimum of 2 enrolled on each plan offered. DHMO/DHMO or PPO/PPO: Minimum 75% participation with a minimum of 10 enrolled; must have a minimum of 2 employees enrolled on each plan offered. Voluntary Plan Voluntary rates apply for any group where the employer contributes less than 50%. Voluntary Plan Voluntary rates apply for any group where the participation is less than 50% on DHMO or 75% on PPO, and all groups with no prior group coverage regardless of contribution & participation. HMO or PPO: Available with minimum of 2 enrolled. DHMO/PPO: Minimum 75% participation with a minimum of 4 enrolled; must have a minimum of 2 enrolled on each plan offered. DHMO/DHMO or PPO/PPO: Minimum 75% participation with a minimum of 10 enrolled; must have a minimum of 2 employees enrolled on each plan offered. Minimum 51% in California. Employer must be based in California. PPO plans offered to out-of-state employees. Not allowed. Must have at least one non-spouse, common law employee on the DE-9C. Dependent Eligibility Dependent children are eligible until age 26. Rev. Date 1/7/16 Page 12 of 20

13 MEDIEXCEL Single plan option only. Single plan option only. Available for medical necessity. N/A N/A Some services are available on a discounted basis. $30 copay per tooth. Adult/Child ortho available for all group sizes. N/A Voluntary Plan Voluntary Plan 1-2 enrollees: $15/mo 3 enrollees: $10/mo 4+ enrollees: no admin fee No minimum. 1 enrollee. No minimum. 1 enrollee. N/A. Employees must work within the service area to be eligible. Allowed. The carve-out classes must be IRS non-discriminatory and in compliance with ACA, and all eligible employees in the non-carve-out class are offered coverage. Not allowed. Allowed. Dependent Eligibility Up to age 26. Rev. Date 1/7/16 Page 13 of 20

14 Voluntary Plan Voluntary Plan METLIFE THROUGH COPOWER (SELECT) Employer sponsored option not available. Single plan or dual choice HMO/PPO combination. Included as standard for anterior and posterior. Riders are not available however cosmetic procedures can be included in specific plan designs. Included under Major services. Exclusions: Initial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. PPO: Child Ortho available. DHMO: Adult/Child Ortho available DE-9C not required. Groups with less than 10 employees, no more than 75% of the group can be direct family members. COBRA enrollees can t exceed 15% of the enrolled lives. Voluntary Dual Choice requires 25+ eligible employees. Employer sponsored option not available. Employer sponsored option not available. Employer contribution must be less than 50% of the employee premium. PPO: 35% and a minimum of 5 enrolled. DHMO: 30% and a minimum of 5 enrolled. Dual Choice: 35% and a minimum of 5 enrolled in each plan. CoPower SELECT MetLife Voluntary plan requirements do not count valid wavers towards participation PPO: 25% or less. PPO dental coverage is not available to groups with employees located in the extraterritorial states of Louisiana, Mississippi, Montana, & Texas DHMO: Not allowed. Allowed. Allowed if owners are not related and also appear on the DE-9C. Ineligible industries include , 8070, 8072, Dependent Eligibility Up to age 26. Rev. Date 1/7/16 Page 14 of 20

