Georgia Dental Insurance Services, Inc. Open Enrollment Package

Georgia Dental Insurance Services, Inc. Open Enrollment Package 2015

Table of Contents 5 Welcome Letter 6 What s New 7 Vision Plan 9 Getting Started 10 POS Low Plan and Rates 11 POS 2000 Plan and Rates 12 POS 1500 Plan and Rates 13 POS 6600 Plan and Rates 14 POS HDHP 3000 Plan and Rates 15 POS 1000 Plan and Rates 16 Required Annual Notices 18 Select Drug List 26 2015 Open Enrollment Form 27 Please Note 2015 GDA Health Plan Renewal 3

November 17, 2014 Dear Plan Participant: Selecting a health insurance plan can be daunting, but the GDA has made the process simple. Working on behalf of our members, we researched hundreds of plans and negotiated competitive rates to bring you all new plans in 2015 that meet a variety of lifestyle and budgetary needs. If after reviewing the enclosed plans you don t find one that meets your individual needs, give us a call and we ll help find one that does. New for 2015: All new health plans to meet the diverse health care needs of our members Lower cost plans available Added vision benefit Individual plans now offered in addition to group plans To renew your health insurance coverage for 2015, please complete the open enrollment form immediately. All forms are due by December 10, 2014. Benefits are effective January 1, 2015. Please note that completing an open enrollment form or waiver is required for every person in the office. This is mandatory for all employees within the practice whether they participate in our plan or are enrolled in another plan. This enrollment packet includes an overview of benefits and programs. Plan summaries will be posted on the website www.mygdis.com. Please note that Georgia Dental Insurance Services (GDIS) is the plan administrator for the GDA health and welfare plan. If you have questions about your coverage or any of the benefit plans or need assistance with an individual plan, please call GDIS and ask for Victoria LeMaire or Skip Jones at 404-636-7553. Sincerely, John H. Ferguson, DDS Chairman Frank J. Capaldo Executive Director 2015 GDA Health Plan Renewal 5

What s new for 2015? Thank you for your patronage Patronage Dividend. As part of your participation in the GDA health and welfare plan, you will receive a one-time patronage dividend. You will notice a reduction in your total premium on your February 2015 statement. All plans are Open Access POS Point of Service (POS). This type of health plan covers services from a network of doctors and hospitals in your area. You can choose your own doctors as long as they are in the POS network. If you pay a little more you can also get care outside of the POS network. Some POS plans may have different rules, so be sure to check your plan details. Announcing a vision benefit Vision Coverage. With Blue View Vision SM, you have access to a network of over 30,000 doctors and more than 25,000 locations across the country, including convenient retail stores like Lens- Crafters, Sears Optical SM, Target Optical, JCPenney Optical and most Pearle Vision stores. The new vision coverage includes a routine eye exam, frames and either eyeglass lenses or contact lenses. (Vision plan details are located on the next two pages.) Kids can get Transitions lenses to protect their eyes from harmful UV rays and polycarbonate lenses to help protect them from damage at no additional cost. 6 2015 GDA Health Plan Renewal

WELCOME TO BLUE VIEW VISION! Good news your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what s covered, your discounts, and much more! Georgia Dental Association January 1, 2015 Blue View Vision SM Your Blue View Vision network Anthem Blue Cross vision members have access to one of the nation s largest vision networks. Blue View Vision is the only vision plan that gives members the ability to use their in-network benefits at 1-800 CONTACTS, or choose a private practice eye doctor, or go in store to LensCrafters, Sears Optical SM, Target Optical, JCPenney Optical and most Pearle Vision locations. Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply. YOUR BLUE VIEW VISION PLAN AT-A-GLANCE VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK Routine eye exam once every calendar year $10 copay, then covered in full $48 allowance Eyeglass frames Once every calendar year you may select an eyeglass frame and receive an allowance toward the purchase price Eyeglass lenses (Standard) Once every calendar year you may receive any one of the following lens options: Standard plastic single vision lenses (1 pair) Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair) Eyeglass lens enhancements When obtaining covered eyewear from a Blue View Vision provider, you may add any of the following lens enhancements at no extra cost. Lenses (for a child under age 19) Standard Polycarbonate (for a child under age 19) Factory Scratch Coating $130 allowance, then 20% off any remaining balance $20 copay, then covered in full $20 copay, then covered in full $20 copay, then covered in full $0 after eyeglass lens copay $0 after eyeglass lens copay $0 after eyeglass lens copay $64 allowance $36 allowance $54 allowance $69 allowance No allowance on lens enhancements when obtained out-of-network Contact lenses once every calendar year Prefer contact lenses over glasses? You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses. Elective Conventional Lenses; or Elective Disposable Lenses; or Non-Elective Contact Lenses Your contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit period. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit period, nor can any unused amount be carried over to the following benefit period. $130 allowance, then 15% off any remaining balance $130 allowance (no additional discount) Covered in full $105 allowance $105 allowance $210 allowance EXCLUSIONS & LIMITATIONS (not a complete list) Combined Offers. Not combined with any offer, coupon, or in-store advertisement. Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing. In-network Member Cost (after any applicable copay) 2015 GDA Health Plan Renewal 7

EXCLUSIONS & LIMITATIONS (not a complete list) Combined Offers. Not combined with any offer, coupon, or in-store advertisement. Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing. In-network Member Cost (after any applicable copay) Retinal Imaging At member s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades lenses (Adults) $75 When obtaining eyewear from a Blue View Vision Standard Polycarbonate (Adults) $40 provider, members may choose to upgrade their Tint (Solid and Gradient) $15 new eyeglass lenses at a discounted cost. UV Coating $15 Eyeglass lens copayment applies. Progressive Lenses Standard $65 Premium Tier 1 $85 Premium Tier 2 $95 Premium Tier 3 Anti-Reflective Coating $110 Standard $45 Premium Tier 1 $57 Premium Tier 2 $68 Other Add-ons and Services 20% off retail price Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider Complete Pair Eyeglass materials purchased separately Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. Contact lens fit and follow-up Available following a comprehensive eye exam Standard contact lens fitting Premium contact lens fitting 40% off retail price 20% off retail price 20% off retail price Up to $55 10% off retail price Conventional Contact Lenses Discount applies to materials only 15% off retail price ADDITIONAL SAVINGS AVAILBLE THROUGH OUR SPECIAL OFFERS PROGRAM Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, * and much more. 1 Please ask your provider for his/her recommendation as well as the progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the coating brands by tier. 3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal. OUT-OF-NETWORK If you choose an out-of-network provider, please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service. To Fax: 866-293-7373 To Email: oonclaims@eyewearspecialoffers.com To Mail: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111 Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit bcbsga.com or call us at 1-866-723-0515. This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member s policy, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the member s policy. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package. Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is influenced by temperature, UV exposure and lens material. Blue Cross and Blue Shield of Georgia, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 7/12 8 2015 GDA Health Plan Renewal Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is influenced by temperature, UV exposure and lens material. Blue Cross and Blue Shield of Georgia, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 7/12

