DENTALBLUE GOLD PLUS VISION - Arkansas Blue Cross · 1 601 s. gaines st. p.o. box 2181 little rock,...

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601 S. Gaines St.P.O. Box 2181Little Rock, AR 72203-2181

SPECIMENJOHN DOE12 MAILINGLITTLE ROCK AR 72205

DENTALBLUE GOLDSM

PLUS VISION

INDIVIDUAL POLICY

GROUP NO.: 371000

PACKAGE NO.: 02

POLICYHOLDERNAME: JOHN DOE

ID NO.: 970030172

ARKANSAS BLUE CROSS AND BLUE SHIELD601 S. GAINES STREET

LITTLE ROCK, ARKANSAS 7220164-313 2012-01-05

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Schedule of BenefitsEffective Date: 02/01/2012

Document Creation Date: 01/05/2012

Identification #: XCD970030172 Coverage Type Contract Type Monthly RateDENTALBLUE GOLD PLUS VISION Dental + Vision Subscriber & Spouse $4.50Group #: 371000-8Premium Billing Frequency: Semi-Annually

MemberNumber Name

Date ofBirth

EffectiveDate

01 JOHN DOE 01/20/1981 02/01/201202 JANE DOE 07/08/1980 02/01/2012

Please verify the information is correct. Claims payment determination will be based on the information noted above. If youhave any questions or if the information on this document is incorrect, please call 1-800-238-8379.

Refer to this Insurance Policy for a full explanation of your benefits, the limitations on these benefits and theservices that are not covered.

Dental Coverage InformationDeductible: $50.00 Per Contract Year for Each Covered PersonContract Year Maximum: $1,000.00Orthodontic Services: No CoverageContract Year Rollover Benefit

Diagnostice & Preventive ServicesCoinsurancePercentage

Your Share ofCoinsurance

Routine Exams and X-rays 100% 00%ProphylaxisFluoride Treatment

Minor Restorative ServicesCoinsurancePercentage


Fillings 80% 20%Simple Extractions

Major Restorative ServicesCoinsurancePercentage


Endodontics 50% 50%Oral SurgerySurgical ExtractionsPeriodonticsInlays, Onlays, Crowns, BridgesPartials and DenturesImplants

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DENTAL WAITING PERIOD END DATES

MemberNumber Name

6-Month MinorRestorative Waiting

Period End Date

12-Month MajorRestorative Waiting

Period End Date01 JOHN DOE 07/31/2012 01/31/201302 JANE DOE 07/31/2012 01/31/2013

Vision Coverage InformationFashion Benefits

Benefit

FrequencyPeriod

Once Every - In-Network CoverageEye Examination 12 months $10.00 Copayment

Spectacle Lenses 12 months $25.00 Copayment

Fashion Level Frames 12 months Included

Contact Lens Evaluation,

Fitting & Follow Up Care

12 months 15% Discount*

Contact Lenses (in lieu of eyeglasses) 12 months Up to $100.00 + 15% Discount* off Balance*Discounts are available at most Participating Providers locations

IMPORTANT NOTICEThis Schedule of Benefits is effective 02/01/2012. If you or the Company makes any modifications inyour coverage after this effective date, the Company will send you a new Schedule of Benefits andIdentification Card that will replace this one. Please make sure you attach your most current Scheduleof Benefits to this Policy.

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DENTALBLUE GOLDSM

GROUP NO.: 371000

PACKAGE NO.: 02

DENTAL COVERAGE

INDIVIDUAL POLICY

OTHER INSURANCE REDUCES BENEFITS – READ CAREFULLY

Attached is the Schedule of Benefits, showing name ofPolicyholder, Policy number, type of Policy (individual

or otherwise), premiums and the effective date.

GUARANTEED RENEWABLE CONDITIONED UPON RESIDENCE IN ARKANSASPREMIUMS SUBJECT TO CHANGE

THIS POLICY CONTAINS A WAITING PERIOD FOR CERTAIN SERVICES.


LITTLE ROCK, ARKANSAS 72201

64-313 1/11 2012-01-05

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Table of Contents

SCHEDULE OF BENEFITS iii. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DENTALBLUE GOLD DENTAL POLICY v. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OUTLINE OF COVERAGE viii. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE I. STATEMENT OF COVERAGE 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE II. DEFINITIONS 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE III. COVERED SERVICES 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE IV. SPECIFIC BENEFIT LIMITATIONS 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE V. SERVICES NOT INCLUDED 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE VI. SUBROGATION 29. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE VII. COORDINATION AGAINST OTHER DENTAL COVERAGE 29. . . . . . . . . . .ARTICLE VIII. OTHER PROVISIONS 31. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE IX. POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS ANDVOTING 34. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .VISION LIMITED BENEFIT POLICY 37. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OUTLINE OF COVERAGE 38. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE I. STATEMENT OF COVERAGE 40. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE II. DEFINITIONS 40. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE III. SPECIFIC BENEFITS AND LIMITATIONS OF THE PLAN 42. . . . . . . . . . . . .ARTICLE IV. SERVICES NOT INCLUDED 43. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE V. SUBROGATION 44. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE VI. OTHER PROVISIONS 44. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARTICLE VII. POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS ANDVOTING 47. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ARKANSAS CONSUMERS INFORMATION NOTICE 49. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .LIMITATIONS AND EXCLUSIONS UNDER THE ARKANSAS LIFE AND HEALTHINSURANCE GUARANTY ASSOCIATION ACT 50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .INDEX 51. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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ARKANSAS BLUE CROSS AND BLUE SHIELD

DENTAL EXPENSE POLICY

OUTLINE OF COVERAGE

If, after examination of your Policy, you are not satisfied with any of its terms or conditions, you may return itto the Company within thirty (30) days of its delivery to you and receive a full refund of all premiums.

READ YOUR POLICY CAREFULLY - This outline of coverage provides a very brief description of theimportant features of your Policy. The outline is not your Policy and only the actual Policy provisions willcontrol. The Policy itself sets forth in detail the rights and obligations of both you and your insurancecompany. It is, therefore, important that you READ YOUR POLICY CAREFULLY.

DENTAL EXPENSE COVERAGE - Policies of this category are designed to provide to persons insured,coverage for dental expenses. Coverage is provided for initial and periodic exams, routine prophylaxis,fluoride treatments, x-rays, fillings, extractions, endodontics, etc. subject to any Deductibles, Coinsurance,Copayment provisions or other limitations which may be set forth in the Policy.

BENEFITS

DEDUCTIBLE: as indicated on your Schedule of Benefits per Benefit Year per Covered Person.

MAXIMUM BENEFIT: maximum benefits per Benefit Year under this Policy shall not exceed $1,000 perCovered Person.

COVERED SERVICESInitial and Periodic ExamsRoutine ProphylaxisFluoride TreatmentsX-raysSealantsFillingsExtractionsEndodonticsOral SurgeryPeriodontal surgeryInlays, Onlays, CrownsBridges, Partials, Implants and Dentures

AGE LIMITATIONS: Dependent Children are covered in accordance with Policy guidelines. You areresponsible for changes in coverage status (from individual to family or from family to individual).

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SPECIAL LIMITATIONS:Two (2) per Benefit Year Routine Exams, Prophylaxis, (Fluoride treatments, Bitewing x-rays for

Dependent children through age 18);One (1) per Benefit Year Bitewing X-rays, one occurrence of two, four or eight vertical

bitewings for adults over age 18;One (1) per 24 months Comprehensive Evaluations limited to one per Covered Person;One (1) per three (3) year period Fixed space maintainers through age 18; rebasing/relining of full or

partial dentures; sealants for Dependents through age 15 onpermanent 1st and 2nd molars;

One (1) per five (5) year period Full mouth radiographs; inlays and onlays for treatment of decay;single crowns; crown buildups including pins; removable prosthetics;resin-bonded retainers; post and core buildups.

One (1) per tooth per lifetime Crowns - stainless steel, prefabricated resin or composite resin; rootcanal therapy; crown lengthening; guided tissue regeneration.

WAITING PERIOD:This Policy contains a Waiting Period prior to certain services being covered. Once the Waiting Period issatisfied, those services are payable, subject to all other terms, conditions, exclusions and limitations of thePolicy. Waiting Periods may or may not be applicable to a particular service. Check your Schedule of Benefitsto determine if the service has a Waiting Period.

BENEFITS AND SERVICES NOT INCLUDED FOR:Orthodontic services; services, procedures or supplies not Dentally Necessary; services or procedures notprescribed or rendered by a dentist; services or supplies collectible under Worker's Compensation or any lawproviding benefits for dependents of military personnel; services for conditions which treatment is provided byfederal or state government or are provided without cost; intentional self-inflicted injuries; accidental injuries;injuries or diseases caused by war; cosmetic services; prescription drugs; local or block anesthesia whenbilled separately; experimental or investigational services; services provided by an immediate relative;

Guaranteed Renewable/Conditioned upon Residence in ArkansasThis Policy and riders are guaranteed renewable so long as you reside in Arkansas. The Company maychange the established premium rate, but only if the rate is changed for all policies and riders of the sameform number and premium classification.

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ARTICLE I. STATEMENT OF COVERAGEA. This Policy contains the insurance benefits provided by Arkansas Blue Cross and Blue Shield, (the

Company) to you and is subject to its terms. Payment for dental services will be made in accordancewith this Policy; however, only services specifically listed herein for the individuals listed on theSchedule of Benefits are covered.

B. This coverage is most effective and advantageous when the services of Participating Dentists areused.

C. Participating Dentists are paid directly by the Company and have agreed to accept the Company'spayment for Covered Services as payment in full except for your Deductible and Coinsurance, ifapplicable, until the Benefit Year Maximum has been reached. You are responsible for yourDeductible, Coinsurance and any charges beyond the policy payment, even if the Benefit YearMaximum has not been reached, when you receive services from a Non-Participating Dentist. Thedetermination of whether a Dentist is a Participating Dentist or Non-Participating Dentist is theresponsibility of the Company. The Company can provide a list of Participating Dentists, or you mayalso access our web site at WWW.ARKANSASBLUECROSS.COM. You should always ask yourchosen provider if he/she participates. We also recommend that you take this Policy with you to yourprovider's office.

D. The decision about whether to use a Participating Dentist is the sole responsibility of the CoveredPerson. Participating Dentists are not employees or agents of the Company. The Company makes norepresentations or guarantees regarding the qualification or experience of any dentist with respect toany service. The evaluation of such factors and the decision about whether to use any dentist is thesole responsibility of the Covered Person.

E. The effective date of your coverage is indicated in the Schedule of Benefits.F. Continuance of coverage under this Certificate shall be contingent upon receipt of premiums remitted

in advance by the Policyholder.G. Under this Policy, notice is effectively delivered when it is mailed to your most recent address as

recorded in our records.H. The Company reserves the right to amend the premiums required for this Policy. If we do so, we will

give thirty (30) days written notice to the Policyholder and the change will go into effect on the dateindicated the notice.

I. No agent or employee of the Company may change or modify any benefit, term, condition, limitationor exclusion of this document. Any change or amendment must be in writing and signed by an Officerof the Company.

ARTICLE II. DEFINITIONSA. Benefit Year and Contract Year mean the twelve–month period ending on the day before the

anniversary of the effective date of the Policy. Calendar year benefits do not apply to this Policy.B. Benefit Year Maximum or Contract Year Maximum means the greatest amount the company will pay

in a Benefit Year for Covered Services. The Maximum amount the Company will pay in a BenefitYear for ALL Covered Services under this Policy is $1,000.

C. Charge, when used in connection with dental services or supplies covered in this contract, will be theamount deemed by the Company to be reasonable. An amount equaling the lesser of the chargebilled by the dentist or the Arkansas Blue Cross and Blue Shield allowance is the basic Charge.However, this Charge may vary, given the facts of the case and the opinion of the Company's DentalAdvisor.

D. Child means the Policyholder's natural Child, legally adopted Child or Stepchild. "Child" also means aChild that has been placed with the Policyholder for adoption. “Child” also means a Child for whomthe Policyholder must provide medical support under a qualified medical Child support order or forwhom the Policyholder has been appointed the legal guardian.

E. Coinsurance means the obligation of the Company "our Coinsurance," to pay a Charge. TheCompany's Coinsurance and your Coinsurance are expressed as a percentage in the Schedule ofBenefits.

F. Company means Arkansas Blue Cross and Blue Shield.

www.arkansasbluecross.com

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G. Cosmetic Treatment means a procedure which is not Dentally Necessary and which is undertakenprimarily, in the opinion of the Company, to improve or otherwise modify the Covered Person'sappearance.

H. Covered Person means the Policyholder upon whom premiums have been paid and his EligibleDependents, if any, for whom premiums have been paid.

I. Covered Services mean a service or supply specified in this Policy or specifically approved by theCompany for which the Company will reimburse charges.

J. Creditable Coverage means dental coverage a Covered Person had prior to this Policy whichprovided benefits for preventive and minor restorative services. There can be no more than a 30-daylapse between prior dental coverage termination and the date the application for this Policy isreceived by the Company for Creditable Coverage to be applied. Time credit only applies to the MinorRestorative Services Waiting Period.

K. Date of Service is the date that treatment is completed.L. Deductible means the amount shown in the Schedule of Benefits that must be paid by the Covered

Person before the Company will assume liability. M. Dental Advisor is a dentist, group of dentists, or another qualified person or persons utilized by the

Company to review claims for treatment.N. Dentally Necessary means a dental service or procedure required to establish or maintain a patient's

dental health. The determination as to when a dental service is necessary shall be governed inaccordance with guidelines established by the Company. In the event of a conflict of opinion betweenthe treating dentist and the Company as to if a dental service or procedure is Dentally Necessary, theopinion of the Company shall be final.

O. Eligible Dependents are the Policyholder's:1. Spouse;2. Child less than 26 years of age;3. unmarried Child who is incapable of self support because of mental retardation or physical

disability, provided 1.) such Child is or was under the limiting age of dependency stated inSubsection b. above at the time of application for coverage under the Policy or 2.) if notunder such limiting age, has had continuous health plan coverage, i.e. no break in coveragegreater than 63 days, at the time of application for coverage.