15 METLIFE 2 50 Single plan or DHMO/PPO. Annual maximum of $2,000 is available to groups with 10+ enrolled lives. Single plan or DHMO/PPO. Annual maximum of $2,000 is available to groups with 10+ enrolled lives. $5,000 available for groups with 30+ enrolled lives. Only available on the 100/80/50 plan option. Included as standard for anterior and posterior. Included under Major services. Exclusions: Initial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Child ortho available with a minimum of 5+ enrolled. Groups of 5-9 enrolled require proof of prior ortho coverage. Groups of 10+ enrolled require proof of prior major coverage. Employer Sponsored PPO plans: DHMO and Voluntary PPO plans: 5-50 Book Rated. DE-9C required for groups with more than 50% family members. Groups with less than 10 employees, no more than 75% of the group can be direct family members. COBRA enrollees can t exceed 15% of the enrolled lives. Must be in business at least 1 year prior to the effective date of the coverage. $15 monthly admin fee applies to groups of 2-9 enrolling. No admin fee for groups 10+. Voluntary Plan Voluntary Plan Minimum 50% of EE premium. DHMO: Minimum 30% and 5 enrolled. PPO 2 4 eligible: Minimum 100% and 2 enrolled. PPO 5 50 eligible: Minimum 50% and 3 enrolled. DHMO/PPO eligible: Minimum 50% and 5 enrolled in each plan. DHMO/PPO eligible: Minimum 50% and 5 enrolled in DHMO, 10 enrolled in PPO. Less than 50% of the employee premium. DHMO: Minimum 30% participation and 5 enrolled. PPO: Minimum 35% participation and 5 enrolled. DHMO/PPO eligible: Minimum 35% and 5 enrolled in DHMO, 10 enrolled in PPO. Rates are developed for all states excluding Florida. Contact MetLife if more than 25% of the EEs do not reside in the situs state. Allowed. Allowed. Retirees, part time, temporary, seasonal, leased and independent contractors (1099) are not eligible. Ineligible industries include 8021, 8072, 8811, All groups of 10 or more eligible lives include an annual open enrollment. Dependent Eligibility Up to age 26. Rev. Date 1/7/16 Page 15 of 20

16 Voluntary Plan Voluntary Plan METLIFE HMO/PPO, or PPO/PPO. HMO/PPO, or PPO/PPO. Up to $3,000 in increments of $50 available for groups of 10+. $5,000 available for groups of 51+. Must be quoted direct through MetLife. Included as standard for anterior and posterior. Riders are not available however cosmetic procedures can be included in specific plan designs. Included under Major services. Exclusions: Initial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Adult/Child Ortho available to groups of 5+ lives. Graduating Dental Benefits program available to groups of 10+. Must request custom quote; not included in book rated products. (excluding copay plans and full service dental for retirees) Members are rewarded for maintaining their dental coverage with an increasing maximum benefit each year for up to 3 years. The highest annual maximum level is capped at 3 years or $3,000. Participants and their dependents maintain the maximum benefit once it s reached for as long as they remain enrolled in the plan with no gap in coverage. If there is an interruption in MetLife dental overage, participants start at the beginning, with the lower benefit level, after re-enrolling in the employer s plan custom rated. DE-9C not required. Minimum 50% employee. Single option: 50% and a minimum of 10 enrolled. HMO/PPO: 65% and a minimum of 25 enrolled. PPO/PPO: 75% and a minimum of 25 enrolled. At least 25% of enrollment must be on the high plan. Between 0 49% of employee premium. Available with 35% participation. May go down to 25% participation if plan includes waiting periods. Requires at least 10 enrolled No limit. Allowed. Allowed. Dependent Eligibility Up to age 26. Ineligible industries include dental offices and dental labs. Included on all DHMO plans. Included on DPPO for groups of 100+ with at least 50% participation. Rev. Date 1/7/16 Page 16 of 20

17 PREMIER ACCESS Single plan, PPO/PPO or DHMO/PPO. Single plan, PPO/PPO or DHMO/PPO. Offered upon request. Offers $2,500. Offered upon request. Offered upon request. Offered if tooth was extracted within 12 months of becoming effective on a plan. Available to employer sponsored groups of 10+. Groups of 3-9 are eligible only if currently offered. Available to voluntary groups of 10+. Employer sponsored groups of 3-9 & Voluntary plans have 12 month wait for Major Services without similar prior coverage. DHMO qualifies as prior coverage for the Premier Plus plans and Voluntary Standard Plan 5 only. Employer sponsored groups of without similar prior coverage will have Major Services paid at 25% for first 12 months; waived with proof of similar prior coverage. Employer sponsored: Voluntary: DE-9C required for groups Voluntary Plan Voluntary Plan Dependent Eligibility Voluntary 5-9: $15 monthly fee. DHMO or PPO 3 9 enrolled: 100% of employee premium. DHMO or PPO enrolled: 75% of employee premium. PPO/PPO or DHMO/PPO: 75% of employee premium on the PPO low option (PPO/PPO) or DHMO (DHMO/PPO). PPO or DHMO: 75% of eligible with a minimum of 3 enrolled. PPO/PPO or DHMO/PPO: 75% of eligible with a minimum of 10 enrolled. A minimum of 5 must enroll in the PPO high option and 2 must enroll in the low option (PPO low or DHMO). All plans, If contribution is 100% then participation must be 90%. Must be less than 75% of employee premium. PPO/PPO or DHMO/PPO: Must be less than 75% of EE premium on the PPO low (PPO/PPO) or DHMO (DHMO/PPO). DHMO: Greater of 20% or 5 enrolled. DPPO: Greater of 20% or 10 enrolled. PPO/PPO: 20% of eligible with a minimum of 10 enrolled. A minimum of 5 must enroll in the PPO high option and 2 must enroll in the low option (PPO low or DHMO). DHMO/PPO: 40% of eligible with a minimum of 25 enrolled. A minimum of 5 must enroll in the PPO high option and 2 must enroll in the low option (PPO low or DHMO). Less than 25% with book rates. Management or Union allowed. Minimum of 3 enrolled on selected plans, or 5 enrolled on Custom Plans. Allowed. No. Some ineligible industries. No. Up to age 26 if full-time student or fully dependent per IRS standards; proof required. May also cover up to age 26 regardless of verification with % rate load. Rev. Date 1/7/16 Page 17 of 20