Deductible Getting started with health insurance Let's start with how health insurance works in general Getting Getting started started with with health health insurance insurance Let s start with how health insurance works in general Let's start with how health insurance works in general Out-of-pocket limit Deductible Out-of-pocket limit What you pay What we pay What you pay What we pay 1. You pay your deductible. This is a set amount that you pay before your plan starts paying for 1. covered You pay services. your deductible. This is a set amount that you pay before your plan starts paying for covered services. 1. 2. You After pay you your meet deductible. your deductible, This is a set you amount and your that plan you share pay the before cost your of covered plan starts services. paying You for pay coinsurance 2. covered (a After percentage you services. meet of the your cost) deductible, each time you you get and care. your Your plan insurance share covers the cost the of rest. covered services. You pay coinsurance (a percentage of the cost) each time you get care. Your insurance covers the rest. 2. 3. After You re you protected meet your by deductible, your plan s out of you and pocket your plan limit. share That s the the cost most of you covered pay for services. covered You health pay coinsurance services 3. (a You re percentage protected of the cost) by your each plan s time you out-of-pocket get care. Your limit. insurance That s covers the most the rest. you pay for covered health each year. With some plans, you still have copays even after you reach your out of pocket limit. services each year. With some plans, you still have copays even after you reach your out-of-pocket limit. 3. You re protected by your plan s out of pocket limit. That s the most you pay for covered health services each Remember, year. Remember, With some this this chart plans, chart is only you is only an still an example. have example. copays Your Your actual even actual after costs costs you will will reach depend your on on the out of pocket type of plan limit. you you choose, choose, the the service you get and the the doctor. To To see see your your actual actual costs, costs, please please refer refer to your to your plan plan information. information. Remember, this chart is only an example. Your actual costs will depend on the type of plan you choose, the Now, let s service get you get started! and the doctor. To see your actual costs, please refer to your plan information. Choose a health plan that works for you Choose a health plan that works for you Now, let s get started! You have six plan options to choose from. All plans give access to the BCBS large statewide network, Choose You have a health six plan plan options that to works choose for from. you All plans give access to the BCBS large statewide network, cover preventive care services 100% in the network, and gives you the financial protection and health cover preventive care services 100% in the network, and give you the financial protection and health care support you desire. You care have support six plan you desire. options to choose from. All plans give access to the BCBS large statewide network, cover preventive care services 100% in the network, and gives you the financial protection and health care Step support 1 Choose a you desire. the plan plan that that works works for you. for you. (Remember, if you if you have have questions questions, call (404) call 404-636-7553) 636 7553) Step 1 Choose a plan that works for you. Step 2 2 Complete an open enrollment form, and fax to the (404) form 634 6099. to 404-634-6099. (Remember, if you have questions call (404) 636 7553) (Online (Print open enrollment forms available from at www.mygdis.com) Step 2 Complete an open enrollment form, and fax to (404) 634 6099. (Online open enrollment form available at www.mygdis.com) Call Us GDIS Call our dedicated insurance customer care team at (404) 636 7553 if you need any assistance with Call choosing the GDIS a plan. dedicated insurance customer care team at 404-636-7553 if you need any assistance with choosing Call a plan. Us Call our dedicated insurance customer care team at (404) 636 7553 if you need any assistance with choosing a plan. 2015 GDA Health Plan Renewal 9

2015 GDA Health Plan and Rates Plan Name: POS Low *Open Access Network Rates Deductible Employee $737.52 Employee + Spouse $1,696.31 You $500 $1,000 Employee + Child(ren) $1,570.93 You + Spouse $1,000 $2,000 Family $2,529.71 You + Child(ren) $1,000 $2,000 You + Family $1,000 $2,000 Office Visit Plan Highlights Plan Highlights Primary $30 per visit Office calls require a $30 co payment. Innetwork hospital stays; outpatient visits, Specialist $30 per visit surgery and other major services from in Deductible applies until met, then pays at 60% network providers are subject to a $500 Co Insurance calendar year deductible (max of 2 per family) and are paid at 80% co insurance. 80% of covered charges For each hospital confinement, a $200 co 60% of covered charges pay is required. You may go to any provider Inpatient Services in the BCBS Open Access POS (OAPOS) network. $200 co payment; deductible applies until met, then pays at 80% $200 co payment; py deductible applies until met, then py pays at 60% Treatment from an non network provider Outpatient Services is subject to a $1,000 calendar year deductible (max 2 per family) and 60% co Deductible applies until met, then pays at 80% payment. Once you pay your deductible(s) Deductible applies until met, then pays at 60% and reach $3,000 (max of 2 per family) in Emergency Room $100 co payment coveredeligible eligible expenses, the plan pays Prescription Card Blue Choice Formulary any remaining covered eligible expenses at 100%. Annual Deductible $200 per person Tier 1 $15 co payment Emergency room treatment requires a $100 Tier 2 $45 co payment after $200 met Tier 3 $60 co payment after $200 met Tier 4 20% co payment up to $200 maximum Out of Pocket hout a referral. You $1,500 $3,000 You + Spouse $3,000 $6,000 reimburses the Plan Administrator for You + Child(ren) $3,000 $6,000 ntributions include a 3% administrative f legal counsel, accountants and other You + Family $3,000 $6,000 e 3% administrative fee and direct * Open Access means no referrals from a primary care physician. You can go direct to any specialist with f direct expenses actually incurred * Open Access means no referrals from a primary care physician. You can go direct to any specialist without a referral. The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc.. The Plan r its direct expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer Con fee to cover such expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees of specialists, plan communication and recordkeeping costs, plan audit fees, claims review, and vendor searches. The expenses are reconciled annually by an independent auditor and any excess portion of the fee above the amount of during each plan year is retained by the Plan. 10 2015 GDA Health Plan Renewal

2015 GDA Health Plan and Rates Plan Name: POS 2000 *Open Access Network In Network Non Network Deductible You $2,000 $4,000 You + Spouse $4,000 $8,000 You + Child(ren) $4,000 $8,000 You + Family $4,000 $8,000 Office Visit Primary $30 per visit Specialist $50 per visit Deductible applies until met, then pays at 60% Co Insurance Inpatient Services Outpatient Services Emergency Room Prescription Card *Select Rx Formulary Annual Deductible Tier 1 Tier 2 Tier 3 Tier 4 Out of Pocket 80% of covered charges 60% of covered charges Deductible applies until met, then pays at 80% Deductible applies until met, then pays py at 60% Deductible applies until met, then pays at 80% Deductible applies until met, then pays at 60% $250 co payment $250 per person $10 co payment $45 co payment after $250 met $60 co payment after $250 met 20% co payment up to $250 maximum. Rates Employee $565.54 Employee + Spouse $1,300.75 Employee + Child(ren) $1,205.17 Family $1,940.37 Plan Highlights This plans offers a $30 co pay when visiting a network primary care doctor. The In network hospital stay, outpatient visits, surgery and other major services from in network providers are subject to the $2,000 calendar year deductible (max 2 per family) and are payable at 80% co insurance. You may go to any provider in the BCBS Open Access POS (OAPOS) network. Treatment from an non network provider is subject to a $4,000 calendar year deductible (max 2 per family) and 60% co insurance. Once you pay your deductible(s) and reach $8,000 (max 2 per family) in covered eligible expenses, the plan pays any remaining covered eligible expenses at 100%. Emergency room treatment requires a $250 co payment. st without a referral. consult with their doctor to ensure he open enrollment packet. You $4,000 $8,000 l b h l d f You + Spouse $8,000 $16,000 You + Child(ren) $8,000 $16,000 You + Family $8,000 $16,000 * Open Access means no referrals from a primary care physician. You can go direct to any specialis * Open Access means no referrals from a primary care physician. You can go direct to any specialist without a referral. e Plan reimburses the Plan Administrator for its r Contributions include a 3% administrative fee s of legal counsel, accountants and other es. The 3% administrative fee and direct ount of direct expenses actually incurred during * While the the Select Select RX drug RX drug list is limited, list is limited, it contains it medications contains for medications every therapeutic for every class. Insureds therapeutic should class. c Insureds should consult with their that they doctor prescribe to ensure a medication that that they is on prescribe the Select a RX medication formulary. Select that drug is on list the is located Select in the RX back formulary. of th Select drug list is located in the back of the open enrollment packet. h The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc.. The direct expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer to cover such expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees specialists, plan communication and recordkeeping costs, plan audit fees, claims review, and vendor searche expenses are reconciled annually by an independent auditor and any excess portion of the fee above the amo each plan year is retained by the Plan. 2015 GDA Health Plan Renewal 11