The Company shall have the right to require satisfactory proof of mental or physical incapacity withthe right to examine your child at the Company's expense, but not more than once bi-annually. Uponfailure to submit such required proof or to permit such an examination, or when your child ceases tobe so incapacitated, coverage with respect to that child shall cease.Note: Domestic partners are not eligible for coverage as Dependents under this Policy.

P. Integral Service means a service or procedure that is considered part of another procedure. Noadditional allowances are given for Integral Services.

Q. Non-Diseased Tooth is a tooth that is whole or properly restored, and is free of decay and/orperiodontal conditions.

R. Non-Participating Dentist means a dentist who does not have a contract with the Company to provideCovered Services.

S. Participating Dentist means a dentist who has signed a contract with the Company to provideCovered Services. The Company will pay a Participating Dentist directly.

T. Placement, or being placed, for adoption means the assumption and retention of a legal obligation fortotal or partial support of a Child by a person with whom the Child has been placed in anticipation ofthe Child's adoption. The Child's Placement for adoption with such person terminates upon thetermination of such legal obligation.

U. Policy means this document, your Schedule of Benefits, the application and any amendments orendorsements signed by an Officer of the Company.

V. Spouse means a member of the opposite sex who is the husband or wife of a Policyholder as aresult of a marriage that is legally recognized in the state of Arkansas.

W. Stepchild means a natural or adopted Child of the Spouse of the Policyholder.X. The masculine gender when used herein shall include the feminine gender.Y. Treatment Plan means a written report of a series of procedures recommended for the treatment of a

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specific dental disease, defect or injury, prepared by the dentist as a result of an examination of theCovered Person.

Z. Waiting Period is the period after the effective date of coverage for which benefits are not payable foreach Covered Person. If a Dependent is added by endorsement, the Waiting Period will begin fromthe effective date of the addition. In the event of a reinstatement, all Covered Persons will be subjectto new Waiting Periods beginning with the effective date of reinstatement. Waiting Periods may ormay not be applicable to a Covered Person's benefits. Check the Schedule of Benefits to determine ifa Waiting Period applies.

AA. We, Our and Us means the Company, Arkansas Blue Cross and Blue Shield.AB. You and Your means a Covered Person.

ARTICLE III. COVERED SERVICESA. Payment for Covered Services. Payment for dental services will be made in accordance with this

Policy. Such payments are subject to Coinsurance, Deductibles, Maximums and Limitations specifiedin this Policy. All payments for Covered Services are subject to a $1000 Benefit Year Maximum.Once the Benefit Year Maximum has been met, the Company has no further liability for theremainder of the Benefit Year. All remaining charges for the balance of the Benefit Year will be thesole responsibility of the Covered Person.

B. Participating Dentists. Participating Dentists have agreed to accept the Charge as payment in fullfor Covered Services except for the Deductible and Coinsurance if applicable. Participating Dentistswill not bill a Covered Person beyond the Charge for Covered Services, unless the Benefit YearMaximum has been met. The Company will pay the Coinsurance percentage of the Charge for theCovered Service stated in the Schedule of Benefits. The Covered Person is responsible for thepayment of the applicable Deductible, Covered Person's Coinsurance and any charges in excess ofthe $1000 Benefit Year Maximum.

C. Non-Participating Dentists. If Covered Services are performed by a Non-Participating Dentist, theCompany will pay contract benefits directly to the Policyholder. Any difference between theNon-Participating Dentist's billed charge and the contract benefits paid by the Company shall be theresponsibility of the Covered Person.

D. Treatment Plan/Predetermination1. The Company requires a Treatment Plan for services for which the dentist expects to bill

$300.00 or more. When a Treatment Plan is required, the dentist must submit suchTreatment Plan to the Company for predetermination prior to the performance by the dentistfor any Covered Service. Substantiating material such as radiographs and perio charting mustbe submitted with the Treatment Plan when requested by the Company.

2. If a Treatment Plan or substantiating material requested by the Company is not submitted,the Company reserves the right to determine benefits payable taking into account alternateprocedures, services or courses of treatment, based on accepted standards of dentalpractice. Any amount, predetermined by the Company, shall be subject to adjustments by theCompany at the time of final payment as may be necessary to correct any mathematicalerrors and to comply with the Policy in effect at the time the Covered Service is provided.

3. The Company shall not be liable under this Policy for any Covered Services, including thoseCovered Services predetermined by the Company, which are performed at a time theCovered Person's coverage is no longer in effect.

E. Alternate TreatmentFrequently, several alternate methods exist to treat a dental condition. For example, a tooth can berestored with a crown or a filling, and missing teeth can be replaced either with a fixed bridge or apartial denture. The Company will make payment based upon the Charge for the less expensiveprocedure if such less expensive procedure meets accepted standards of dental treatment asdetermined by the Company. The Company's decision does not commit the Covered Person to theless expensive procedure. However, if the Covered Person and the dentist choose the moreexpensive procedure, the Covered Person is responsible for the additional charges beyond those paidor allowed by the Company.

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Examples:1. Resin fillings are covered for anterior teeth; however, resin fillings in posterior teeth are paid

at amalgam allowables from the fee schedule. Resin may be used for restoration of theposterior teeth, but only the amount normally paid for an amalgam will be reimbursed. TheCovered Person is responsible for the difference in cost.• D2391 is paid as D2140.• D2392 is paid as D2150.• D2393 is paid as D2160.• D2394 is paid as D2161.

2. If a crown is placed on a tooth when a filling would meet accepted standards of care, theamount normally reimbursed for a filling will be paid to the dentist or the Covered Person.The Covered Person is responsible for the difference in cost.

3. If precious metal (gold, etc.) is used for a partial denture rather than a non-precious metal orother suitable substitute, the amount normally paid for the non-precious metal or lessexpensive substitute will be reimbursed to the dentist or Covered Person. The CoveredPerson is responsible for the difference in cost.

4. If a bridge is provided when a partial denture could satisfactorily replace the missing teeth,the payment will be made for the partial denture. The Covered Person is responsible forthe difference in cost. If teeth are missing in two different quadrants of the same arch, apartial denture reimbursement will be made. The Covered Person is responsible for thedifference in cost.• (D6740, D6245, D6740) are paid as D5213 or D5214.• (D6750, D6240, D6750) are paid as D5213 or D5214.• (D6751, D6241, D6751) are paid as D5213 or D5214.• (D6752, D6242, D6752) are paid as D5213 or D5214.• (D6790, D6210, D6790) are paid as D5213 or D5214.• (D6791, D6211, D6791) are paid as D5213 or D5214.• (D6792, D6212, D6792) are paid as D5213 or D5214.

5. Amalgams are paid as an automatic alternate benefit for all inlay restorations and all twosurface onlay restorations. The Covered Person is responsible for the difference in cost.• D2510 is paid as D2140• D2520 is paid as D2150• D2530 is paid as D2160• D2542 is paid as D2150• D2610 is paid as D2140• D2620 is paid as D2150• D2630 is paid as D2160• D2630 is paid as D2160• D2642 is paid as D2150• D2650 is paid as D2140• D2651 is paid as D2150• D2652 is paid as D2160• D2662 is paid as D2150

6 Stainless steel crowns are paid as an alternate benefit to stainless steel crowns with resinwindows, prefabricated esthetic stainless steel crowns or prefabricated resin crowns. Stainlesssteel crowns are covered once per tooth per lifetime for children under age 14. The CoveredPerson is responsible for the difference in cost.• D2932 is paid as D2930• D2933 is paid as D2930• D2934 is paid as D2930

7. Free soft tissue graft procedures (including donor site surgery) is the alternate treatment forthe combined connective tissue and double pedicle graft. The Covered Person is

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responsible for the difference in cost.• D4276 is paid as D4271

8. Pre–fabricated posts and cores are the alternate treatment to cast posts and cores for singlecrowns and/or bridge abutment teeth. The Covered Person is responsible for thedifference in cost.• D2952 is paid as D2954• D6970 is paid as D6972

9. Maxillary partial dentures and mandibular partial dentures are the alternate treatment toimplant/abutment supported removable dentures. The Covered Person is responsible forthe difference in cost.• D6053 is paid as D5213• D6054 is paid as D5214

F. Diagnostic and Preventive Services. The following American Dental Association CDT-4 Codes andtheir descriptions are Covered Services as listed in the Schedule of Benefits under the Diagnostic andPreventive Services Category. Services performed in this category are subject to the Deductible andare paid at the Coinsurance percentage set out in the Schedule of Benefits. Covered Services in thiscategory contribute to the calculation of the Benefit Year Maximum.

Proc Code DescriptionD0120 PERIODIC ORAL EXAMINATIOND0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSEDD0145 ORAL EVALUATION FOR A PATIENT UNDER THE AGE OF 3D0150 COMPREHENSIVE ORAL EXAMINATIOND0160 DETAILED AND EXTENSIVE ORAL EXAM - PROBLEM FOCUSEDD0210 INTRAORAL - COMPLETE SERIES (INCLUDING BITEWINGS)D0220 INTRAORAL - PERIAPICAL-FIRST FILMD0230 INTRAORAL - PERIAPICAL-EACH ADDITIONAL FILMD0240 INTRAORAL - OCCLUSAL FILMD0250 EXTRAORAL - FIRST FILMD0260 EXTRAORAL - EACH ADDITIONAL FILMD0270 BITEWING - SINGLE FILMD0272 BITEWINGS - TWO FILMSD0273 BITEWINGS - THREE FILMSD0274 BITEWINGS - FOUR FILMSD0277 VERTICAL BITEWINGS - 7 TO 8 FILMSD0330 PANORAMIC FILMD0460 PULP VITALITY TESTSD0470 DIAGNOSTIC CASTSD1110 PROPHYLAXIS - ADULTSD1120 PROPHYLAXIS - CHILDD1203 TOPICAL APPLICATION OF FLUORIDE (CHILD)D1204 TOPICAL APPLICATION OF FLUORIDE ADULT THROUGH AGE 18D1206 TOPICAL FLUORIDE VARNISH - HIGH CARIES RISK PATIENTSD1351 SEALANT - PER TOOTHD1510 SPACE MAINTAINER - FIXED UNILATERALD1515 SPACE MAINTAINER - FIXED - BILATERAL TYPED1550 RECEMENTATION OF SPACE MAINTAINERD9110 PALLIATIVE EMERGENCY TREATMENT

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G. Special Limitations for Diagnostic and Preventive Services1. One (1) in a Benefit Year:

a. Limited evaluation, problem focused, (D0140), one per patient per dentist.b. Bitewings x-rays, one occurrence of two bitewings (D0272), three bitewings (D0273),

four bitewings (D0274) or eight vertical bitewings (D0277) for adults over the age of18.

c. Detailed and extensive evaluation, problem focused (D0160), one per patient perdentist.

2. Two (2) in a Benefit Year:a. Routine exams (D0120, D0145)b. Routine prophylaxis (D1110, D1120)c. Fluoride treatment for dependent children through age 18 (D1203, D1204)d. Bitewing x-rays (D0272) for dependent children through age 18.

3. One (1) in a 24 month period:Comprehensive evaluations (D0150) limited to one per patient per dentist. Additionalcomprehensive evaluations during the 24-month period will be processed as periodicevaluations (D0120).

4. One (1) in a three year period:a. Sealants (D1351) - Dependents through age 15 on permanent first and second

molars.b. Fixed space maintainers (D1510, D1515) - Dependents through the age of 18 for

premature loss of primary molars and permanent first molars, or those that havenot/will not develop.

5. One (1) in a five year period:Full mouth radiographs (D0210 & D0330).

H. Minor Restorative Services. The following American Dental Association CDT-4 Codes are coveredunder the Minor Restorative Services Category as listed in the Schedule of Benefits. Servicesperformed in this category are subject to a Waiting Period, a Deductible per Benefit Year and arepaid at the Coinsurance percentage listed in the Schedule of Benefits. Covered Services in thiscategory contribute to the calculation of the Benefit Year Maximum. Prior Creditable Coverage mayoffset all or part of the Waiting Period for this category. Please review the Schedule of Benefits todetermine the Waiting Period applied to Minor Restorative Services.