18 Voluntary Plan PRINCIPAL PPO/EPO available with 10+ enrolled employees. DHMO option available through CDN. Available. Up to a $3,000 Calendar Year Max. Offered as a rider up to 4 per year. Up to $3,000 or up to $5,000 with ortho. Preventive Passport rider available. Applies to preventive services. Offered as a rider. Offered as a rider. Offered as a rider using quoted max or as a rider with a separate max. Benefits for the initial placement of bridges, partials and dentures are not covered if those teeth were missing prior to becoming insured under the Principal Life policy. The Replacement of Prior Plan Provision, also referred to as a No Loss of Coverage provision, applies to takeover or transfer business from one carrier to another. It assures the initially covered persons and their dependents won t be deprived of coverage due to a change in carriers. However, the provision doesn t guarantee coverage levels will be the same. It applies to only those persons and their dependents who were covered under the prior benefits on the date of its termination and who are eligible and enrolled under our benefits on its date of issue. It waives the missing tooth provision (provided that missing tooth was extracted while the covered person was insured under the prior plan). Child Ortho available for 5+ lives. Adult Ortho available for 25+ lives. Not available for Voluntary DE-9C not required. Must be in business one year to qualify for Dental. Other timeframes available with rate load. Minimum 50% of employee premium. Non-contributory: 100% of employees and 50% of eligible dependents. Contributory: 75% of employees and 50% of eligible dependents. No contribution required for Voluntary. Voluntary Plan 20% or 5 enrolling, whichever is greater, and 50% of dependents. Allowed. Employers can also request to exclude dependents under age 19. Allowed. Yes (Already built into rates). Annual enrollment included. Employees who waive and return will have deferred coverage, those not previously enrolled will have full coverage. Dependent Eligibility Dependent children are eligible for dental coverage up to age 26 and ortho coverage up through age 18. Rev. Date 1/7/16 Page 18 of 20