2015 GDA Health Plan and Rates Plan Name: POS 1500 *Open Access Network In Network Non Network Deductible You $1,500 $3,000 You + Spouse $3,000 $6,000 You + Child(ren) $3,000 $6,000 You + Family $3,000 $6,000 Office Visit Primary $40 per visit Specialist $50 per visit Deductible applies until met, then pays at 50% Co Insurance Plan Highlights Plan Highlights This plan offers a $40 co pay when visiting a network primary care doctor. The In network hospital stay, outpatient visits, surgery and other major services from in network providers are subject to the $1500 calendar year deductible (max 2 per family) and are payable py at 70% co insurance. 70% of covered charges Inpatient hospital visits require a $250 co pay 50% of covered charges before the deductible and co insurance. You may go to any provider in the BCBS Open Inpatient Services Access POS (OAPOS) network. $250 co payment; deductible applies until met then pays 70% Treatment Deductible applies until met, then pays py at 50% from an non network provider is subject to a $3,000 calendar year deductible Outpatient Services (max 2 per family) and 50% co insurance. Deductible applies until met, then pays at 70% Once youpay your deductible(s) and reach $6,600 (max 2 per family) in covered eligible Deductible applies until met, then pays at 50% expenses, the plan pays any remaining Emergency Room $250 co payment covered eligible expenses at 100%. Prescription Card *Select Rx Formulary Emergency room treatment requires a $250 Annual Deductible $250 per person Tier 1 $10 co payment Tier 2 $45 co payment after $250 met without a referral. Tier 3 $80 co payment after $250 met Tier 4 20% co payment up to $250 maximum. nsult with their doctor to ensure that Out of Pocket n enrollment packet. You $6,600 $6,600 Plan reimburses the Plan Administrator for its You + Spouse $13,200 $13,200 ontributions include a 3% administrative fee to egal counsel, accountants and other specialists, You + Child(ren) $13,200 $13,200 ministrative fee and direct expenses are reconciled You + Family $13,200 $13,200 tually incurred during each plan year is retained by * Open Access means no referrals from a primary care physician. You can go direct to any specialist w * Open Access means no referrals from a primary care physician. You can go direct to any specialist without a referral. * While the the Select Select RX drug RX drug list is limited, list is limited, it contains it medications contains medications for every therapeutic for every class. Insureds therapeutic should class. con Insureds should consult with they prescribe a medication is on the Select RX formulary. Select drug list is located in the back of the open their doctor to ensure that they prescribe a medication that is on the Select RX formulary. Select drug list is located in the back of the open enrollment packet. The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc.. The P direct expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer Co cover such expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees of le plan communication and recordkeeping costs, plan audit fees, claims review, and vendor searches. The 3% adm annually by an independent auditor and any excess portion of the fee above the amount of direct expenses act the Plan. Rates Employee $510.89 Employee + Spouse $1,175.05 Employee + Child(ren) $1,088.71 Family $1,752.86 12 2015 GDA Health Plan Renewal

2015 GDA Health Plan and Rates Plan Name: POS 6600 Open Access Network In Network Non Network Deductible You $6,600 $10,000 You + Spouse $13,200 $20,000000 You + Child(ren) $13,200 $20,000 You + Family $13,200 $20,000 Office Visit Primary 100% after deductible is met Specialist 100% after deductible is met Deductible applies until met, then pays at 60% Co Insurance Inpatient Services Outpatient Services Emergency Room Prescription Card *Select Rx Formulary Annual Deductible Tier 1 Tier 2 Tier 3 Tier 4 Out of Pocket 100% of covered charges 60% of covered charges 100% after deductible is met Deductible applies until met, then pays at 60% 100% after deductible is met Deductible applies until met, then pays at 60% $250 co payment $250 per person $10 co payment py $45 co payment after $250 met $80 co payment after $250 met 20% co payment up to $250 maximum. You $6,600 $20,000 You + Spouse $13,200 $40,000 You + Child(ren) $13,200 $40,000 000 You + Family $13,200 $40,000 Rates Employee $431.85 Employee + Spouse $993.26 Employee + Child(ren) $920.2727 Family $1,481.69 Plan Highlights This plan has a $6,600 calendar year deductible (max of 2 per family) applicable to all covered eligible expenses. You may go to any provider in the BCBS Open Access POS (OAPOS) network. After the calendar year deductible(s) is satisfied, the plan either pays 100% in networknetwork or 60% non network of covered eligible expenses depending upon whether your provider is a member of the BCBSGA Open Access POS Network of providers. Emergency room treatment requires a $250 copayment. st without a referral. consult with their doctor to ensure that en enrollment packet. e Plan reimburses the Plan Administrator for its r Contributions include a 3% administrative fee to f legal counsel, accountants and other specialists, administrative fee and direct expenses are expenses actually incurred during each plan year is * Open Access means no referrals from a primary care physician. You can go direct to any specialis * Open Access means no referrals from a primary care physician. You can go direct to any specialist without a referral. * While the Select RX RX drug drug list is list limited, is limited, it contains it contains medications medications for every therapeutic for every class. therapeutic Insureds should class. c Insureds should consult with their they prescribe doctor to a medication ensure that they is on the prescribe Select RX a formulary. medication Select that drug is list on is the located Select in the RX back formulary. of the op Select drug list is located in the back of the open enrollment packet. The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc.. The direct expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer cover such expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees of plan communication and recordkeeping costs, plan audit fees, claims review, and vendor searches. The 3% a reconciled annually by an independent auditor and any excess portion of the fee above the amount of direct retained by the Plan. 2015 GDA Health Plan Renewal 13

2015 GDA Health Plan and Rates Plan Name: POS HDHP 3000 *Open Access Network In Network Non Network Deductible You $3,000 $3,000 You + Spouse $6,000 $6,000 You + Child(ren) $6,000 $6,000 You + Family $6,000 $6,000 Office Visit Primary Specialist Co Insurance Inpatient Services Outpatient Services Emergency Room Prescription Card *Select Rx Formulary Annual Deductible Tier 1 Tier 2 Tier 3 Tier 4 Deductible applies until met, then pays at 100% Deductible applies until met, then pays at 100% Deductible applies until met, then pays at 70% 100% covered charges 70% covered charges Deductible applies until met, then pays at 100% Deductible applies until met, then pays at 70% Deductible applies until met, then pays at 100% Deductible applies until met, then pays at 70% Deductible applies until met, then pays at 100% Deductible applies until met, then co payment $10 co payment applies after deductible is met $45 co payment applies after deductible is met $80 co payment applies after deductible is met 20% co payment (up to $250 maximum) applies after Out of Pocket You $4,000 $8,000 You + Spouse $8,000 $16,000 You + Child(ren) $8,000 $16,000 You + Family $8,000 $16,000 * Open Access means no referrals from a primary care physician. You can go direct to any specialist * Open Access means no referrals from a primary care physician. You can go direct to any specialist el, accountants and without other specialists, a referral. plan While the Select RX drug list is limited, it contains medications for every therapeutic class. Insureds should co curred during each plan year is retained by the Plan. * While the Select RX drug list is limited, it contains medications for every therapeutic class. Insureds should consult with prescribe a medication that is on the Select RX formulary. Select drug list is located in the back of the open enr their doctor to ensure that they prescribe a medication that is on the Select RX formulary. Select drug list is located in the back GDA, of GDIS, the BCBS open and enrollment your employer packet. are not responsible for funding of the account. It is your resp GDA, GDIS, BCBS and your employer are not responsible for funding the account. It is your responsibility for all tax recordkeeping. The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc.. The P expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer Contrib expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees of legal counse communication and recordkeeping costs, plan audit fees, claims review, and vendor searches. The 3% admini by an independent auditor and any excess portion of the fee above the amount of direct expenses actually inc Rates Employee $520.30 Employee + Spouse $1,196.71 Employee + Child(ren) $1,108.77 Family $1,785.18 Plan Highlights Plan Highlights This High Deductible Health Plan is a Blue Choice open access plan and a qualified HSA plan. In network office visits, hospital stays, outpatient visits, surgery and other major services are subject to a $3,000 000individual calendar yeardeductible ($6,000 family) and are payable at 100% for in network covered eligible services. For family coverage, the full $6,000 family deductible must be met before expenses are payable at 100%. In network out of pocket maximums are $4000/$8000, which includes deductibles and pharmacy copays. Treatment from non network providers will be covered at 70% co insurance after meeting the deductibles. Once the annual out of pocket maximum of $8,000 individual/$16,000 family has been met, the plan pays 100% of remaining covered eligible expenses. All prescription drug expenses apply toward the deductible beforethe drug co payment. After the deductible has been met, all in network drug expenses are paid according to the normal prevailing Rx plan as outlined below in the Additional Benefits section. This plan allows you to setup a custodial bank account in a qualified Health Savings Account bank. t without a referral. onsult with their doctor to ensure that they rollment packet. ponsibility for all tax recordkeeping Plan reimburses the Plan Administrator for its direct butions include a 3% administrative fee to cover such istrative fee and direct expenses are reconciled annually 14 2015 GDA Health Plan Renewal