Proc Code DescriptionD2140 AMALGAM - ONE SURFACE, PRIMARY OR PERMANENTD2150 AMALGAM - TWO SURFACES, PRIMARY OR PERMANENTD2160 AMALGAM - THREE SURFACES, PRIMARY OR PERMANENTD2161 AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENTD2330 RESIN - ONE SURFACE, ANTERIORD2331 RESIN - TWO SURFACES, ANTERIORD2332 RESIN - THREE SURFACES, ANTERIORD2335 RESIN - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE

(ANTERIOR)D2390D2391D2392D2393

RESIN - BASED COMPOSITE CROWN, ANTERIORRESIN - BASED COMPOSITE - ONE SURFACE, POSTERIORRESIN - BASED COMPOSITE - TWO SURFACES, POSTERIORRESIN - BASED COMPOSITE - THREE SURFACES, POSTERIOR

D2394 RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIORD2910 RECEMENT INLAY

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Proc Code DescriptionD2920 RECEMENT CROWND2930 PREFABRICATED STAINLESS CROWN - PRIMARY TOOTHD2931 PREFABRICATED STAINLESS CROWN - PERMANENT TOOTHD2932 PREFABRICATED RESIN CROWND2933 PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOWD2934 PREFABRICATED ESTHETIC COATED CROWN - PRIMARY TOOTHD2950 CORE BUILDUP, INCLUDING ANY PINSD2951 PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATIOND2954 PREFABRICATED POST & CORE IN ADDITION TO CROWND2980 CROWN REPAIR - BY REPORTD3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)D3310 ROOT CANAL THERAPY - ANTERIOR (EXCLUDING FINAL RESTORATION)D3320 ROOT CANAL THERAPY - BICUSPID (EXCLUDING FINAL RESTORATION)D3330 ROOT CANAL THERAPY - MOLAR (EXCLUDING FINAL RESTORATION)D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - ANTERIORD3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - BICUSPIDD3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - MOLARD3351 APEXIFICATION/RECALCIFICATION - INITIAL VISITD3352 APEXIFICATION/RECALCIFICATION - INTERIM VISITD3353 APEXIFICATION/RECALCIFICATION - FINAL VISITD3354 PUPAL REGENERATIOND3410 APICOECTOMY/PERIRADICULAR SURGERY - ANTERIORD3421 APICOECTOMY/PERIRADICULAR SURGERY - BICUSPID (FIRST ROOT)D3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLAR (FIRST ROOT)D3426 APICOECTOMY/PERIADICULAR SURGERY EACH ADDT'L ROOTD3430 RETROGRADE FILLING - PER ROOTD3450 ROOT AMPUTATION - PER ROOTD3920 HEMISECTION (INCLUDING ANY ROOT REMOVAL)D3950 CANAL PREPARATION & FITTING OF PREFORMED DOWEL OR POSTD4341 PERIODONTAL SCALING AND ROOT PLANING - PER QUADRANTD4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, PER

QUADRANTD4910 PERIODONTAL MAINTENANCE PROCEDURES (FOLLOWING ACTIVE THERAPY)D5410 ADJUST COMPLETE DENTURE - UPPERD5411 ADJUST COMPLETE DENTURE - LOWERD5421 ADJUST PARTIAL DENTURE - UPPERD5422 ADJUST PARTIAL DENTURE - LOWERD5510 REPAIR BROKEN COMPLETE DENTURE BASED5520 REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH)D5610 REPAIR RESIN SADDLE OR BASED5620 REPAIR CAST FRAMEWORKD5630 REPAIR OR REPLACE BROKEN CLASPD5640 REPLACE BROKEN TEETH - PER TOOTH

D6080 IMPLANT MAINTENANCED6092 RECEMENT IMPLANT/ABUTMENT SUPPORTED CROWND6093 RECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE

D6930 RECEMENT BRIDGED6972 PREFABRICATED POST AND CORE IN ADDITION TO BRIDGE RETAINER

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D6973 CORE BUILDUP FOR RETAINER, INCLUDING ANY PINSD6980 BRIDGE REPAIR - BY REPORTD7111 CORONAL REMNANTS - DECIDUOUS TOOTHD7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOTD7210 SURGICAL REMOVAL OF ERUPTED TOOTHD7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUED7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONYD7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONYD7241 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY WITH COMPLICATIONSD7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS - CUTTING PROCEDURESD7251 CORONECTOMYD7260 ORAL ANTRAL FISTULA CLOSURED7261 PRIMARY CLOSURE OF SINUS PERFORATIOND7280 SURGICAL ACCESS TO AN UNERUPTED TOOTHD7310 ALVEOPLASTY IN CONJUNCTION WITH EXTRACTIONS - PER QUADRANTD7311 ALVEOPLASTY IN CONJUNCTION WITH EXTRACTIONS (1-3 TEETH)D7320 ALVEOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - PER QUADRANTD7340 VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION)D7350 VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, ETC.)D7471 REMOVAL OF EXOSTOSIS - MAXILLA OR MANDIBLED7472 REMOVAL OF TORUS PALATINUSD7473 REMOVAL OF TORUS MANDIBULARISD7485 SURGICAL REDUCTION OF OSSEOUS TUBEROSITYD7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUED7530 REMOVAL OF FOREIGN BODY, SKIN, OR SUBCUTANEOUS ALVEOLARD7560 MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN

BODYD7960 FRENULECTOMY - SEPARATE PROCEDURED7970 EXCISION OF HYPERPLASTIC TISSUE-PER ARCHD7971 EXCISION OF PERICORONAL GINGIVAD9220 DEEP SEDATION/GENERAL ANESTHESIA - FIRST 30 MIND9221 DEEP SEDATION/GENERAL ANESTHESIA - EACH ADD'L 15 MIND9241 IV CONSCIOUS SEDATIOND9242 IV CONSCIOUS SEDATION - EACH ADDITIONAL 15 MINUTES

I. Special Limitations for Minor Restorative Services1. One (1) in a six month period:

Recementation of space maintainers, crowns or bridges, but not within six months of insertionby the same dentist.

2. One (1) in a twelve month period:One restoration per surface on all teeth.

3. One (1) in twenty-four month period:Periodontal scaling and root planning (D4341, D4342)

4. Two (2) in a twelve month periodImplant maintenance procedures (D6080), including removal of prosthesis, cleansing ofprosthesis and abutments and reinsertion of prosthesis.

5. One (1) in a three year period:Rebasing, relining of partials and dentures

6 One (1) in a five year period:Single crown and abutment buildups, including pins.

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7 One (1) per tooth per lifetime:a. Stainless steel crowns (D2930, D2931) - under age 14.b. Stainless steel crowns with resin window (D2933) - under age 14.c. Prefabricated resin crowns (D2932) - under age 14.d. Prefabricated esthetic coated stainless steel crown (D2934) - under age 14e. Composite resin crown (D2390) for primary teeth only.f. Root canal therapy (D3310, D3320, D3330), no allowance for additional canals.

J. Major Restorative Services. The following American Dental Association CDT-4 Codes are coveredunder the Major Restorative Services Category as listed in the Schedule of Benefits. Servicesperformed in this category are subject to the Waiting Period, the Deductible per Benefit Year and arepaid at the Coinsurance percentage listed in the Schedule of Benefits. Covered Services in thiscategory contribute to the calculation of the Benefit Year Maximum.

(* - Indicates that X-rays are required upon claim submission.)Proc Code * Description

D2510 INLAY - METALLIC - ONE SURFACED2520 INLAY - METALLIC - TWO SURFACESD2530 INLAY - METALLIC - THREE SURFACESD2542 * ONLAY - METALLIC - TWO SURFACESD2543 * ONLAY - METALLIC - THREE SURFACESD2544 * ONLAY-METALLIC - FOUR OR MORE SURFACESD2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACED2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACESD2630 INLAY - PORCELAIN/CERAMIC - THREE SURFACESD2642 * ONLAY- PORCELAIN/CERAMIC - TWO SURFACESD2643 * ONLAY-PORCELAIN/CERAMIC - THREE SURFACESD2644 * ONLAY-PORCELAIN/CERAMIC - FOUR OR MORE SURFACESD2650 INLAY - COMPOSITE/RESIN - ONE SURFACED2651 INLAY - COMPOSITE/RESIN - TWO SURFACED2652 INLAY - COMPOSITE/RESIN - THREE OR MORE SURFACESD2662 * ONLAY - COMPOSITE/RESIN - TWO SURFACESD2663 * ONLAY - COMPOSITE/RESIN - THREE SURFACESD2664 * ONLAY - COMPOSITE/RESIN - FOUR OR MORE SURFACESD2740 * CROWN - PORCELAIN/CERAMIC SUBSTRATED2750 * CROWN - PORCELAIN FUSED TO HIGH NOBLE METALD2751 * CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METALD2752 * CROWN - PORCELAIN FUSED TO NOBLE METALD2780 * CROWN - 3/4 CAST HIGH NOBLE METALD2781 * CROWN - 3/4 CAST PREDOMINATELY BASE METALD2782 * CROWN - 3/4 CAST NOBLE METALD2783 * CROWN - 3/4 PORCELAIN/CERAMIC (NOT VENEERS)D2790 * CROWN - FULL CAST HIGH NOBLE METALD2791 * CROWN - FULL CAST PREDOMINANTLY BASE METALD2792 * CROWN - FULL CAST NOBLE METALD2952 * CAST POST & CORE IN ADDITION TO CROWND2962 * LABIAL VENEER (PORCELAIN LAMINATE) - LABD4210 * GINGIVECTOMY/GINGIVOPLASTY - PER QUADRANTD4211 * GINGIVECTOMY/GINGIVOPLASTY- ONE TO THREE TEETH, PER QUADRANTD4240 GINGIVAL FLAP, INCLUDING ROOT PLANING - PER QUADRANT

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D4241 GINGIVAL FLAP, INCLUDING ROOT PLANING - ONE TO THREE TEETH, PERQUADRANT

D4249 CROWN LENGTHENING - HARD/SOFT TISSUE, BY REPORTD4260 * OSSEOUS SURGERY (INCLUDING FLAP ENTRY & CLOSURE - PER QUADRANTD4261 * OSSEOUS SURGERY (INCLUDING FLAP ENTRY & CLOSURE- ONE TO THREE

TEETH, PER QUADRANT)D4263 * BONE REPLACEMENT GRAFT - SINGLE SITED4264 * BONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANTD4266 GUIDED TISSUE REGENERATION - RESORBABLE BARRIER PER SITE PER

TOOTHD4267 GUIDED TISSUE REGENERATION - NONRESORBABLE BARRIER PER SITE PER

TOOTHD4270 PEDICLE SOFT TISSUE GRAFT PROCEDURED4271 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE)D4273 SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURED4275 SOFT TISSUE ALLOGRAFTD4276 COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFTD5110 COMPLETE DENTURE - UPPERD5120 COMPLETE DENTURE - LOWERD5130 IMMEDIATE DENTURE - UPPERD5140 IMMEDIATE DENTURE - LOWERD5211 UPPER PARTIAL - RESIN BASE (WITH CONVENTIONAL CLASPS, RESTS &

TEETHD5212 LOWER PARTIAL - RESIN BASE (WITH CONVENTIONAL CLASPS, RESTS &

TEETHD5213 UPPER PARTIAL - CAST METAL BASE WITH RESIN SADDLESD5214 LOWER PARTIAL - CAST METAL BASE WITH RESIN SADDLESD5225 MAXILLARY PARTIAL DENTURE - FLEXIBLE BASED5226 MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASED5281 REMOVABLE UNILATERAL PARTIAL DENTURE -1 PIECE CAST METALD5650 ADD TOOTH TO EXISTING PARTIAL DENTURED5660 ADD CLASP TO EXISTING PARTIAL DENTURED5670 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAME WORK

(MAXILLARY)D5671 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK

(MANDIBULAR)D5710 REBASE COMPLETE UPPER DENTURED5711 REBASE COMPLETE LOWER DENTURED5720 REBASE UPPER PARTIAL DENTURED5721 REBASE LOWER PARTIAL DENTURED5730 RELINE COMPLETE UPPER DENTURE (CHAIRSIDE)D5731 RELINE COMPLETE LOWER DENTURE (CHAIRSIDE)D5740 RELINE UPPER PARTIAL DENTURE (CHAIRSIDE)D5741 RELINE LOWER PARTIAL DENTURE (CHAIRSIDE)D5750 RELINE COMPLETE UPPER DENTURE (LAB)D5751 RELINE COMPLETE LOWER DENTURE (LAB)D5760 RELINE UPPER PARTIAL DENTURE (LAB)D5761 RELINE LOWER PARTIAL DENTURE (LAB)

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D6010 IMPLANT - ENDOSTEAL/ENDOSSEOUSD6012 SURGICAL PLACEMENT OF INTERIM IMPLANT BODY FOR TRANSITIONAL

PROSTHESIS: ENDOSTEAL IMPLANTD6040 SURGICAL PLACEMENT: ENDOSTEAL IMPLANTD6050 SURGICAL PLACEMENT: TRANSOSTEAL IMPLANTD6053 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE, EDENTULOUS ARCHD6054 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE, PARTIALLY

EDENTULOUS ARCHD6055 CONNECTING BAR - IMPLANT OR ABUTMENT SUPPORTEDD6056 PREFABRICATED ABUTMENT - INCLUDES PLACEMENTD6057 CUSTOM ABUTMENT - INLCUDES PLACEMENTD6058 ABUTMENT SUPPORTED PROCELAIN/CERAMIC CROWND6059 ABUTMENT SUPPORTED PROCELAIN FUSED TO METAL CROWN (HIGH NOBLE

METAL)D6060 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN

(PREDOMINANTLY BASE METAL)D6061 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE

METAL)D6062 ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL)D6063 ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINATLY BASE METAL)D6064 ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL)D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWND6066 IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM,

TITANIUM ALLOY, HIGH NOBLE METAL)D6067 IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH

NOBLE METAL)D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPDD6069 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(HIGH NOBLE METAL)D6070 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(PREDOMINATLY BASE METAL)D6071 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(NOBLE METAL)D6072 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE

METAL)D6073 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINATLY

BASE METAL)D6074 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE METAL)D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPDD6076 IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(TITANIUM, TITANIUM ALLOY OR HIGH NOBLE METAL)D6077 IMPLANT SUPPORTED RETAINER FOR CAST METAL FPD (TITANIUM, TITANIUM

ALLOY OR HIGH NOBLE METAL)D6078 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR COMPLETELY

ENDENTULOUS ARCHD6079 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR PARITALLY

ENDENTULOUS ARCHD6080 IMPLANT MAINTENANCE PROEDURES, INCLUDING REMOVAL OF PROSTHESIS,

CLEANSING OF PROSTHESIS AND ABUTMENTS AND REINSERTION OFPROSTHESIS

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D6090 REPAIR IMPLANT SUPPORTED PROSTHESIS, BY REPORTD6091 REPLACEMENT OF SEMI-PRECISION OR PRECISION ATTACHMENT OF