19 RELIANCE STANDARD Single plan option only. Single plan option only. Note: Posterior composites are not covered and the plan does not consider white composites (fillings) on back teeth as an eligible expense Limited prior extraction coverage provides for a procedure to replace teeth extracted while insured under a prior plan, applies to initial insureds only. A 12-month maximum time period between extraction (while insured under prior plan) and replacement (while insured under our plan). Adult and child orthodontia included on Plan B. not available on Plan A or Plan C. Voluntary Plan Voluntary Plan MaxRewards included on all plans. To qualify for rewards, member must submit at least 1 claim per year for a covered procedure and total paid claims must be under the plans annual threshold limit. A bonus is earned for utilizing PPO providers. Earned rewards are added to the next years calendar year maximum benefit and have a maximum accumulation amount based on the plan benefit. 12-months for Major. Waived with proof of 12 consecutive months similar prior group coverage with no lapse in coverage. Plan B Groups of 2-9: 24-months for orthodontic services. This cannot be waived. Groups 10-19: 12-months for orthodontic services. Waived on takeover plans. SmartChoice DE-9C not required but may be requested. Must be in business one year to qualify for Dental. Yes for groups of Groups with 2 enrolled must also enroll in two additional lines of coverage. 24 month option available. $5/month for electronic billing, or $12/month for paper billing. (Groups enrolling in dental must elect paper billing) Employer may contribute from 0-100% of the premium. 2 eligible employees: 100% of eligible. 3-5 eligible employees: All but one must enroll. 6-9 eligible employees: All but two must enroll eligible employees: 75% must enroll. Part-time EEs working hours/week may be included if less than 25% of total eligible. requirements apply to eligible dependents as well. If employer contributes 100% then 100% participation is required. Plan C Only: Employers may add the Reduced Option which allows for 50% participation with a minimum of 5 lives insured. All plans may be 100% employee paid, full participation requirements must still be met. All plans may be 100% employee paid, full participation requirements must still be met. No limit. Dependent Eligibility Allowed with 2 or more eligible employees within a class. 20% rate load applies. Allowed. 20% load on the following industries: Beauty Shops, Funeral Services, Jewelry Business, Automotive Dealers, Direct Selling Establishments, Security & Commodity Brokers/Dealers, Real Estate Agents/Developers, Educational Services. Ineligible groups: Dental offices, association groups, trusts, membership organizations, fraternal organizations, unions where benefits and rates are subject to labor mgmt negoations, voluntary arrangements (e.g., cafeteria plans, section 125 plans) Up to age 19 if unmarried and not working for the company or up to age 24 if unmarried and a full-time student. Rev. Date 1/7/16 Page 19 of 20

20 ELIGIBLITY Voluntary Plan Voluntary Plan UNITEDHEALTHCARE Single plan, HMO/HMO, HMO/PPO, PPO/PPO. Single plan, HMO/HMO, HMO/PPO, PPO/PPO. FlexAppeal Enhanced rider available on certain PPO plans. This benefit allows for any combination of 4 cleanings or periodontal maintenance treatments in a 12-month period. $3,500 annual max (in network only) available for groups of 10+. FlexAppeal Preventive MaxMultiplier rider available on certain PPO plans to groups with 10+ eligible. FlexAppeal Enhanced rider available on certain PPO plans. Available to large group (100+) only. FlexAppeal Enhanced rider available on certain PPO plans. No missing teeth clause. Child only or Adult/Child Ortho available for groups with a minimum of 10 eligible and 8 enrolled. Consumer MaxMultiplier available to groups of 2+. To be eligible a member must use their dental benefits at least once per year. If the total of all claims paid for the member is less than the established threshold amount then the member receives an award that is added to the next years annual maximum. Members can earn an additional $100 award if all services and claims during the year are from in-network providers. There is an accumulation limit for the Consumer MaxMultiplier account that will be based on the value of the plans original annual maximum. Voluntary plans 2 9 eligible: 12 month for Major, waived with prior coverage DE-9C required. Minimum 50% of employee premium. HMO: Minimum 75% of employees. PPO: Minimum 75% of employees and 51% including valid waivers. HMO/HMO: Minimum 5 eligible and 3 enrolled; plans must be high/low combinations. HMO/PPO: Min 5 eligible and 3 enrolled. PPO/PPO: Minimum 10+ enrolled; plans must differ by more than ortho coverage. No minimum. Minimum of 2 enrolled for single plan. Dual PPO requires 10+ enrolled. Dual HMO/HMO or HMO/PPO requires 5+ enrolled. No limit. Plans/rates available based the state with 51% of the employees. Available with 5+ eligible and enrolling employees. Eligible class descriptions include: Salary/Hourly, Union/Non-Union and Management/Non-Management Employees No more than 25% of the enrolled groups can be 1099 employees. Not allowed. Must have at least one non-spouse, common law employee on the DE-9C. Dependent Eligibility Dependent children are eligible until age 26. All information published herein is gathered from sources which are thought to be reliable, but the reader should not assume that the information is official or final. Reliance on this information received from LISI shall be at your sole risk, and LISI assumes no responsibility for any errors, omissions, or damages arising. Users of this information are encouraged to confirm with other sources, and to seek qualified advice if embarking on any actions that could carry personal or organizational liabilities. Rev. Date 1/7/16 Page 20 of 20