2015 GDA Health Plan and Rates Plan Name: POS 1000 *Open Access Network In Network Non Network Deductible You $1,000 $2,000 You + Spouse $2,000 $4,000 You + Child(ren) $2,000 $4,000 You + Family $2,000 $4,000 Office Visit Primary $40 per visit Specialist $50 per visit Deductible applies until met, then py pays at 50% Co Insurance Inpatient Services Outpatient ti t Services Emergency Room Prescription Card Blue Choice Formulary Annual Deductible Tier 1 Tier 2 Tier 3 Tier 4 Out of Pocket 70% of covered charges 50% of covered charges $250 co payment; deductible applies until met, then pays 70% Deductible applies until met, then pays at 50% Deductible applies until met, then pays at 70% Deductible applies until met, then pays at 50% $250 co payment $250 per person $10 co payment py $45 co payment after $250 met $80 co payment after $250 met 20% co payment up to $250 maximum. You $6,600 $6,600 You + Spouse $13,200 $13,200 You + Child(ren) $13,200 $13,200 You + Family $13,200 $13,200 Rates Employee $537.77 Employee + Spouse $1,236.88 Employee + Child(ren) $1,145.99145 Family $1,845.10 Plan Highlights Plan Highlights This plan offers a $40 co payment when visiting a in network primary care doctor. The in network network hospital stay, outpatient visits, surgery and other major services from in network providers are subject to the $1,000 calendar year deductible (max 2 per family) and are payable at 70% co insurance. Inpatient hospital visits require a $250 co pay before the deductible and co insurance. You may go to any provider in the BCBS Open Access POS (OAPOS) network. Treatment from an non network provider is subject to a $2,000 calendar year deductible (max 2 per family) and 50% co insurance for all inpatient and outpatient services. Once you pay your deductible(s) d and reach $6,600 600 (max 2 per family) in covered eligible expenses, the plan pays any remaining covered eligible expenses at 100%. Emergency room treatment requires a $250 co payment. without a referral. an reimburses the Plan Administrator for its direct tions include a 3% administrative fee to cover unsel, accountants and other specialists, plan trative fee and direct expenses are reconciled ually incurred during each plan year is retained by * Open Access means no referrals from a primary care physician. You can go direct to any specialist w * Open Access means no referrals from a primary care physician. You can go direct to any specialist without a referral. The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc.. The Pla expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer Contribut such expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees of legal cou communication and recordkeeping costs, plan audit fees, claims review, and vendor searches. The 3% administ annually by an independent auditor and any excess portion of the fee above the amount of direct expenses actu the Plan. 2015 GDA Health Plan Renewal 15

Required annual notices Women s Health and Cancer Rights Act of 1998 In keeping with the Women s Health and Cancer Rights Act of 1998, a federal law, we would like to remind you of your rights regarding benefits for mastectomy-related services. Your contract includes benefits for certain services or supplies that relate to reconstructive surgery in connection with a mastectomy. (Mastectomy is surgical removal of a breast.) The covered service and supplies are listed here. Reconstruction of the breast on which the mastectomy was performed. Surgery and rebuilding of the other breast for a symmetrical appearance. Prostheses and physical complications at all stages of mastectomy. This includes services related to treating swollen lymph glands. These benefits are subject to annual deductibles and coinsurance that apply to your contract. Please review your Contract of Group Service Agreement for more details about these benefits and your coverage in general. Statement of Rights under the Newborns and Mothers Health Protection Act Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child less than 48 hours following vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay in excess of 48 hours (or 96 hours). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Georgia Dental Association has taken the appropriate steps to bring its health plans into compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule as of April 14, 2004. The Company is committed to protecting the medical and other personal health information of its enrollees. Georgia Dental Association will not create or receive protected health information as defined in the HIPAA Privacy Rule except for summary health information and enrollment information. 16 2015 GDA Health Plan Renewal

In addition, Georgia Dental Association will not retaliate if an enrollee feels that their rights have been violated under the HIPAA Privacy Rule. No enrollee will be required to waive the privacy rights granted to them under HIPAA. The Company s insurance carriers provide enrollees with a Notice of Privacy Practices as required under the HIPAA Privacy Rule. The Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) If you decline enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may be able to enroll yourself and your dependents in a benefit plan offered by your employer in the future. You have special enrollment rights if you or your dependent becomes eligible for the optional state premium assistance program if available in your state. Paul Wellstone and Pete Domenici Mental Health Parity and Addition Equality Act of 2008 All group health plans (exempting small employers) that provide medical and surgical benefits and mental health or substance abuse disorder benefits will be required to comply with the following requirements: The financial requirement applicable to mental health or substance abuse disorders benefits are more restrictive than the predominant financial requirements applied to the substantially all medical and surgical benefits covered by the plan. The treatment limitations applicable to mental health or substance abuse disorder benefits are more restrictive than the predominant treatment limitation supplied to substantially all medical and surgical benefits covered by the plan. There can be no separate cost sharing requirements or treatment limitations that are applicable only with respect to mental health or substance use disorder benefits. 2015 GDA Health Plan Renewal 17

Select Drug List 4 Tier Formulary 40627MUMENABS Effective 1/14 18 2015 GDA Health Plan Renewal