IMPLANT/ABUTMENT SUPPORTED PROSTHESIS, PER ATTACHMENTD6094 ABUTMENT SUPPORTED CROWN - (TITANIUM)D6095 REPAIR IMPLANT ABUTMENT, BY REPORTD6100 IMPLANT REMOVAL, BY REPORTD6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD (TITANIUM)D6210 * PONTIC - CAST HIGH NOBLE METALD6211 * PONTIC - CAST PREDOMINANTLY BASE METALD6212 * PONTIC - CAST NOBLE METALD6240 * PONTIC - PORCELAIN FUSED TO HIGH NOBLE METALD6241 * PONTIC - PORCELAIN FUSED TO PREDOMINANTLY BASE METALD6242 * PONTIC - PORCELAIN FUSED TO NOBLE METALD6245 * PONTIC - PORCELAIN / CERAMICD6545 * RETAINER - CAST METAL FOR ACID ETCHED FIXED PROSTHESISD6548 * RETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED FIXED PROSTHESISD6600 INLAY - PORCELAIN/CERAMIC, TWO SURFACESD6601 INLAY - PORCELAIN/CERAMIC, THREE OR MORE SURFACESD6602 INLAY - CAST HIGH NOBLE METAL, TWO SURFACESD6603 INLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACESD6604 INLAY - CAST PREDOMINANTLY BASE METAL, TWO SURFACESD6605 INLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACESD6606 INLAY - CAST NOBLE METAL, TWO SURFACESD6607 INLAY - CAST NOBLE METAL, THREE OR MORE SURFACESD6608 * ONLAY - PORCELAIN/CERAMIC, TWO SURFACESD6609 * ONLAY - PORCELAIN/CERAMIC, THREE OR MORE SURFACESD6610 * ONLAY - CAST HIGH NOBLE METAL, TWO SURFACESD6611 * ONLAY - CAST HIGH NOBLE METAL, THREE OR MORE SURFACESD6612 * ONLAY - CAST PREDOMINANTLY BASE METAL, TWO SURFACESD6613 * ONLAY - CAST PREDOMINANTLY BASE METAL, THREE OR MORE SURFACESD6614 * ONLAY - CAST NOBLE METAL, TWO SURFACESD6615 * ONLAY - CAST NOBLE METAL, THREE OR MORE SURFACESD6740 * CROWN - PORCELAIN / CERAMICD6750 * CROWN - PORCELAIN FUSED TO HIGH NOBLE METALD6751 * CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METALD6752 * CROWN - PORCELAIN FUSED TO NOBLE METALD6780 * CROWN - 3/4 CAST HIGH NOBLED6781 * CROWN 3/4 CAST PREDOMINATELY BASED METALD6782 * CROWN 3/4 NOBLE METALD6783 * CROWN 3/4 PORCELAIN / CERAMICD6790 * CROWN - FULL CAST HIGH NOBLE METALD6791 * CROWN - FULL CAST PREDOMINANTLY BASE METALD6792 * CROWN - FULL CAST NOBLE METALD6920 CONNECTOR BARD6970 * CAST POST & CORE IN ADDITION TO BRIDGE RETAINERD9940 OCCLUSAL GUARD

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K. Special Limitations for Major Restorative Services1. One (1) in a three year period:

Rebasing/ relining of full or partial dentures.2. One (1) in a five year period:

a. Inlays and onlays, only if treatment is for decay purposes.b. Single crowns, only if treatment is for decay purposes or a broken tooth. This does

not include fracture-line repair in teeth. Crowns are not covered for patients underage 14 unless rationale is provided and approved by a Dental Advisor.

c. Removable prosthetics, including complete and partial dentures.d. Fixed prosthetics, including pontics and abutments (These are not covered for

patients under age 15 unless rationale is provided and approved by a DentalAdvisor.)

e. Partial denture retainers (D6545, D6548).f. Post & cores.

3. One (1) per tooth per lifetime:a. Crown lengthening (D4249), only covered when bone is removed. b. Guided tissue regeneration is allowed once per site (two adjacent teeth). Dental

Advisor review is required. 4. Crowns for members will include an allowance for single-tooth implants (the fixture and

abutment portion) (D6010) in addition to the allowance for the crown for the implant, subjectto the following:a. One (1) for each tooth every five (5) year period:b. The implant excludes third molar placement.c. For members age sixteen (16) or older.

L. Contract (Benefit) Year Maximum Rollover Benefit1. A Rollover Benefit is a portion of a Covered Person's un-used Benefit Year Maximum that

may be carried over to the next Contract Year, thereby increasing the next Contract YearMaximum amount, provided the following conditions are met:a. the Covered Person is an active member of the Plan on the last day of the Contract

Year;b. the Covered Person submits at least one (1) claim for a Covered Service during a

Contract Year;c. the Covered Person's total claims paid during a Contract Year do not exceed the

Yearly Threshold Amount of $500; andd. the Accumulated Rollover Maximum of $1,000 has not been reached.

2. Beginning with the second (2nd) Contract Year of coverage under this Policy, a CoveredPerson's Contract Year Maximum of $1,000 may be increased by $350 if all the above listedconditions are met. If coverage under this benefit is first provided during a partial ContractYear, the Rollover Benefit will be calculated as if coverage was provided for a full ContractYear.

Here's an example of how the Rollover Benefit works.Contract Year One (1) Two (2) Three (3) Four (4)

Contract Year Maximum shown on the Schedule ofBenefits

$1,000 $1,000 $1,000 $1,000

Accumulated Rollover Amount credit from prior year N/A $350 $700 $700

Adjusted Contract Year Maximum $1,000 $1,350 $1,700 $1,700

Covered Service received Yes Yes No

Total Claims Paid during Contract Year $275 $480 $0

Rollover Amount $350 $350 $0

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Contract Year One (1) Two (2) Three (3) Four (4)

Accumulated Rollover Amount $350 $700 $700

3. The Rollover Amount can be accumulated from one Contract Year to the next, up to theAccumulated Rollover Maximum, unless:a. the Covered Person's total claims paid during a Contract Year exceed the Yearly

Threshold Amount (in this instance, there will be no additional Rollover Amount forthat Contract Year), or

b. no claims for Covered Services are incurred during a Contract Year (in this instance,there will be no additional Rollover Amount for that Contract Year).

4. If total claims paid during any one Contract Year exceed the Contract Year Maximum of$1,000, the excess amount will be deducted from the Accumulated Rollover Amount availablefor that Contract Year. No additional Rollover Amount will be earned for that Contract Yearand the Accumulated Rollover Amount available for the next Contract Year will be reduced bythe amount deducted for the excess claim amount.

5. To properly calculate the Rollover Amount, claims should be submitted in a timely manner, asdescribed in this Policy.

6. Rollover Amounts are not available for the following expenses related to a Covered Person'sdental services:a. Deductibles;b. Coinsurance;c. copayments;d. balance billed amountse. non-covered amountsf. charges billed by Non-Participating Providers which exceed the allowed amount for

the services rendered; org. orthodontic benefits.

7. When Your Contract Year Maximum Rollover Benefit EndsYou will lose your right to any annual rollover benefit (or accumulated rollover maximumbenefit) when you cancel your Policy. The accumulated rollover benefit can be used onlywhile you are covered under this Policy. This means if you cancel your Policy, you lose yourright to any rollover benefit that has not been used.

ARTICLE IV. SPECIFIC BENEFIT LIMITATIONSThe following services will be subject to the limitations set forth below:A. Integral Services

These services are considered part of another service. No additional allowance will be paid if billedas a separate service.1. Supragingival scaling is Integral to a prophylaxis.2. Prophylaxis on the same day as a periodontal maintenance visit (D4910) or periodontal

treatment, including surgery.3. Prophylaxis on the same day as scaling and root planing (D4341, D4342), regardless of the

number of quadrants or teeth reported.4. Sealants on the same day as a resin restoration.5. Periapical x-rays taken on the same day as a panorex (D0330).6. Periapical x-rays and /or bitewings taken on the same day as a full series (D0210).7. Pulp vitality tests (D0460) with root canal therapy on same day.8. Adjunctive procedures that are Integral to crowns, inlays, and onlays.9. Intraoral I&D (D7510) with root canal therapy.10. Diagnostic x-ray taken the same day as the initial root canal therapy is covered. Any other

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x-rays 30 days before or after root canal therapy are Integral.11. Pulpotomies, in conjunction with root canal therapy by the same dentist within 45 days prior

to root canal therapy completion date are Integral to root canal therapy.12. Pulpotomy on the same date as deciduous root canal therapy.13. Payment is made for the most extensive periodontal surgical procedure that includes any

lesser procedures on the same date. If procedures are fragmented, the lesser procedures willbe denied as Integral.

14. Scaling and root planing same day as surgical periodontal procedures.15. Periodontal maintenance when reported with scaling and root planing on the same date

regardless of the number of quadrants or teeth reported.16. Periodontal maintenance on the same day and same dentist as surgical periodontal

procedures.17 Complete or partial denture adjustments within six months of insertion.18. Additional clasps (billed separately) are combined to the partial denture.19. Recementation of crowns and bridges when provided within 12 months following insertion by

the same dentist (unless there is an indication of root canal therapy) and then it is coveredonce per 12 months thereafter.

20. Temporary cementation of crowns or bridges.21. Frenulectomy (D7960) when provided the same date, same dentist, same area of the mouth

is Integral to soft tissue grafts.22. Apical curettage and small odontogenic cysts are denied as being Integral to apicoectomies.23. Rebasing/relining of full or partial denture within six months of insertion by the same dentist.24. Small cysts are denied as being Integral to extractions and surgical procedures in the same

area of the mouth by the same dentist.25. Crown lengthening on the same day by same dentist and same area as osseous surgery.

The osseous surgery will be denied as being Integral to the crown lengthening.26. Palliative emergency treatment is denied as being Integral to definitive treatment when

provided on the same day.27. Isolation of tooth with rubber dam.28. Local and block anesthesia.

B. The following services are specifically limited with the following conditions:1. Sealants (D1351) are covered for Dependent children through age 15 on permanent first and

second molars, and are limited to one sealant per three year period. 2. If the allowance for the combination of multiple periapicals, bitewings or full series of x-rays

exceeds the allowance for a full series they will be combined to a full series.3. Vertical bitewing x-rays (7 to 8 films, D0277) are paid with the same benefit limitations as four

bitewing x-rays (D0274).4. Protective restorations (D2940) are allowed as palliative treatment in emergency situations,

otherwise they deny as not covered.5. An allowance is made for pins (D2951) per restoration regardless of the number used, and

pins without a restoration are not covered.6. A crown must be necessary on its own merit, not just because it will support a partial.7. Intraoral incision and drain without root canal therapy is processed as a palliative treatment.

On an inquiry basis, the I&D is allowed if it was the only treatment required.8. Four quadrants of osseous surgery reported on the same date will require a Dental Advisor

review.9. Periodontal scaling without root planing will process as a routine prophylaxis or periodontal

maintenance treatment.10. Scaling and root planing for patients under age 19 requires diagnostic material submission

and a Dental Advisor review.11. Payment for periodontal maintenance does not include an evaluation.

If an evaluation is reported it will be processed as a separate procedure. We will decrease

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the allowance for D4910 by the current allowance for existing code D0120.12. Separate restorations may be allowed on same surface for anterior teeth. Separate lines

represent separate restorations. Procedures related to a restoration are not paid as separate,including repairs/replacements for 12 months.

13. Multiple posterior restorations are paid as one multi-surface restoration when provided on thesame day by the same dentist regardless of being reported as separate restorations.

14. Pins and/or posts reported, in addition to a buildup or post & core, are combined to thebuildup or post & core.

15. Buildups involving posts must be preceded by root canal therapy.16. Incomplete endodontic therapy of an inoperable or fractured tooth is covered by report

following review by the Dental Advisor.17. Deciduous root canal therapy is limited through age 5 for teeth D-G and N-Q, and through

age 11 for teeth A-C, H-J, K-M, and R-T.18. Apicoectomies, in absence of root canal therapy, are denied unless the canals are calcified.

Apicoectomy is not allowed within 30 days of root canal therapy.19. The final apexification visit includes root canal therapy. If billed separately, the root canal

therapy will be combined to the final visit.20. Pulpotomies are covered only on deciduous teeth.21. Relining and rebasing of full or partial dentures on the same day and the same dentist,

merges to the rebase (D5710, D5711, D5720, D5721.)22. Surgical extractions (D7210) denied for lack of coverage remain denied if resubmitted as

simple extractions (D7111, D7140) unless; on an inquiry basis, x-rays substantiate that it is asimple extraction.

23. The degree of impaction of teeth is determined via x-ray review (D7220, D7230, D7240, &D7241).

24. Complex vestibuloplasties, as well as a vestibuloplasty on the same day as other surgicalprocedures, requires Dental Advisor review.

25. Periodontal maintenance is covered if:a. the patient has periodontal coverageb. it follows active periodontal treatmentc. a routine prophylaxis has not been allowed on the same dayd. the number of periodontal maintenance procedures does not exceed two per year.

26. Diagnostic x-rays are not covered if there is no documentation in the patient's recordsindicating why the radiographs were ordered and/or what was diagnosed by the dentist uponreviewing the prescribed films.

27. Root canal retreatment (D3346, D3347, D3348) is allowed only if it has been three (3) yearsfollowing initial root canal therapy.

ARTICLE V. SERVICES NOT INCLUDED(American Dental Association CDT-4 procedure code numbers listed below are merely examples of codenumbers not covered. Other code numbers may apply to services not covered. You may contact theCompany to receive a full list of CDT-4 procedure codes at no cost.)Except as specifically provided in this Policy, no coverage will be provided for:A. a service, procedure or supply which is not Dentally Necessary or which is not listed in the Schedule

of Benefits;B. a service, procedure, or supply which is not prescribed or rendered by or under the direct supervision

of a dentist;C. any treatment, service, or supply received for any illness or accidental injury arising out of, or in the

course of employment or occupation for wage, profit or gain.Nor will the Company pay benefits for injury or illness for which the Covered Person receives anybenefits from motor vehicle no-fault law, regardless of any limitations in scope or coverage amountwhich may apply to his benefits claim under such laws.