Anthem Blue Cross and Blue Shield Select Drug List Your prescription drug benefit includes coverage for medicines that you ll find on the Select Drug List. You can often find more savings when your doctor prescribes medicine that is on our Select Drug List. Here are some commonly asked questions and answers about how the Select Drug List works with your prescription drug plan. Q. What is a Select Drug List? A. The Select Drug List, also called a formulary is a list of U.S. Food and Drug Administration (FDA)-approved brand-name and generic drugs that have been reviewed and recommended for their quality and how well they work. The review is done by the National Pharmacy and Therapeutics (P&T) Process. The P&T Process is performed by an independent group of practicing doctors and pharmacists in charge of the research and decisions surrounding our Select Drug List. This group meets regularly to review new and existing drugs and they choose the top drugs for our list based on their safety, how they work and their value. Because the drugs on our list are reviewed from time to time, it s a good idea to check the list to find out if any drugs have been added or removed. You can do this by going to anthem.com. Q. What if my medication is not on the Select Drug List? A. You may want to first check with your doctor about prescribing a drug that is on the Select Drug List. If your doctor prescribes a drug that s not on the Select Drug List, you will have to pay the amount described in your policy for non-formulary drugs. Q. Can I request that a drug be added to the Select Drug List? A. You or your doctor can put in a request to add a drug to the Select Drug List. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the Select Drug List review. Please note that if a drug request is approved, it does not guarantee coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your insurance Certificate or Evidence of Coverage to know for sure. Preventive Care Drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). Q. What are Tiers? A. Drugs on the Select Drug List are grouped into tiers. There are several factors that are used to determine under which tier a drug will be put in. This can include (but it s not limited to): }} Cost of the drug }} Cost of the drug in comparison to other drugs used for the same type of treatment }} Availability of over-the-counter options }} Other clinical and cost factors. Q. What is a brand-name drug? A. These are drugs that are developed by a company who holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-name drugs through advertising or because you know people who take them. Q. What is a generic drug? A. Generics are simply copies of brand-name drugs. Brand-name and generic drugs have the same active ingredients, strength and dose. And the FDA requires that generic drugs meet the same high standards for purity, quality, safety and strength. Please note: In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a non-covered product. Anthem has criteria that permits a member to obtain a non-covered medication in a closed drug list plan. If specific criteria are met, a member can receive a non-covered drug for a drug list co-pay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. An appeals process is in place for any medications that do not meet the criteria. 1 2015 GDA Health Plan Renewal 19

For more information about your drug plan, you can do the following: }} Go to anthem.com. }} Call Customer Service at the number on your ID card. }} Speech and hearing impaired users (TDD/TTY) should call 800-221-6915, Monday Friday, 8:30 a.m. 5 p.m., ET. TIER DEFINITIONS Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions. Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 4 specialty drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA. Specialty drugs are used to treat complex, chronic conditions and may need special handling. Tier 1 Acarbose Acebutolol Acetasol HC Acetazolamide tab, ER cap Aclometasone Acticin Acyclovir tab, cap, oral susp. Adapalene Afeditab CR QL DO Albuterol inhl soln., syrup Alendronate QL Alfuzosin Allopurinol tab Alprazolam tab Amantadine Amcinonide Amiloride tab Aminophylline tab Amiodarone tab Amitriptyline Amlodipine QL DO Amlodipine/ atorvastatin QL DO Amlodipine/benazepril Ammonium lactate cream, lotion Amnesteem PA Amoxapine Amoxicillin Amoxicillin/clavulanate Amoxicillin/ clavulanate ER Amphetamine/ dextroamphetamine salts, ER PA QL Androxy PA Antipyrine/ benzocaine ear drop Apraclonidine Atenolol Atenolol/chlorthalidone Atorvastatin QL DO Atovaquone/proguanil Azelastine nasal spray, drops QL Azithromycin tab, susp., packet QL Bacitracin/polymixin B Baclofen 2 Balsalazide Benazepril Benazepril/HCTZ Benzonatate Benzoyl peroxide Benztropine Betamethasone dipropionate Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives) Bisoprolol Bisoprolol/HCTZ Brimonidine Bromocriptine Budesonide 0.25mg/2mL, 0.5mg/2mL QL Bumetanide tab Buprenorphine tab PA QL Bupropion QL Bupropion SR, XL QL DO Buspirone Butalbital/ acetaminophen Butalbital/ acetaminophen/caffeine Butalbital/ acetaminophen/ caffeine/codeine QL Butalbital/aspirin/ caffeine Butalbital/aspirin/ caffeine/codeine Butorphanol nasal spray PA QL Cabergoline Calcipotriene Calcitriol cap, soln, oint Candesartan/HCTZ PA QL DO Captopril Captopril/HCTZ Carbamazepine, ER, XR Carbidopa/ Levodopa, ER, ODT Carbinoxamine Carisoprodol Carteolol Cartia XT QL DO Carvedilol Cefaclor, ER Cefadroxil Cefdinir Cefditoren Pivoxil Cefprozil Cefuroxime Axetil Cephalexin Cetirizine syrup QL Chlorhexidine gluconate Chlorhexidine Rinse Chloroquine Chlorothiazide tab Chlorpromazine tab PA Chlorpropamide Chlorthalidone Chlorzoxazone Cholestyramine Ciclopirox Cimetidine tab, soln. Ciprofloxacin ear and eye drops Ciprofloxacin tab QL Citalopram QL DO Claravis PA Clarithromycin, ER Clemastine 2.68mg Clemastine syrup Clindamycin cap, oral soln, topical preparations Clindamycin/Benzoyl Peroxide Gel Clobetasol Clomipramine Clonazepam, ODT Clonidine tab Clopidogrel PA (75mg only) QL Clotrimazole 1% cream, troche Clotrimazole/ betamethasone Codeine sulfate tabs QL Codeine/ acetaminophen QL Codeine/butalbital/ aspirin/caffeine Colestipol Cortisone tab Covaryx, H.S. Cromolyn eye drops QL Cromolyn neb soln. Cyclobenzaprine tab Cyproheptadine Depade Dermazene Desloratadine, ODT QL Desmopressin nasal spray, tab PA Desonide Desoximetasone Dexamethasone eye drop Dexamethasone tab, oral soln. Dexchlorpheneramine Dexmethylphenidate PA QL Dextroamphetamine, ER PA QL Diazepam tab, oral soln. Diclofenac eye drop Diclofenac, ER Dicloxacillin Dicylomine cap, tab, syrup Diflorasone Diflunisal Digoxin tab, oral soln. Diltiazem, ER, XR, CD QL DO Diphenhydramine 50mg cap Diphenoxylate/atropine Dipyridamole tab Disopyramide Disulfiram Divalproex, ER, DR Donepezil 5mg, 10mg, ODT QL Dorzolamide eye drops Dorzolamide/timolol eye drops Doxazosin Doxepin Doxycycline hyclate tab, cap Doxycycline hyclate, delayed release PA Doxycycline monohydrate tab, cap Dylix Econazole Enalapril Enalapril/HCTZ Endocet QL Endodan QL 20 2015 GDA Health Plan Renewal