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In the event that the Company pays any claim by the Covered Person for insurance benefits underthis Policy, and subsequently learn that the Covered Person had filed a claim for workers'compensation benefits as to such claim, or that the Covered Person had settled a workers'compensation claim with any workers' compensation carrier, or has otherwise received any amounttoward payment of such a claim under the Arkansas Workers' Compensation Law, state or federalworkers' compensation, employer's liability or occupational disease law, or motor vehicle no-fault law,the Covered Person agrees to reimburse the Company to the full extent of the Company's paymentson such claim;

D. conditions to which dental treatment is provided by a federal or state government agency (notincluding medical assistance) or are provided without cost to any Covered Person by any politicalsubdivision or governmental authority (This does not include plans of insurance or other benefit plansprovided by the federal or state governments to government employees and employee's dependents);

E. Services for intentional self-inflicted injuries, including Drug Overdose, where the act resulted from nomedical condition (physical or mental)

F. Disease contracted or injuries sustained while serving in the military forces of any nation.G. any condition to which services, treatment, or supplies of any kind are furnished or paid for under

Title XVIII (Medicare) or the Social Security Act, as amended;H. services, procedures or supplies with respect to congenital mouth malformations or skeletal

imbalances, including, but not limited to:1. Treatment related to cleft palate therapy;2. Treatment related to disharmony of facial bone; or3. Treatment related to or required as a result of orthognathic surgery;

I. services or supplies that are cosmetic in nature or performed on an elective basis, e.g., teethbleaching, crowns or veneers on sound teeth, etc;

J. prescription drugs;K. local or block anesthesia, when billed separately;L. general anesthesia, for a non-covered service, as well as simple extractions, or routine chairside

procedures;M. any experimental or investigational services or supplies or for any condition or complication arising

from or related to the use of such experimental or investigational services or supplies. The Companyshall have full discretion to determine whether a dental treatment is experimental or investigational.Any dental treatment may be deemed experimental or investigational, in the Company's discretion, if:1. reliable evidence (as defined below) shows that the majority opinion among experts, as stated

in the published authoritative literature, regarding the dental treatment or procedure is thatfurther studies or clinical trials are necessary to determine its efficacy or its efficacy ascompared with a standard means of treatment or diagnosis.

2. reliable evidence (as defined below) shows that a majority opinion among experts, as statedin the published authoritative literature, regarding the dental treatment or procedure neithersupports nor denies its use for a particular condition or disease.

3. reliable evidence (as defined below) shows that the majority opinion among experts, as statedin the published authoritative literature, regarding the dental treatment or procedure shouldnot be used as a first line therapy for a particular condition or disease.“Reliable Evidence” shall mean only the following sources:(a) the patient's dental records or other information from the treating Dentist(s) or from a

consultant(s) regarding the patient's dental history, treatment or condition;(b) the written protocol(s) under which the treatment or procedure is provided to the

patient;(c) any consent document the patient has executed or will be asked to execute, in order

to receive the treatment or procedure;(d) published reports and articles in the authoritative dental and scientific literature,

signed by or published in the name of a recognized dental expert, regarding thetreatment or procedure at issue as applied to the injury, illness or condition at issue;or

(e) the written protocol(s) used by another facility studying substantially the same dental

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treatment or procedure.N. the cost to replace lost, stolen, or damaged prosthetic appliances;O. house calls (D9410) and hospital calls (D9420) for dental services;P. services incurred prior to the Covered Person's effective date or after the termination date of

coverage with the Company;Q. resorbable fillings (D3230, D3240) on endodontic-treated deciduous teeth;R. any dental or medical services performed by a physician for services covered or otherwise provided

to the Covered Person by a medical-surgical plan;S. services which the Covered Person incurs at no cost;T. services which are necessitated by lack of patient cooperation or failure to follow a professionally

prescribed Treatment Plan;U. plaque control programs, oral hygiene or dietary instructions;V. any procedure deemed by the Dental Advisor to be of questionable efficacy;W. charges for broken appointments;X. any dental services or supplies required as the result of any accidental or traumatic injury;Y. any dental services or supplies resulting from an injury or condition caused by another party;Z. dental procedures requiring appliances or restorations that are necessary for full mouth rehabilitation,

the restoration of occlusion, or to alter vertical dimensions of occlusion (except when involving full orpartial dentures);

AA. non-intravenous conscious sedation (D9248), analgesia, anxiolysis or inhalation of nitrous oxide(D9230);

AB. services by an immediate relative. "Immediate relative" means your spouse, parents, children, brother,sister, or legal guardian of the person who received the services;

AC. duplicate, interim, and temporary procedures, devices and appliances. (e.g., when a dentist begins acrown and places a temporary crown, then submits charges for a permanent crown; coverage for thetemporary crown will be denied.);

AD. procedures requiring the presence of a tooth will be denied if history indicates the tooth has beenextracted (e.g., a crown is being reported and the tooth is listed as extracted in history);

AE. gold foil restorations; (D2410, D2420, D2430).AF. if a course of treatment is performed by more than one (1) dentist, the Company will pay only the

charges that would have been made by a single dentist for those services;AG. charges for the completion of any insurance forms;AH. applications of desensitizing medicaments, sub-gingival irrigations, and the localized delivery of

chemotherapeutic agents (D4381);AI. double abutments unless there is evidence of decay noted on x-ray;AJ. removable space maintainers (D1520, D1525) and maintainer repairs;AK. post removal (not in conjunction with endodontic therapy);AL. synthetic grafts placed in extraction sites.AM. periodontal provisional splinting, intracoronal or extracoronal;AN. any services to restore tooth structure lost in order to rebuild or maintain occlusal surfaces due to

mal-aligned or maloccluded teeth, lost from wear, or for stabilizing the teeth;AO. silicate cements;AP. tissue conditioning (D5850, D5851);AQ. athletic mouthguards (D9941);AR. overdentures (D5860, D5861);AS. precision attachments (D5862, D6950);AT. gross debridement (D4355);AU. fiberotomies (D7291);AV. x-ray and intraoral imaging (D0260, D0290, D0310, D0320, D0321, D0322, D0350);AW. tests / laboratory examinations (D0415, D0425, D0472, D0473, D0474, D0480, D0502);AX. nutritional counseling (D1310);

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AY. tobacco counseling (D1320);AZ. replacement of fillings due to mercury sensitivity;BA. prefabricated resin crowns, stainless steel crowns, or stainless steel crowns with resin windows for

patients age 14 and older.BB. pulpectomy on a permanent tooth;BC. extraoral I&D (D7520); BD. direct (D3110) and indirect (D3120) pulp caps ;BE. procedure for isolation of tooth with rubber dam (D3910);BF. bleaching of teeth (D9972, D9973, & D9974) ;BG. intentional re-implantation (D3470);BH. dressing change (D4920) ;BI. maxillofacial prosthetics;BJ. precious metal for partial dentures;BK. partial dentures are not covered for patients under age 14 unless rationale is reported and approved

by the Dental Advisor;BL. specialized procedures (D5862, D6920, D6940, D6950, D6975);BM. alveoloplasties involving less than five teeth ;BN tooth transplantation (D7272) or tooth reimplantation (D7270);BO. excision / destruction of lesions (D7410, D7411, D7412, D7413, D7414, D7415, D7440, D7441,

D7450, D7451, D7460, D7461);BP. treatment of simple and compound fractures (D7610 - D7680, D7710 - D7760, D7770, D7771,

D7780);BQ. treatment and reduction of dislocation and management of TMJ/TMD (Temporomanibular Joint /

Temporomandibular Joint Dysfunction) (D7810 - D7899) including diagnostic x-rays, occlusalappliances, and/or splints;

BR. consultations (D9310);BS. drugs, medicaments, and/or injections (D9610, D9630);BT. behavior management (D9920);BU. occlusal analysis (D9950) and occlusal adjustments (D9951, D9952);BV. pulpotomy on a permanent tooth will deny as not covered unless there is an indication of an

emergency in which case it is paid as a palliative treatment;BW. bridges for patients under age 14;BX. replacement of teeth if there is insufficient space;BY. root recovery (D7250) not completely covered by bone, if provided by the same dentist who extracted

the tooth;BZ. splinted crowns not replacing teeth; abutment crown(s) can be allowed if the tooth is diseased or

badly broken down;CA. gross pulpal debridement (D3221);CB. distal or proximal wedge procedure (D4274);CC. procedures performed prior to coverage or placed after termination of coverage are not covered.CD. pallative emergency treatment (D9110) when definitive treatment is provided by the same dentist on

the same day.CE. protective restorations (D2940)CF. re-evaluation limited, problem focused (D0170) and comprehensive periodontal evaluation (D0180);CG. oral surgery procedures for jaw deformities, resections, etc. (D7920, D7940, D7941, D7943, D7944,

D7945, D7946, D7947, D7948, D7949, D7950, D7955, D7972, D7980, D7981, D7982, D7983,D7990, D7991, D7995, D7996 and D7997);

CH. apically positioned flap procedure (D4245);CI. enamel microbrasion (D9970);CJ. odontoplasty (D9971);CK. sleep apnea appliances;

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CL. biologic materials to aid in soft and osseous tissues regeneration (D4265);CM. provisional pontic (D6253); titanium pontic (D6214); indirect resin pontic (D6205)CN. provisional retainer crown (D6793);CO. pediatric partial denture-fixed (D6985);CP. mobilization of erupted or malpositioned tooth to aid eruption (D7282);CQ. cytology sample collection (D7287);CR. a panoramic film or panorex (D0330) is not covered for Children under the age of five.CS. fixed partial denture resin crowns, retainer or pontics on permanent teethCT. orthodontic treatment for any reason is not covered.CU. hospital or anesthesia fees due to the management of the patient.CV. hospital facility fees for dental services.CW. biopsy of oral tissue (D7285, D7286);CX. Preventive resins (D1352)CY. Any service not listed under ARTICLE III. Covered Services.

ARTICLE VI. SUBROGATIONIf a Covered Person is injured by a third party, the Company is subrogated to all rights the Covered Personmay have against any party liable for payment of medical treatment (including any and all insurance carriers)to the extent of payment for the services or benefits provided. The Covered Person must cooperate fully withthe Company in its efforts to collect from the third party, and if the Covered Person fails to do so, theCompany shall be entitled to withhold coverage of or offset future claim payments for benefits, services,payments or credits due under this Benefit Certificate. The Company may assert its subrogation rightsindependently of the Covered Person. In addition to the above-referenced subrogation rights, the Companyalso has reimbursement rights should the Covered Person, or the legal representative, estate or heirs of theCovered Person recover damages by settlement, verdict or otherwise, for an accident, injury or illness. If arecovery is made, the Covered Person shall promptly reimburse the Plan any monetary recovery made by theCovered Person and includes, but is not limited to, uninsured and underinsured motorist coverage, anyno-fault insurance, medical payments coverage, direct recoveries from liable parties, or any other source.

ARTICLE VII. COORDINATION AGAINST OTHER DENTAL COVERAGEA. Definitions:

1. Allowable Expense is a necessary, reasonable, and customary item of expense for dentalcare; when the item of expense is covered at least in part by one or more plans covering theinsured for whom claim is made.When a plan provides benefits in the form of services, the reasonable cash value of eachservice rendered will be considered both an allowable expense and a benefit paid.

2. Claim Determination Period is a Benefit Year. However, it does not include any part of ayear during which a Covered Person has no coverage under this Policy.

3. Other Dental Plan is any form of coverage which is separate from this Policy with whichcoordination is allowed. Other Dental Plans shall be any of the following which providesdental benefits or services:a. Group insurance or group-type coverage, whether insured or uninsured, including

prepayment groups. It does not include school accident type coverage (grammar, highschool and college student coverages, including athletic injury, either on a twenty-four(24) hour basis or on a "to and from school basis") or group or group type hospitalindemnity benefits of $100 or less per day.

b. Individually underwritten dental plan with a coordination of benefits provision.c. Coverage under a governmental plan, or coverage required or provided by law. This

does not include a state plan under Medicaid (Title XIX, Grants to States for MedicalAssistance Programs, of the United States Social Security Act, as amended).

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Each contract or other arrangement for coverage under a., b. or c. is a separate plan. Also, ifan arrangement has two parts and COB rules apply only to one of the two, each of the partsis a separate plan.

4. Primary Plan is the plan which determines its benefits first and without considering the otherplan's benefits. A plan that does not include a COB provision may not take the benefits ofanother plan into account when it determines its benefits. In other words, a plan that does nothave a COB provision is always the Primary Plan.

5. Secondary Plan is the plan which determines its benefits after those of the other plan(Primary Plan). Benefits may be reduced because of the other plan's (Primary Plan) benefits.When there are more than two plans covering the person, This Plan may be a Primary Planas to one or more other plans, and may be a Secondary Plan as to a different plan or plans.

6. This Plan is this Individual Policy.B. Applicability

If either a Policyholder or Eligible Dependent are covered by any other dental benefits plan andreceive services covered by both This Plan and the other plan, benefits will be coordinated. Thismeans that one plan will be primary, while the other plan will be secondary. Each plan will provideonly that portion of its benefit that is required to cover expenses. Coordination of Benefits preventsduplicate payments and overpayments.The Company will determine the Allowable Expense in accordance with ADA guidelines oncoordination of benefits.

C. Order of Benefit Determination Rules1. General

When there is a basis for a claim under This Plan and another Plan, This Plan is aSecondary Plan which has its benefits determined after those of the other plan, unless;a. The other plan has rules coordinating its benefits with those of This Plan; andb. Both those rules and This Plan's rules require that This Plan's benefits be determined

before those of the other plan.2. Rules

This Plan determines its order of benefits using the first of the following rules which applies:a. Non-Dependent/Dependent - The benefits of the plan which covers the Covered

Person as an employee, member or subscriber are determined before those of theplan which covers the Covered Person as a dependent; except that: if the CoveredPerson is also a Medicare beneficiary, and as a result of the rule established by TitleXVIII of the Social Security Act and implementing regulations, Medicare is(i) Secondary to the plan covering the Covered Person as a dependent and(ii) Primary to the plan covering the Covered Person as other than a dependent

then the benefits of the plan covering the Covered Person as a dependentare determined before those of the plan covering that Covered Person asother than a dependent.

b. Dependent Child/Parents Not Separated or Divorced - Except as stated in Paragraphc. below, when This Plan and another plan cover the same child as a dependent ofdifferent persons, called parents:(i) The benefits of the plan of the parent whose birthday falls earlier in a year

are determined before whose of the plan of the parent whose birthday fallslater in that year; but

(ii) If both parents have the same birthday, the benefits of the plan whichcovered one parent longer are determined before those of the plan whichcovered the other parent for a shorter period of time.

(iii) The word "birthday" refers only to month and day in a calendar year, not theyear in which the person was born.

However, if the other plan does not have the rule described in (i) immediately above,but instead has a rule based on gender of the parent, and if, as a result, the plans donot agree on the order of benefits, the rule in the other plan will determine the orderof benefits.