Epidrin Epinastine eye drops QL Epitol Eprosartan PA QL Ergocalciferol (Vit D2) caps Ergotamine/caffeine Ery-Tab 250mg, 333mg tab Erythromcyin eye oint. Erythromycin 2% gel, topical solution Erythromycin ethylsuccinate 400mg Filmtab Erythromycin Filmtab, 250mg cap Erythromycin stearate Erythromycin/benzoyl peroxide gel Erythromycin/ sulfisoxazole Escitalopram QL DO Estazolam Estradiol patch QL Estradiol tab Estrogen/ methyltestosterone Estropipate Ethambutol Ethosuximide Etodolac, ER Famciclovir Famotidine tab, oral soln. Felbamate Felodipine ER QL Fenofibrate Fenofibric acid Fenoprofen Fentanyl citrate lozenge PA QL Finasteride 5mg tab PA Flavoxate Fluconazole tab, oral soln. Flucytosine Fludrocortisone Flunisolide nasal spray ST QL Fluocinolone body oil, scalp oil PA Fluocinolone cream, topical soln., oint., ear drop Fluocinonide Fluorometholone eye drops Fluorouracil cream, topical solution Fluoxetine, DR (except 60mg) QL DO Fluphenazine tab, oral soln. PA Flurbiprofen eye drop Flurbiprofen tab Fluticasone nasal spray QL Fluticasone topical Fluvastatin QL DO Fluvoxamine QL DO Folic acid 1mg Fosinopril Fosinopril/HCTZ Furosemide tab, oral soln. Garamycin eye drops Gemfibrozil Gentamycin eye drops, oint. Glimepiride Glipizide, ER, XL Glipizide/metformin Glyburide Glyburide, micronized Glyburide/metformin Griseofulvin Guaifenesin/ codeine syrup Guanfacine Guanidine Halac Halobetasol propionate Haloperidol tab PA Hydralazine tab Hydrochlorothiazide Hydrocodone/ acetaminophen QL Hydrocortisone tab Hydrocortisone 2.5% cream, lotion, oint. Hydrocortisone acetate 2% gel Hydrocortisone acetate suppository Hydrocortisone butyrate 0.1% cream, oint., soln. Hydrocortisone enema Hydrocortisone valerate 0.2% cream, ointment Hydrocortisone/acetic acid ear drops Hydrocortisone/ pramoxine cream, ointment Hydromorphone suppository Hydromorphone tab, oral soln. QL Hydroxychloroquine Hydroxyzine HCL tab, oral soln. Hydroxyzine pamoate Hyomax-FT 0.125 chew melt Ibandronate ST QL Ibuprofen Imipramine HCL tab Imiquimod PA QL Indapamide Indomethacin, ER cap Ipratropium bromide neb soln. QL Irbesartan PA QL DO Irbesartan/HCTZ PA QL DO Isometheptene/ acetaminophen/caffeine Isometheptene/ acetaminophen/ dichloralphenazone Isonarif Isoniazid tab, oral soln. Isosorbide dinitrate, ER tab Isosorbide mononitrate, ER tablet Isradipine Ketoconazole Ketoprofen, ER Ketorolac eye drops Ketorolac tab QL Klor-Con tab Labetolol tab Lactulose Lamotrigine tab (immediate release) Lansoprazole, DR QL Latanoprost 3 Levobunolol eye drops Levocetirizine QL Levofloxacin tab QL Levothroid Levothyroxine tab Levoxyl Lidocaine viscous soln. Lidocaine/hydrocortisone 3/0.5% cream Lidocaine/prilocaine Lindane Liothyronine tab Lisinopril Lisinopril/HCTZ Lithium carbonate, ER Lithium citrate oral soln. Lonox Losartan QL DO Losartan/HCTZ QL DO Lovastatin QL DO Loxapine PA Malathion Maprotiline Matzim LA QL DO Mebendazole Meclizine tab Meclofenamate cap Medroxyprogesterone tab Mefenamic acid Mefloquine Megestrol Meloxicam oral suspension Meloxicam tab QL Meperidine tab, oral soln. QL Meprobamate QL Metadate ER PA QL Metaproterenol Metaxalone Metformin, ER Methadone tab, oral soln. QL Methamphetamine PA QL Methanamine MD Methazolamide Methimazole Methocarbamol Methscopolamine bromide Methyclothiazide Methyldopa Methyldopa/HCTZ Methylergonovine tab Methylphenidate, CD, ER, SR PA QL Methylprednisolone tab Metipranolol eye drops Metoclopramide tab, oral soln. Metolazone Metoprolol tab, ER Metoprolol/HCTZ Metronidazole 0.75% gel Metronidazole tab, capsule, cream, lotion Miconazole 200mg vaginal suppository Minocycline Minocycline ER PA Minoxidil tab Mirtazapine Misoprostol PA Modafinil PA QL Moexipril Moexipril/HCTZ Mometasone cream, oint, topical soln. Montelukast QL Morphine sulfate IR tab QL Morphine sulfate oral soln. QL Morphine sulfate suppository Mupirocin oint. Nabumetone Nadolol Nadolol/ bendroflumethiazide Naltrexone Naphazoline eye drops Naproxen, DR Naratriptan QL Nature-Throid Nefazodone Neomycin tab Neomycin/polymixin/ bacitracin eye oint. Neomycin/polymixin/ bacitracin/ hydrocortisone eye oint. Neomycin/polymixin/ dexamethasone eye drops, oint. Neomycin/polymixin/ gramicidin eye drops Neomycin/polymixin/ hydrocortisone ear and eye drops Nicardipine caps Nifedipine cap Nifedipine tab ER, XL QL DO Nisoldipine ER QL DO Nitro-Bid oint. Nitrofurantoin Nitroglycerin, ER, SR Nizatidine Norethindrone nortriptyline NP Thyroid Nystatin cream, oint., powder, tab Nystatin/triamcinolone Ofloxacin ear and eye drops Ofloxacin tab QL Omeprazole caps QL Orphenadrine ER Oxaprozin Oxcarbazepine Oxybutynin, ER Oxycodone QL Oxycodone/ acetaminophen tab, cap QL Oxycodone/aspirin QL Oxymorphone Oxymorphone ER QL Pacerone Pancrelipase Paramomycin Paroxetine, CR, ER QL DO Penicillin VK Pentazocine/naloxone QL Pentoxifylline, ER Perindopril Permethrin cream Perphenazine PA Phenazopyridine Phenelzine Phenobarbital tab, oral soln. 2015 GDA Health Plan Renewal 21