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c. Dependent Child/Separated or Divorced - If two or more plans cover an CoveredPerson as a dependent child of divorced or separated parents, benefits for the childare determined in this order:(i) First, the plan of the parent with custody of the child;(ii) Then, the plan of the spouse of the parent with custody;(iii) Finally, the plan of the parent not having custody of the child.However, if the specific terms of a court decree state that one of the parents isresponsible for the health care expense of the child, and the entity obligated to pay orprovide the benefits of the plan of that parent has actual knowledge of those terms,the benefits of that plan are determined first. The plan of the other parent shall be theSecondary Plan. This paragraph does not apply with respect to any ClaimDetermination Period or Plan Year during which any benefits are actually paid orprovided before the entity has that actual knowledge.

d. Joint Custody - If the specific terms of a court decree state that the parents shallshare joint custody, without stating that one of the parents is responsible for thedental care expenses of the child, the plans covering the child shall follow the orderof benefit determination rules outlined in Paragraph b.

e. Continuation Coverage - If a Covered Person whose coverage is provided under aright of continuation pursuant to federal or state law also is covered under anotherplan, the following shall be the order of benefit determination:(i) First, the benefits of a plan covering the Covered Person as an employee,

member or subscriber (or as that Covered Person's dependent);(ii) Second, the benefits under the continuation coverage.

If the other plan does not have the rules described above, and if, as a result,the plans do not agree on the order of benefits, this rule is ignored.

f. Longer/Shorter Length of Coverage - If none of the above rules determine the orderof benefits, the benefits of the plan which covered a, member or subscriber longerare determined before those of the Plan which covered that Covered Person for theshorter term.

D. Effect on the Benefits of This Plan:1. When This Section Applies

This section applies when This Plan is the Secondary Plan in accordance with the order ofbenefits determination outlined above. In that event, the benefits of This Plan may be reducedunder this section.

2. Reduction in this Plan's BenefitsThe benefits of This Plan will be reduced when the sum of:a. The benefits that would be payable for the allowable expense under This Plan in the

absence of this COB provision; andb. The benefits that would be payable for the allowable expense under the other plans,

in the absence of provisions with a purpose like that of this COB provision; whetheror not claim is made, exceeds those allowable expenses in a claim determinationperiod. In that case, the benefits of This Plan will be reduced so that they and thebenefits payable under the other plans do not total more than those allowableexpenses.

When the benefits of This Plan are reduced as described above, each benefit is reduced inproportion. It is then charged against any applicable benefit limit of This Plan.

ARTICLE VIII. OTHER PROVISIONSA. Entire Policy.

This Policy, any amendments thereto, and this Application, Change Request Form and the Scheduleof Benefits constitute the entire agreement between the parties. No part of this Policy shall bechanged or waived in any way except by written amendment signed by the President of the

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Company. No Agent has the authority to change any of its terms.You hereby expressly acknowledge your understanding that this Policy constitutes a contract solelybetween you and Arkansas Blue Cross and Blue Shield, that Arkansas Blue Cross and Blue Shield isan independent corporation operating under a license from the Blue Cross and Blue ShieldAssociation, an association of independent Blue Cross and Blue Shield Plans, (the "Association")permitting Arkansas Blue Cross and Blue Shield to the use the Blue Cross and Blue Shield ServiceMarks in the State of Arkansas, and that Arkansas Blue Cross and Blue Shield is not contracting asthe agent of the Association. You further acknowledge and agree that you have not entered into thisContract based upon representations by any person other than Arkansas Blue Cross and Blue Shieldand that no person, entity, or organization other than Arkansas Blue Cross and Blue Shield shall beheld accountable or liable to you for any of the obligations created under this Policy.

B. Time Limit on Certain Defenses.1. Except for fraudulent misstatements made by you in the application for this Policy, no

misstatement shall be used to void any of its terms after three (3) years.2. Incontestable. Except for a disease or physical condition excluded from coverage by name or

description no claim for loss occurring after twelve (12) months from the effective date of thisPolicy shall be denied.

C. Termination of a Covered Person's Coverage for Cause:1. The Company may terminate coverage under this Policy upon fifteen (15) days' written notice

for:a. concealment of information, misrepresentation (whether intentional or not) or fraud in

obtaining coverage; orb. concealment of information, misrepresentation (whether intentional or not) or fraud in

the filing of a claim for services, supplies, or in the use of services or facilities.2. For purposes of this termination for cause provision, concealment of information or a

misrepresentation occurs if (i) information is withheld or if incorrect information is providedand (ii) the Company would not have issued this Policy, would have charged a higherpremium, would have required the Policy to be amended, or would not have paid a claim inthe manner it was paid had the Company known the facts concealed or misrepresented.

3. Termination for cause shall be effective upon the later of (i) fifteen (15) days after a writtennotice of termination for cause is posted in the U.S. Mail, addressed to the Policyholder at hisor her last known address as provided by Policyholder to Company; or (ii) the date stated inthe termination notice letter to Policyholder.

4. A Covered Person may appeal a termination for cause action. Such an appeal must besubmitted in writing, addressed to the Appeals Coordinator of Arkansas Blue Cross and BlueShield, 601 S. Gaines Street, Little Rock, Arkansas 72203. In order for the appeal to beconsidered the Appeals Coordinator must receive the appeal prior to the later of (i) fifteen(15) days after a written notice of termination for cause is posted in the U.S. Mail, addressedto the Policyholder at his or her last known address as provided by Policyholder to Company;or (ii) the termination effective date stated in the termination notice letter to Policyholder.

D. Notice and Proof of Claim.1. You must submit written proof of any services, supplies or treatment and the Charges to the

Company within one hundred eighty (180) days after such services, supplies or treatmentwere received.

2. The Company, upon receipt of such notice, will furnish to you such forms as are usuallyfurnished by it for filing proof of loss. If such forms are not so furnished within fifteen (15)days after the Company receives such notice, you shall be deemed to have complied with therequirements as to proof of loss upon submitting, within the time fixed for filing proof of loss,written proof covering the occurrence, character and extent of the loss for which claim ismade.

3. Subject to all applicable statutory provisions and rules and regulations of the ArkansasInsurance Department, all benefits payable under this Policy will be payable immediately uponreceipt of written proof of loss.

E. Legal Actions. No Court suit shall be brought to recover on this Policy before sixty (60) days afterwritten proof of loss has been furnished in accordance with the requirements of this Policy. No legal

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action shall be brought after the expiration of three (3) years from the time written proof of loss isrequired to be furnished.

F. This Policy shall be in effect until terminated by its terms.G. Unless you change residence from Arkansas (See ARTICLE VIII., L.) this Policy and any

amendments or riders to it are guaranteed renewable. The initial premium you pay for this Policy willnot increase during the first twelve (12) months this Policy is in force. After twelve (12) months, yourpremium rate will be subject to any changes in premium resulting from your age increasing over oneof the premium rate age–bands or the Company changing the established premium rate for allpolicies and riders of the same form number and premium classification as this Policy.

H. A grace period of thirty–one (31) days will be granted for the payment of premiums becoming payableafter the first such payment, during which grace period the Policy shall continue in force. If premiumsare not paid within thirty–one (31) days after they become due and payable this Policy is terminatedas of the date on which the premiums were due and payable.

I. Reinstatement: If any renewal premium is not paid within the grace period, a subsequent acceptanceof premium by the Company or by any agent authorized by the Company to accept such premium,without requiring in connection therewith an application for reinstatement, shall reinstate the Policy;provided, however, that if the Company or such agent requires an application for reinstatement andissues a conditional receipt for the premium tendered, the Policy will be reinstated upon approval ofsuch application by the Company or, lacking such approval, upon the forty–fifth day following the dateof such conditional receipt unless the Company has previously notified the Covered Person in writingof its disapproval of such application. The reinstated Policy shall cover only loss as may begin morethan ten (10) days after such date. In all other respects, the Covered Person and Company shallhave the same rights there under as they had under the Policy immediately before the due date ofthe defaulted premium, subject to any provisions endorsed hereon or attached hereto in connectionwith the reinstatement. Any premium accepted in connection with a reinstatement shall be applied toa period for which premium has not been previously paid, but not to any period more than sixty (60)days prior to the date of reinstatement.

J. This Policy shall terminate upon the death of the Policyholder. In such event, the Company shallreturn all unearned premiums to your estate or other appropriate party.

K. Before any benefits can be paid, you agree, as a condition of coverage under this Policy, andauthorize and direct any provider of dental services or supplies to furnish Arkansas Blue Cross andBlue Shield, its agents, or any of its subsidiaries, upon request, all records, or copies thereof, relatingto such services or supplies. Further, as a condition of your coverage, you authorize the release ofsuch records to any third party review person or entity, for purposes of dental review or secondopinion surgery. Finally, as a condition of coverage, you agree to fully and truthfully respond toinquiries from the Company about your claim or condition, including, but not limited to, your otherinsurance coverage, third party liability, or workers' compensation benefits and to request that anydentist or other provider so respond to all such inquiries. You understand and agree that your failureto respond to inquiries from the Company, or failure to cooperate fully to obtain information requestedby the Company from your dentist or other provider shall be, by itself, grounds for denial of benefitsunder this Policy.

L. Change of Residence. Upon a Policyholder moving permanently to another state, this Policy shall bevoid at the end of the period for which premiums have been paid. Upon application to the Company,membership shall be transferred to the Company in the area of your new residence. Upon transfer,rates and benefits may be substantially different.

M. Assignment. No assignment of benefits under this Policy shall be valid until approved and acceptedby the Company. The Company reserves the right to make payment of benefits, in its sole discretion,directly to the provider of service or to the Policyholder.

N. Upon termination of this Policy all benefits, except charges incurred prior to termination, shall cease.O. How To Appeal A Claim

1. If a claim for benefits is denied either in whole or in part, you will receive a notice explainingthe reason or reasons for the denial. You may request a review of a denial of benefits for anyclaim or portion of a claim by sending a written request to the Appeals Coordinator ofArkansas Blue Cross and Blue Shield, 601 S. Gaines Street, Little Rock, Arkansas 72203.Your request must be made within sixty (60) days after you have been notified of the denialof benefits.

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2. In preparing your request for review, you or your duly authorized representative will have theright to examine documents pertinent to your claim. However, medical information can bereleased to you only upon the written authorization of your physician. You or yourrepresentative may submit, with your request for review, any additional information relevant toyour claim and may also submit issues and comments in writing. A complete review will thenbe made of all information relating to your claim. You will receive a final decision in writingwithin sixty (60) days after the receipt of your review request, except where specialcircumstances require extensive review. A final decision will be sent to you after no longerthan one hundred twenty (120) days.

3. The Company acting on behalf of the Plan shall have authority and full discretion todetermine all questions arising in connection with your insurance benefits, including but notlimited to eligibility, interpretation of Plan language, and findings of fact with regard to anysuch questions. The actions, determinations and interpretations of the Company acting onbehalf of the Plan with respect to all such matters, and with respect to any other matterswithin the scope of its authority, shall be conclusive and binding on you and the Plan.

P. Despite our best efforts, we may make a claim payment which is not for a benefit provided under thisPolicy, or we may make payment to you when payment should have gone directly to the Provider oftreatment or services instead. In the event of an erroneous or mistaken payment, you agree to refundthe full amount of such payment to us promptly upon our request. The Company will have the right tooffset future payments made to you or your provider if prompt refund of such payment is notreceived.

ARTICLE IX. POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS AND VOTINGA. Membership

By virtue of ownership of this Policy, the Policyholder is a member of Arkansas Blue Cross and BlueShield. This Policy is a non-participating policy. This means that the Policyholder does not receivedistribution of any premium, revenues, savings or assets of the Company.

B. Annual MeetingAn annual meeting of the members shall be held each and every calendar year in the State ofArkansas for the purpose of electing directors, receiving and considering reports as to the businessand affairs of the Company and transacting such other business as may properly come before themeeting. The meeting shall be held between January 1 and April 1 of each year at such place, dateand time as shall be fixed by the Board of Directors or the Chief Executive Officer. The Board ofDirectors may, from time to time, provide that the place, date and time of the annual meeting shall beset forth in the Policy of members as set out in Section D. below.

“THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD EACH YEAR ATTHE HOME OFFICE, LOCATED AT 601 GAINES STREET, LITTLE ROCK,ARKANSAS, ON THE THIRD MONDAY IN MARCH AT 1:00 P.M. (PROVIDED, IFSUCH DAY SHALL BE A LEGAL HOLIDAY, THEN AT THE SAME TIME ANDPLACE ON THE NEXT SUCCEEDING DATE WHICH IS NOT A LEGAL HOLIDAY).”

C. Special MeetingsA special meeting of members for any purpose may be called by the Board of Directors or ChiefExecutive Officer, and shall be called by the Chief Executive Officer of the Secretary at the request ofmembers holding one-third (1/3) of the voting power entitled to vote thereat. Such request shall statethe purpose or purposes of the meeting, and no other business outside the scope of the statepurpose or purposes shall be transacted. Unless ordered by the Board of Directors, the time andplace of each special meeting of members shall be determined by the Chief Executive Officer.

D. Notice of MeetingsSo long as each insurance Policy issued by the Company sets forth the place, date and hour of theannual meeting of members, no notice of any annual meeting shall be required to be given to anymember, regardless of the number or nature of proposals to be considered and voted upon at theannual meeting. If notice of the annual meeting is not set forth in each insurance Policy, written orprinted notice of the annual meeting and every special meeting of the members, stating the place,date, time and the purpose or purposes of such meeting shall be given to the members entitled to

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vote at such meeting not less than ten (10), nor more than sixty (60), days before the date of themeeting. All such notices shall be given, either personally or by the mail, by or at the direction of theChief Executive Officer or Secretary unless ordered by the Board of Directors. Notices which shall bemailed shall be deemed to be "given" when deposited in the United States Mail addressed to themember at the member's address as it appears on the records of the Company, with postage prepaid[first class mail], if the notice is mailed thirty (30) days or less before the date of the meeting], andany notice transmitted other than by mail shall be deemed to have been "given" when delivered tothe member.

E. QuorumExcept as otherwise provided by applicable law, a majority of the members of the Company (presentin person or by proxy) shall be necessary to constitute a quorum for the transaction of business atany annual or special meeting of the members of the Company.

F. Voting RightsEach member shall be entitled to one vote for each policy held by him upon each matter coming to avote at meetings of members provided, a group policyholder shall be entitled to a number of votesequal to the number of certificate holders insured under this Group Policy. Such vote may beexercised in person or by written proxy.

G. Vote RequiredA majority of the voting power represented at any meeting of members shall be necessary andsufficient to approve any given matter. There shall be no cumulative voting.

H. ProxyAt all meetings of members a member may vote by proxy executed in writing by the member or bythe member's duly authorized attorney in fact. Such proxy shall be filed with the Secretary beforecommencement of the meeting or at such late time as shall be expressly permitted by the Corporateofficer presiding at such meeting. Once a Policy is issued by the Company, the Policyholder shallreceive a proxy form for the Policyholder's signature. The proxy form shall contain a provisionpursuant to which the Policyholder thereof grants a revocable proxy to the Board of Directors withrespect to all matters to be considered and voted upon by members at any meeting occurring whilesuch insurance Policy is in force.

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VISION

LIMITED BENEFIT POLICY

GROUP NO.: 371000

PACKAGE NO.: 02

INDIVIDUAL POLICY

Attached is the Schedule of Benefits, showing name ofPolicyholder, Policy number, type of Policy (individual

or otherwise), premiums and the effective date.

GUARANTEED RENEWABLE CONDITIONED UPON RESIDENCE IN ARKANSASPREMIUMS SUBJECT TO CHANGE


LITTLE ROCK, ARKANSAS 7220117-278 1/12 2012-01-05

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ARKANSAS BLUE CROSS AND BLUE SHIELD

VISION EXPENSE POLICY

OUTLINE OF COVERAGE

If, after examination of your Policy, you are not satisfied with any of its terms or conditions, you may return itto the Company within thirty (30) days of its delivery to you and receive a full refund of all premiums.

READ YOUR POLICY CAREFULLY - This outline of coverage provides a very brief description of theimportant features of your Policy. The outline is not your Policy and only the actual Policy provisions willcontrol. The Policy itself sets forth in detail the rights and obligations of both you and your insurancecompany. It is, therefore, important that you READ YOUR POLICY CAREFULLY.

VISION EXPENSE COVERAGE - Policies of this category are designed to provide to persons insured,coverage for vision expenses. Coverage is provided for a vision examination and vision materials subject toany Copayment provisions or other limitations which may be set forth in the Policy.

BENEFITS

COPAYMENT - is the amount the Covered Person must pay for Covered Services in any Frequency Periodbefore benefits will be paid, subject to the limitations shown on the Schedule of Benefits.

COVERED SERVICES -Vision Exam - One exam every twelve (12) monthsSpectacle Lenses - Up to two lenses provided one time every twelve (12) monthsFrame - One frame provided one time every twelve (12) monthsContact Lens Allowance - Contact lenses benefit provided in lieu of lenses and/or frame one timeevery twelve (12) months.

ALLOWABLE CHARGE -Frame - The amount the Policy will allow for frames. Any amount over the Allowable Charge is the CoveredPerson's responsibility.Contact Lenses - The amount the Policy will allow for materials and services. Any amount over the AllowableCharge is the Covered Person's responsibility.

AGE LIMITATIONS - Dependent Children are covered in accordance with Policy guidelines. You areresponsible for changes in coverage status (from individual to family or from family to individual).

SPECIAL LIMITATIONSVision Examination and Vision Materials - Fees charged by a Provider for services other than VisionExamination or covered Vision Materials must be paid in full by the Covered Person to the Provider. Suchfees or materials are not covered under this Policy.

BENEFITS AND SERVICES NOT INCLUDED FOR:Services or supplies collectible under Worker's Compensation or any law providing benefits for dependents ofmilitary personnel; services for conditions which treatment is provided by federal or state government or areprovided without cost; experimental or investigational services; services provided by an Immediate Relative;Charges for services or supplies for which no charge is made that the Covered Person is legally obligated topay; charges for which no charge would be made in the absence of vision coverage; charges for service byother than a Provider; charges by a Provider to complete forms for benefit determinations; fees charged by aProvider for services other than covered Vision Examination or covered Vision Materials must be paid in full

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by the Covered Person to the Provider; such fees or materials are not covered under this Policy; benefits forservices of materials started prior to the date the Covered Person was eligible under this Policy; orthoptic orvision training, subnormal vision aids, and any associated supplemental testing; aniseikonic lenses; medicaland/or surgical treatment of the eye, eyes, or supporting structures; any vision examination or any correctiveeyewear required by an employer as a condition of employment and safety eyewear, unless specificallycovered under this Policy; Plano (non-prescription) lenses; non-prescription sunglasses; two pair of glasses inlieu of bifocals; lost or broken lenses, frames, glasses or contact lenses will not be replaced except in thenext Frequency Period when Vision Materials would next become available; charges for services when aclaim is received from a Non-Participating Provider for payment more than 12 months after services arerendered; specialized techniques that entail procedure and process over and above that which is normallyadequate; any additional fee is the Covered Person's responsibility; all other services not specifically listed asbenefits herein.

Guaranteed Renewable/Conditioned upon Residence in ArkansasThis Policy and riders are guaranteed renewable so long as you reside in Arkansas. The Company maychange the established premium rate, but only if the rate is changed for all policies and riders of the sameform number and premium classification.

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ARTICLE I. STATEMENT OF COVERAGEA. This Policy contains the insurance benefits provided by Arkansas Blue Cross and Blue Shield, (the

Company) to you and is subject to its terms. Payment for vision services will be made in accordancewith this Policy; however, only services specifically listed herein for the individuals listed on theSchedule of Benefits are covered.

B. This coverage is most effective and advantageous when the services of Participating Providers areused.

C. Participating Providers are paid directly by the Company. You are responsible for any chargesbeyond the Policy payment. The determination of whether a Provider is Participating Provider orNon-Participating Provider is the responsibility of the Company. The Company can provide a list ofP a r t i c i p a t i n g P r o v i d e r s , o r y o u m a y a l s o a c c e s s o u r w e b s i t e a tWWW.ARKANSASBLUECROSS.COM. You should always ask your chosen Provider if he/sheparticipates. We also recommend that you take this Policy with you to your Provider's office.

D. The decision about whether to use a Participating Provider is the sole responsibility of the CoveredPerson. Participating Providers are not employees or agents of the Company. The Company makesno representations or guarantees regarding the qualification or experience of any Provider withrespect to any service. The evaluation of such factors and the decision about whether to use anyProvider is the sole responsibility of the Covered Person.

E. The effective date of your coverage is indicated in the Schedule of Benefits. F. Continuance of coverage under this Policy shall be contingent upon receipt of premiums remitted in

advance by the Policyholder.G. Under this Policy, notice is effectively delivered when it is mailed to your most recent address as

recorded in our records. H. The Company reserves the right to amend the premiums required for this Policy. If we do so, we will

give thirty (30) days written notice to the Policyholder and the change will go into effect on the dateindicated the notice.

I. No agent or employee of the Company may change or modify any benefit, term, condition, limitationor exclusion of this document. Any change or amendment must be in writing and signed by an Officerof the Company.

ARTICLE II. DEFINITIONSA. Allowable Charge, when used in connection with Vision Examinations and Vision Materials covered in

this Policy, will be the amount deemed by the Company to be reasonable. An amount equaling thelesser of the charge billed by the Provider or the Arkansas Blue Cross and Blue Shield allowance isthe basic charge. However, this charge may vary, given the facts of the case and the opinion of theCompany's Vision Advisor.

B. Child means the Policyholder's natural Child, legally adopted Child or Stepchild. "Child" also means aChild that has been placed with the Policyholder for adoption. “Child” also means a Child for whomthe Policyholder must provide medical support under a qualified medical Child support order or forwhom the Policyholder has been appointed the legal guardian.

C. Collection means the frame or contact lens collection shown in the Schedule of Benefits.D. Company means Arkansas Blue Cross and Blue Shield.E. Copayment means the amount required to be paid to a Provider by or on behalf of a Covered Person

in connection with Covered Services. Copayments are listed in the Schedule of Benefits and in theFee Schedule provided by the Company.

F. Covered Person means the Policyholder upon whom premiums have been paid and his EligibleDependents, if any, for whom premiums have been paid.

G. Covered Services mean a service or supply specified in this Policy or specifically approved by theCompany for which the Company will reimburse charges.

H. Date of Service is the date that treatment is completed.I. Discount means the percentage in which a Participating Provider has agreed to reduce the charge for

the requested service, material or procedure. Discounts are available at most Participating Providerlocations.

http://WWW.ARKANSASBLUECROSS.COM

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J. Eligible Dependents are the Policyholder's:1. Spouse;2. Child less than 26 years of age;3. unmarried Child who is incapable of self support because of mental retardation or physicaldisability, provided 1.) such Child is or was under the limiting age of dependency stated in Subsection2. above at the time of application for coverage under the Policy or 2.) if not under such limiting age,has had continuous health plan coverage, i.e. no break in coverage greater than 63 days, at the timeof application for coverage.The Company shall have the right to require satisfactory proof of mental or physical incapacity withthe right to examine your child at the Company's expense, but not more than once bi-annually. Uponfailure to submit such required proof or to permit such an examination, or when your child ceases tobe so incapacitated, coverage with respect to that child shall cease.Note: Domestic partners are not eligible for coverage as Dependents under this Policy.

K. Frequency Period means the time period during which you are eligible for the Vision Examination andVision Materials as stated in the Schedule of Benefits. This time period is measured from the date ofyour last Vision Examination or the date you received Vision Materials.

L. Immediate Relative means a person who ordinarily resides in the Covered Person's home, includingself, or is related to the Covered Person as a Spouse, parent, Child, brother or sister, grandparentand grandchild, whether the relationship is by blood or exists in law.

M. Medically Necessary Contact Lenses are contact lenses provided when functional vision correctioncannot be achieved with prescription eyeglasses but can be achieved with contact lens wear.Conditions that may justify Medically Necessary Contact Lenses include Keratoconus, Anisometropia,Aniseikonia, Astigmatism, Pathological Myopia, Post-traumatic Disorders, Aphakia, Aniridia, certaincorneal conditions and instances in which visual acuity is not correctable with conventionalspectacles. The Provider makes the clinical determination whether or not a patient is eligible forMedically Necessary contact lenses during a comprehensive eye examination. If a Provider feels thata patient needs medically necessary contact lenses for a condition that is not on the list and canclinically justify the need, then that request is evaluated by a clinical specialist. Medically NecessaryContact Lenses will be covered-in-full when supplied by a Participating Provider; however, PriorApproval is necessary.The Utilization Review Committee reviews and determines whether treatment, procedures andservices are medically necessary. The Committee conducts prior approval, concurrent and respectivereviews and issues determinations in accordance with regulatory and accreditation standards andtimeframes. The Utilization Review Committee establishes criteria for monitoring utilization and tracksand trends utilization.

N. Non-Participating Provider means a Provider who does not have a contract with the Company,directly or indirectly, to provide Covered Services.

O. Participating Provider means a Provider who has signed a contract with the Company, directly orindirectly, to provide Covered Services. The Company will pay a Participating Provider directly.

P. Placement, or being placed, for adoption means the assumption and retention of a legal obligation fortotal or partial support of a Child by a person with whom the Child has been placed in anticipation ofthe Child's adoption. The Child's Placement for adoption with such person terminates upon thetermination of such legal obligation.

Q. Policy means this document, your Schedule of Benefits, the application and any amendments orendorsements signed by an Officer of the Company.

R. Prior Approval means the process by which the Company determines in advance of the CoveredPerson obtaining Medically Necessary Contact Lenses or laser vision correction meets coveragerequirements. Note that Prior Approval does not mean that the Medically Necessary Contact Lensesor the laser vision correction will be covered regardless of other terms, conditions or limitationsoutlined in this Policy, but means only that coverage will not be denied for failing to meet medicalnecessity requirements if complete and accurate information has been furnished to the Companywhen Prior Approval is given. Without limiting the application of other coverage limitations orexclusions, for example, Prior Approval shall not be interpreted to waive eligibility requirements suchas dependent status or timely premium payment, nor shall Prior Approval be deemed to waivenetwork benefit limits or any other specific Policy condition, exclusion or limit, such as a Frequency

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Period maximum or policy limit.S. Provider means a licensed physician or optometrist who is operating within the scope of his or her

license or a dispensing optician.T. Spouse means a member of the opposite sex who is the husband or wife of a Policyholder as a

result of a marriage that is legally recognized in the state of Arkansas.U. Stepchild means a natural or adopted Child of the Spouse of the Policyholder.V. The masculine gender when used herein shall include the feminine gender.W. Vision Examination means a comprehensive ophthalmological service as defined in the Current

Procedural Technology (CPT). Comprehensive ophthalmological service describes a generalevaluation of the complete visual system. The comprehensive services constitute a single serviceentity but need not be performed at one session. The service includes history, general medicalobservation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotorexamination. It often includes, as indicated by examination, biomicroscopy, examination withcyclopedia or mydriasis and tonometry. It always includes initiation of non-medical diagnostic andnon-medical treatment programs.

X. Vision Materials means corrective lenses and/or frames or contact lenses.Y. We, Our and Us means the Company, Arkansas Blue Cross and Blue Shield.Z. You and Your means a Covered Person.

ARTICLE III. SPECIFIC BENEFITS AND LIMITATIONS OF THE PLANA. Coverage for Vision Examination and Vision Materials. Subject to all other terms, conditions,

exclusions and limitations of the plan as set forth in this Policy, coverage for Vision Examinations andVision Materials begins on the Covered Person's effective date and is limited to the Frequency Periodstated in the Schedule of Benefits. When Vision Examinations and/or Vision Materials are receivedfrom a Participating Provider, You are responsible for:1. The Copayment, if a cash payment is due at the time services are rendered; or2. The difference between the Allowable Charge plus any negotiated Discount and the

scheduled fee; the Company will pay the dollar amount of the Allowable Charge or the actualcharge, whichever is less; or

3. the difference between any negotiated Discount and the scheduled fee.B. Non-Participating Provider Benefits. Benefits for services or materials received from a

Non-Participating Provider are shown in terms of the dollar amount We will reimburse You for thatservice or material, not the total amount for which You are responsible. If You use a Non-ParticipatingProvider, Your total responsibility is the difference between the reimbursement and the total amountcharged by the Non-Participating Provider; We will pay the dollar amount of the reimbursement forthat service or material or the actual charge, whichever is less.You will not be paid a separate benefit, charged an additional Copayment or incur any additional costfor any services listed as "included" on the Schedule of Benefits.