Phenytoin ext. cap Pilocarpine eye drops Pindolol Pioglitazone QL Piroxicam Podofilox Polymixin/trimethoprim eye drops Potassium 25mEq tab effervescent Potassium chloride ER tab, ER cap Potassium Citrate ER Tab Potassium citrate/citric acid Pramipexole Pravastatin QL DO Prazosin Prednicarbate Prednisolone eye drops Prednisolone oral soln. Prednisone Prenatal Vitamins (all generic covered) Primidone Probenecid Probenecid/colchicine Procentra QL Prochlorperazine tab Progesterone, micronized cap Promethazine tab, suppository, syrup Promethazine VC syrup Promethazine VC syrup with codeine Promethazine/ codeine syrup Promethazine-DM syrup Propranolol ER Propranolol HCTZ Propranolol tab, oral soln. Propylthiouracil Protriptyline Pyrazinamide Pyridostigmine Quetiapine PA Quinapril Quinapril/HCTZ Quinidine sulfate, ER Quinine sulfate PA QL Ramipril Ranitidine 150, 300mg tab, cap Ranitidine oral soln. Rifampin Rimantadine Risperidone, ODT, oral soln. PA Rizatriptan, ODT QL Ropinirole, ER Roxicet tab, caplet QL Selegiline Selenium sulfide 2.5% lotion, shampoo Sertraline QL DO Silver sulfadiazine cream Simvastatin 80mg PA QL DO Simvastatin QL DO Sodium polystyrene sulfate 30gm/120ml enema Sodium polystyrene sulfate powder Sodium polystyrene sulfonate Sodium sulfacetamide/ sulfur Sodium sulfacetamide/ sulfur/urea Spinosad Spironolactone Sucralfate Sulfacetamide eye drops, oint. Sulfacetamide sodium Sulfacetamide sodium/ prednisolone eye drops Sulfacetamide sodium/ sulfur Sulfacetamide sodium/ sulfur/urea Sulfacetamide sodium/ urea Sulfamethoxazole/ trimethoprim, DS Sulfasalazine Sulindac Sumatriptan tab QL Tamsulosin Taztia XT QL DO Terazosin Terbinafine tab PA Terbutaline tab Terconazole Tetracycline caps Theochron ER Theophylline ER, oral soln. Thioridazine PA Thiothixene PA Ticlopidine Timolol eye drops, gel Timolol tab Tizanidine Tobramycin eye drops Tobramycin/ dexamethasone eye drops Tolazamide Tolbutamide Tolmetin Tolterodine Topiramate PA Torsemide tab Tramadol, ER tab QL Trandolapril Tranexamic acid 650mg Tranylcypromine Trazodone Tretinoin cream, gel PA Triamcinolone cream, lotion, oint. Triamcinolone nasal spray QL Triamcinolone paste Triamterene/HCTZ Trifluoperazine PA Trifluridine eye drops Trihexyphenidyl Trimethobenzamide cap Trimethoprim Trimipramine Tropicamide eye drops Unithroid Valacyclovir Valproid acid cap, oral soln. Valsartan/HCTZ PA QL DO Venlafaxine Venlafaxine, ER QL DO Verapamil tab, ER PM QL DO Verapamil tab, ER tab, cap Vicodin, ES, HP QL Warfarin 4 Westhroid Zafirlukast Zaleplon ST QL Ziprasidone PA Zolpidem (immediate release) QL Tier 2 Accu-Chek Products Advair Diskus, HFA QL Anaspaz ODT Asmanex Twisthaler QL Bethanechol tab Bromfenac eye drops Budesonide EC Buprenorphine syringe, vial Calcitonin QL Calcium acetate tab Cefpodoxime Cevimeline Cilostazol Clozapine, ODT PA Danazol Dantrolene Demeclocycline Desipramine Dronabinol Dulera QL Eliphos Entacapone Epipen, Jr. Eplerenone Ergoloid Etidronate Evista Fentanyl patch ST QL Flecainide Flovent HFA QL Flovent QL Fortical nasal spray QL Gabapentin Galantamine, ER QL Glucagen Granisetron tab QL Humalog Humalog Mix Humulin N, R, 70-30 Itraconazole PA Ketorolac inj. QL Lantus Lantus Solostar Leflunomide Levalbuterol neb soln. Levemir Levetiracetam Levetiracetam ER PA QL Levocarnitine tab, oral soln. Levorphanol tab QL Methenamine hippurate Mexiletine Morphine sulfate ER QL Nateglinide PA Nimodipine Nitroglycerin spray Nitrostat Novolin N Novolog Novolog Mix Olanzapine tab, ODT PA Ondansetron tab, ODT, oral soln. QL One Touch Product Line Oxandrolone PA Pantoprazole QL Pilocarpine tabs Proair HFA ST QL Propafenone Prudoxin Pulmicort 1mg/2mL respules QL Pulmicort Flexhaler QL Qvar QL Relenza QL Rivastigmine QL Serevent Diskus QL Sotalol tab, AF tab Sulfadiazine Sumatriptan inj QL Symbicort QL Tamiflu QL Tiagabine PA Tranexamic acid 1000mg/10mL Trospium chloride ER ST Ursodiol Valcyte 450mg Vancomycin caps PA Voriconazole tab PA Zenpep Zonisamide Tier 3 Abilify tab PA Aciphex QL Actonel ST QL Aczone Aggrenox QL Alamast PA Albenza Alinia Alocril PA QL Alomide PA QL Altabax Amitiza Anadrol-50 Androgel PA QL Antivert 50mg Anzemet tablet QL Apidra, Solostar ST Apriso ER Arcapta Neohaler QL Arestin Atacand PA QL DO Avandia ST QL Avodart Axert ST QL Azelex PA Azilect Azopt Bactocill Banzel QL Benicar PA QL DO Bepreve PA QL Besivance Beyaz ST Biltricide Brilinta QL Brovana QL Buphenyl tablet PA Butrans QL Bydureon ST QL Bystolic Cambia QL Campral Cantil Cataflam Cedax Celebrex ST QL Celontin Cenestin Cesamet PA 22 2015 GDA Health Plan Renewal

Chantix PA QL Chemet Cialis 2.5mg, 5mg PA Ciclodan Cipro HC ear drops Ciprodex ear drops PA Clindacin Cloderm Coartem Colcrys PA QL Coly-Mycin ear drops Combigan Cordran, SP Cortisporin cream, oint. Crestor ST QL DO Cresylate Cuprimine Cycloset Cymbalta PA QL DO Daliresp QL Dapsone Daraprim Denavir Dexilant ST QL Dibenzyline Differin 0.1% lotion, 0.3% gel Dificid PA Diovan PA QL DO Dipentum Durezol QL Dyrenium Edarbi QL DO Edecrin Effient QL DO Elidel PA Ella Elmiron Emadine PA QL Emend caps QL Emsam QL Enablex ST Enjuvia Epiduo Ergomar Ertaczo Estring Eurax Exalgo ER ST QL Exelderm Factive QL Fanapt PA Finacea Flector ST Fluoridex Fluoroplex FML S.O.P Focalin XR PA QL Fosamax oral soln. Fosamax Plus D ST QL Fosrenol PA Frova ST QL Generess Fe Glyset Gynazole 1 Halog Hectoral caps Horizant PA Intuniv ER PA Invega tab PA Janumet, XR QL Januvia ST QL Kapvay, ER PA Ketek Lacrisert Lanoxin tab Latuda PA Levatol Livalo ST QL DO Lo Loestrin Fe Lodosyn ST Loestrin 24 FE Lotemax Lotronex PA Lovaza Lufyllin Lumigan Lunesta PA QL Lyrica PA QL Marplan Maxair QL Maxalt, MLT QL Menest Mentax Mepron Methitest Micardis PA QL DO Migranal nasal spray QL Morgidox PA Motofen Moviprep Moxatag Multaq Mycobutin Myrbetriq ST Mytelase Naftin cream, 1% gel Namenda QL Natacyn Natazia ST Nevanac Nexium PA QL Niaspan ER Norinyl 1+50-28 Noroxin QL Noxafil Nucynta, ER QL Nuedexta Nuox Nuvaring Nuvigil PA QL Omnaris ST QL Onglyza ST QL Oracea Orap PA Ortho Evra Ortho Tri-cyclen Lo Osmoprep Oxistat Oxsoralen-Ultra PA Oxycontin ST QL Panretin Paser Pataday PA QL Patanase QL Patanol PA QL Peganone Perforomist QL Phisohex Phospholine iodide Picato PA QL Potiga QL Pradaxa QL Prandin PA Pred-G Pred-G S.O.P Premarin Cream Premarin tab ST Premphase Prempro Prevident 5000 Booster Plus Priftin Primaquine Primsol Pristiq QL DO Proglycem Prolia PA Proquin XR Protopic PA Proventil HFA ST QL Ranexa Rapaflo Rectiv Regranex PA Relistor PA Relpax ST QL Renvela PA Restasis Ridaura Rifater Rosadan Rozerem ST QL Sabril Safyral ST Samsca PA Sancuso Santyl Saphris PA Savella QL Scopace Seroquel XR PA Silenor ST Skelid Solaraze PA QL Soriatane Spiriva QL Strattera PA QL Stromectol Sulfamylon Suprax tab, susp. Symlin PA Synera Syprine Taclonex scalp suspension Taclonex suspension Tasmar Tazorac PA Tekturna QL DO Teveten 400mg QL Thyrolar Tikosyn Tobradex eye oint. Toviaz ER ST Tradjenta ST QL Transderm-Scop PA Travatan Z Trecator Trilipix Tyzine Ulesfia Uloric ST Vagifem Valcyte 50mg/mL solution Ventolin HFA ST QL Veregen Vesicare ST Vexol Vfend oral susp. PA Victoza ST QL Vigamox PA Viibryd ST Vimpat QL Visicol Vivelle-Dot PA QL Voltaren gel Voltaren-XR Vyvanse PA QL Welchol Xarelto QL Xenazine PA Xifaxan PA QL Xopenex HFA ST QL Xyrem PA Zemplar caps Zetia PA QL Ziana ST Zinotic Zioptan Zipsor Zirgan Zomig tab PA QL Zomig ZMT PA QL Zyflo, CR PA Zymaxid Zyvox tab, oral soln. PA QL Tier 4 Abacavir Actemra PA Adagen Adcirca PA Afinitor PA Aldurazyme PA Alkeran tab Amevive PA Ampyra PA QL Anagrelide Anastrazole tab PA Apokyn PA Aptivus Aranesp PA Atripla Aubagio PA QL Azathioprine tab Baraclude PA Benlysta PA Bicalutamide Bosulif PA Caprelsa PA Carbaglu PA CeeNU Cimzia PA QL Cometriq PA Copaxone PA Crixivan Cyclophosphamide tab Cyclosporine Cyclosporine cap, soln. Didanosine DR Droxia Edurant Emcyt PA Emtriva Enbrel PA QL Enoxaparin PA Epivir HBV soln. PA Epzicom Erivedge PA Etopophos Etoposide caps Exemestane PA Exjade PA Extavia ST Fareston Ferriprox PA Flutamide 5 2015 GDA Health Plan Renewal 23

Fondaparinux PA Forteo PA Fragmin PA Fuzeon Gengraf Gilenya PA QL Gleevec PA Hepsera Hexalen Humira PA QL Hycamtin caps Hydroxyurea Iclusig PA Incivek PA Infergen PA Inlyta PA Innohep PA Intelence Intron A PA Invirase Iressa Isentress Jakafi PA Kaletra Kalydeco PA QL Kineret PA Kuvan PA Lamuvidine Lamuvidine/zidovudine Letairis PA Letrozole Leucovorin tab Leukeran Leuprolide PA Lexiva Lysodren Matulane Melphalan Mercaptopurine Methotrexate tab Mycophenolate Myfortic Myleran Nebupent Neulasta PA QL Neupogen PA Nevirapine Nexavar PA Nilandron Norvir Oforta PA Omontys PA Orencia PA QL Orfadin Pegasys PA QL Pegintron PA Pomalyst Prezista Procrit PA Promacta PA QL DO Rapamune Rebif PA Reclast Remicade PA Remodulin PA Rescriptor Revlimid PA QL Reyataz Ribavirin PA Rilutek Rituxan PA Sandostatin LAR PA Selzentry Sensipar Simponi PA QL Sildenafil 20mg tab PA Simulect Somatuline Somavert PA Sprycel PA Stavudine Stelara PA QL Stivarga PA Sustiva Sutent PA Synarel PA Synribo Tabloid Tacrolimus Tamoxifen Tarceva PA Targretin PA Tasigna PA Temodar cap PA Tev-Tropin PA Thalomid PA Topotecan Torisel Tracleer Trelstar Depot PA Trelstar PA Tretinoin 10mg capsule Trizivir Truvada Tykerb PA Tysabri Tyzeka PA Vandetanib PA Ventavis PA Victrelis PA Viracept Viread PA Votrient PA VPRIV PA Xalkori PA Xeloda PA Xtandi PA Zavesca PA Zelboraf PA Zidovudine Zolinza PA Zytiga PA KEY = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification requirements are met, this brand-name drug may no longer be covered by your prescription drug plan. Check anthem.com to find out about changes in tier status. PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month. ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule. Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Member Services at the telephone number listed on your identification card. 6 24 2015 GDA Health Plan Renewal

For more information, please visit anthem.com. }} If you have additional questions about your prescription benefits, please call the Member Services number on your ID card. }} Speech and hearing impaired (TDD/TTY users) should call 800-221-6915, Monday Friday, 8:30 a.m. 5 p.m., ET. }} For the most current version of this Selected Drug List, please visit anthem.com. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. 40627MUMENABS Effective 1/14 (IN, KY, ME, MO, OH, NH, VA) 2015 GDA Health Plan Renewal 25

2015 Open Enrollment Form Endorsed by For individual coverage effective January 1, 2015 Please FAX completed form to: (404) 634-6099 or mail to: GDIS, 7000 Peachtree Dunwoody Rd NE, Suite 200, Building 17, Atlanta GA 30328-1655. Part I: General Information - All Employees MUST complete form, please PRINT or TYPE Name of Dentist/Employer: (Applicant) Last Name First Name Middle Initial (Applicant) Mailing address City State ZIP Code Home phone no. Business phone no. Email ( ) ( ) Part 2: Medical Coverage - Please select your choice: ENROLL (Complete parts 2a, 3 & 4) CANCEL - Effective Date: (Sign & date below) (All insureds are required to select a new plan in 2015) (Date must be last day of month) WAIVE coverage (Must state reason for waiver. Sign & date below) Reason for Waiver: Part 2a: Medical Coverage - Please select your plan: Select ONE of the following plans below: POS Low Plan POS 2000 Plan (w/ Select Rx) POS 6600 Plan (w/select Rx) POS HDHP 3000 Plan (w/select Rx) (High Deductible Health Plan) - H.S.A. Compatible Part 2b: Vision Coverage - New! Blue View Vision Blue View Vision Plan POS 1500 Plan (w/select Rx) POS 1000 Plan Part 3: Coverage Background Information Add Drop Name (Last, First MI) Social Security Number Date of Birth mm/dd/yyyy Male Female Applicant Spouse Child Child Child Part 4: Authorization (It is a Federal crime to knowingly provide false information on a medical coverage application) I REQUEST COVERAGE UNDER THIS GROUP PLAN. I have completed the information on this form. I understand that enrollment in this plan is subject to all the terms of the group plan, and that to be eligible, I must (a) be employed by the named employer in a class eligible for the coverage and (b) engaged in and perform the normal duties of such employment on a regular basis for at least the minimum number of hours per week (excluding duties performed at my residence or while confined in a hospital). I also understand that coverage will not become effective for me or any eligible dependent until all the applicable eligibility requirements of the group plan are met. I understand that coverage will not be effective unless I satisfy the conditions on this form. I understand that inaccurate answers to the questions on this enrollment form may void my coverage under this plan. I hereby acknowledge that Blue Cross and Blue Shield of Georgia/Blue Cross Blue Shield Healthcare Plan of Georgia (BCBSGA/ BCBSHP) has informed me of the following prior to my enrollment in their health care coverage plan: a. number, mix and location of participating/network health care providers; b. limitations on choices of participating/network health care providers; c. disclosure of contractual relationship between participating/network provider and BCBSGA/BCBSHP. Applicant s Signature Date Signed 26 2015 GDA Health Plan Renewal

Please note Expenses of Plan Administrator. The Plan does not pay compensation to the Plan Administrator, Georgia Dental Insurance Services, Inc. The Plan reimburses the Plan Administrator for its direct expenses incurred in performing its duties on behalf of the Plan. Accordingly, Employee and Employer Contributions include a 3% administrative fee to cover such expenses. Expenses reimbursable to the Plan Administrator include, but are not limited to, fees of legal counsel, accountants and other specialists, plan communication and recordkeeping costs, plan audit fees, claims review and vendor searches. The 3% administrative fee and direct expenses are reconciled annually by an independent auditor and any excess portion of the fee above the amount of direct expenses actually incurred during each plan year is retained by the Plan. Subscription Fee. The Plan Administrator charges an employer subscription fee of $30.00 directly to employers in connection with their participation in the Plan. The fee is paid by the employers out of their general assets and is receivable by the Plan Administrator to its general assets. The fee is not an Employer Contribution to the Plan. 2015 GDA Health Plan Renewal 27

You put your family first. So does your GDA. When you re a GDA member, you re family. Let us create a health insurance plan that s right for you. Competitive rates, expanded coverage and personalized options are just the beginning. GDA health coverage, where family comes first. For additional information call 404-636-7553 and speak with a GDIS representative: Victoria LeMaire lemaire@gadental.org Skip Jones jones@gadental.org Margo Null null@gadental.org