C. Vision Examination Benefit. A Vision Examination includes but is not limited to, case history (eyeand vision history and medical history); entrance distance acuities; external ocular evaluationincluding slit lamp examination; internal ocular examination; tonometry; distance refraction (objectiveand subjective); binocular coordination and ocular motility evaluation; evaluation of papillary function;biomicroscopy; gross visual fields; assessment and planning; vision care counseling; form completion;and Dilated Fundus Examination (DFE) (diagnostic procedure used in the detection and managementof diabetes, glaucoma, hypertension and other ocular and/or systemic diseases when professionallyindicated).

D. Vision Materials Benefit. If a Vision Examination results in a Covered Person needing correctiveVision Materials for their visual health and welfare, those Vision Materials prescribed by Providers willbe covered, subject to the following limitations:1. Spectacle Lenses - up to two lenses provided one time in each Frequency Period;2. Frames - one Collection frame provided one time in each Frequency Period; Participating

Providers that do not display the frame Collection will apply the Allowable Charge towards anon-collection frame.

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3. Contact Lenses - contact lens benefit provided in lieu of frames and/or lenses no more thanone time in each Frequency Period. Participating Providers will apply the Allowable Chargetowards a contacts supply.

E. Medically Necessary Contact Lenses. Medically Necessary Contact Lenses are subject to PriorApproval and are limited to one pair of lenses per Frequency Period unless a subsequent VisionExamination shows a prescription change that qualifies for another lens or lenses due to medicalnecessity. You or your attending Provider must send a completed request to the Company forMedically Necessary Contact Lenses before the lenses are dispensed initially or due to a change inprescription. Any amount due over the Allowable Charge for such lenses is Your responsibility. If Youdo not obtain Prior Approval for Medically Necessary Contact Lenses initially or due to a prescriptionchange, the entire charge is Your responsibility.

F. Low Vision Coverage. Subject to Prior Approval, coverage is provided for low-vision services andoptical devices as described below.1. One comprehensive low-vision evaluation every five years, with a maximum charge of $300.

This examination, sometimes called a functional vision assessment, can determine distanceand clarity of vision, the size of readable print, the existence of blind spots or tunnel vision,depth perception, eye-hand coordination, problems perceiving contrast and lightingrequirements for optimum vision.

2. Maximum low-vision aid allowance of $600 with a lifetime maximum of $1,200 for items suchas high power spectacles, magnifiers and telescopes. These devices are utilized to maximizeuse of available vision, reduce problems of glare or increase contrast perception, based onthe individual's visual goals and lifestyle needs.

3. Follow-up care: four visits in any five-year period, with a maximum charge of $100 for eachvisit.

G. Laser Vision Correction Discounts. A Covered Person is entitled to savings of up to 25% off theProvider's charge, or a 5% Discount on any advertised special through Our network of physicians andrefractive surgery centers (some centers provide a flat fee equating to these Discount levels).

H. Replacement Contact Lens Program. A Covered Person is eligible for the replacement contact lensprogram. This mail order program provides a Discount on contact lens replacement materials.

I. Ancillary Product Discount. Most Participating Providers provide a twenty percent (20%) courtesyDiscount for items not covered by this Policy, e.g. second pair of glasses, sunglasses, etc.Disposable contact lenses are available at a ten percent (10%) courtesy Discount.

ARTICLE IV. SERVICES NOT INCLUDEDExcept as specifically provided in this Policy, no coverage will be provided for:A. Services or supplies collectible under Worker's Compensation or any law providing benefits for

dependents of military personnel; services for conditions which treatment is provided by federal orstate government or are provided without cost;

B. experimental or investigational services;C. services provided by an Immediate Relative;D. Charges for services or supplies for which no charge is made that the Covered Person is legally

obligated to pay; charges for which no charge would be made in the absence of vision coverage;E. charges for service by other than a Provider;F. charges by a Provider to complete forms for benefit determinations;G. fees charged by a Provider for services other than covered Vision Examination or covered Vision

Materials must be paid in full by the Covered Person to the Provider;H. benefits for services of materials started prior to the date the Covered Person was eligible under this

Policy;I. orthoptic or vision training, subnormal vision aids and any associated supplemental testing and

aniseikonic lenses;J. medical and/or surgical treatment of the eye, eyes or supporting structures;K. any vision examination or any corrective eyewear required by an employer as a condition of

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employment and safety eyewear, unless specifically covered under this Policy;L. Plano (non-prescription) lenses or non-prescription sunglasses;M. two pair of glasses in lieu of bifocals;N. lost or broken lenses, frames, glasses or contact lenses will not be replaced except in the next

Frequency Period when Vision Materials would next become available;O. charges for services when a claim is received from a Non-Participating Provider for payment more

than 12 months after services are rendered;P. specialized techniques that entail procedure and process over and above that which is normally

adequate - any additional fee is the Covered Person's responsibility;Q. Medically Necessary Contact Lenses or laser vision correction for which Prior Approval was not

obtained from the Company;R. all other services not specifically listed as benefits herein.

ARTICLE V. SUBROGATIONIf a Covered Person is injured by a third party, the Company is subrogated to all rights the Covered Personmay have against any party liable for payment of medical treatment (including any and all insurance carriers)to the extent of payment for the services or benefits provided. The Covered Person must cooperate fully withthe Company in its efforts to collect from the third party, and if the Covered Person fails to do so, theCompany shall be entitled to withhold coverage of or offset future claim payments for benefits, services,payments or credits due under this Policy. The Company may assert its subrogation rights independently ofthe Covered Person. In addition to the above-referenced subrogation rights, the Company also hasreimbursement rights should the Covered Person, or the legal representative, estate or heirs of the CoveredPerson recover damages by settlement, verdict or otherwise, for an accident, injury or illness. If a recovery ismade, the Covered Person shall promptly reimburse the Plan any monetary recovery made by the CoveredPerson and includes, but is not limited to, uninsured and underinsured motorist coverage, any no-faultinsurance, medical payments coverage, direct recoveries from liable parties, or any other source.

ARTICLE VI. OTHER PROVISIONS

A. Entire Policy.This Policy, any amendments thereto, and the Application, Change Request Form and the Scheduleof Benefits constitute the entire agreement between the parties. No part of this Policy shall bechanged or waived in any way except by written amendment signed by the President of theCompany. No Agent has the authority to change any of its terms.You hereby expressly acknowledge your understanding that this Policy constitutes a contract solelybetween you and Arkansas Blue Cross and Blue Shield, that Arkansas Blue Cross and Blue Shield isan independent corporation operating under a license from the Blue Cross and Blue ShieldAssociation, an association of independent Blue Cross and Blue Shield Plans, (the "Association")permitting Arkansas Blue Cross and Blue Shield to the use the Blue Cross and Blue Shield ServiceMarks in the State of Arkansas, and that Arkansas Blue Cross and Blue Shield is not contracting asthe agent of the Association. You further acknowledge and agree that you have not entered into thisContract based upon representations by any person other than Arkansas Blue Cross and Blue Shieldand that no person, entity, or organization other than Arkansas Blue Cross and Blue Shield shall beheld accountable or liable to you for any of the obligations created under this Policy.

B. Time Limit on Certain Defenses.1. Except for fraudulent misstatements made by you in the application for this Policy, no

misstatement shall be used to void any of its terms after three (3) years.2. Incontestable. Except for a disease or physical condition excluded from coverage by name or

description no claim for loss occurring after twelve (12) months from the effective date of thisPolicy shall be denied.

C. Termination of a Covered Person's Coverage for Cause:1. The Company may terminate coverage under this Policy upon fifteen (15) days' written notice

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for:a. concealment of information, misrepresentation (whether intentional or not) or fraud in

obtaining coverage; orb. concealment of information, misrepresentation (whether intentional or not) or fraud in

the filing of a claim for services, supplies, or in the use of services or facilities.2. For purposes of this termination for cause provision, concealment of information or a

misrepresentation occurs if (i) information is withheld or if incorrect information is providedand (ii) the Company would not have issued this Policy, would have charged a higherpremium, would have required the Policy to be amended, or would not have paid a claim inthe manner it was paid had the Company known the facts concealed or misrepresented.

3. Termination for cause shall be effective upon the later of (i) fifteen (15) days after a writtennotice of termination for cause is posted in the U.S. Mail, addressed to the Policyholder at hisor her last known address as provided by Policyholder to Company; or (ii) the date stated inthe termination notice letter to Policyholder.

4. A Covered Person may appeal a termination for cause action. Such an appeal must besubmitted in writing, addressed to the Appeals Coordinator of Arkansas Blue Cross and BlueShield, 601 S. Gaines Street, Little Rock, Arkansas 72203. In order for the appeal to beconsidered the Appeals Coordinator must receive the appeal prior to the later of (i) fifteen(15) days after a written notice of termination for cause is posted in the U.S. Mail, addressedto the Policyholder at his or her last known address as provided by Policyholder to Company;or (ii) the termination effective date stated in the termination notice letter to Policyholder.

D. Notice and Proof of Claim.1. You must submit written proof of any services, supplies or treatment and the Charges to the

Company within one hundred eighty (180) days after such services, supplies or treatmentwere received from a Participating Provider. You must submit written proof of any services,supplies or treatment and the Charges to the Company within one calendar year after suchservices, supplies or treatment were received from a Non-Participating Provider.

2. The Company, upon receipt of such notice, will furnish to you such forms as are usuallyfurnished by it for filing proof of loss. If such forms are not so furnished within fifteen (15)days after the Company receives such notice, you shall be deemed to have complied with therequirements as to proof of loss upon submitting, within the time fixed for filing proof of loss,written proof covering the occurrence, character and extent of the loss for which claim ismade.

3. Subject to all applicable statutory provisions and rules and regulations of the ArkansasInsurance Department, all benefits payable under this Policy will be payable immediately uponreceipt of written proof of loss.

E. Legal Actions. No Court suit shall be brought to recover on this Policy before sixty (60) days afterwritten proof of loss has been furnished in accordance with the requirements of this Policy. No legalaction shall be brought after the expiration of three (3) years from the time written proof of loss isrequired to be furnished.

F. This Policy shall be in effect until terminated by its terms.G. Unless you change residence from Arkansas, this Policy and any amendments or riders to it are

guaranteed renewable. The initial premium you pay for this Policy will not increase during the firsttwelve (12) months this Policy is in force. After twelve (12) months, your premium rate will be subjectto any changes in premium resulting from your age increasing over one of the premium rateage-bands or the Company changing the established premium rate for all policies and riders of thesame form number and premium classification as this Policy.

H. A grace period of thirty-one (31) days will be granted for the payment of premiums becoming payableafter the first such payment, during which grace period the Policy shall continue in force. If premiumsare not paid within thirty-one (31) days after they become due and payable this Policy is terminatedas of the date on which the premiums were due and payable.

I. Reinstatement: If any renewal premium is not paid within the grace period, a subsequent acceptanceof premium by the Company or by any agent authorized by the Company to accept such premium,without requiring in connection therewith an application for reinstatement, shall reinstate the Policy;provided, however, that if the Company or such agent requires an application for reinstatement and

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issues a conditional receipt for the premium tendered, the Policy will be reinstated upon approval ofsuch application by the Company or, lacking such approval, upon the forty-fifth day following the dateof such conditional receipt unless the Company has previously notified the Covered Person in writingof its disapproval of such application. The reinstated Policy shall cover only loss as may begin morethan ten (10) days after such date. In all other respects, the Covered Person and Company shallhave the same rights there under as they had under the Policy immediately before the due date ofthe defaulted premium, subject to any provisions endorsed hereon or attached hereto in connectionwith the reinstatement. Any premium accepted in connection with a reinstatement shall be applied toa period for which premium has not been previously paid, but not to any period more than sixty (60)days prior to the date of reinstatement.

J. This Policy shall terminate upon the death of the Policyholder. In such event, the Company shallreturn all unearned premiums to your estate or other appropriate party.

K. Before any benefits can be paid, you agree, as a condition of coverage under this Policy, andauthorize and direct any Provider of vision services or supplies to furnish Arkansas Blue Cross andBlue Shield, its agents, or any of its subsidiaries, upon request, all records, or copies thereof, relatingto such services or supplies. Further, as a condition of your coverage, you authorize the release ofsuch records to any third party review person or entity, for purposes of coverage determination andpayment. Finally, as a condition of coverage, you agree to fully and truthfully respond to inquiriesfrom the Company about your claim or condition, including, but not limited to, your other insurancecoverage, third party liability, or workers' compensation benefits and to request that any Provider sorespond to all such inquiries. You understand and agree that your failure to respond to inquiries fromthe Company, or failure to cooperate fully to obtain information requested by the Company from yourProvider shall be, by itself, grounds for denial of benefits under this Policy.

L. Change of Residence. Upon a Policyholder moving permanently to another state, this Policy shall bevoid at the end of the period for which premiums have been paid. Upon application to the Company,membership shall be transferred to the Company in the area of your new residence. Upon transfer,rates and benefits may be substantially different.

M. Assignment. No assignment of benefits under this Policy shall be valid until approved and acceptedby the Company. The Company reserves the right to make payment of benefits, in its sole discretion,directly to the Provider of service or to the Policyholder.

N. Upon termination of this Policy all benefits, except charges incurred prior to termination, shall cease.O. How To Appeal A Claim

1. If a claim for benefits is denied either in whole or in part, you will receive a notice explainingthe reason or reasons for the denial. You may request a review of a denial of benefits for anyclaim or portion of a claim by sending a written request to the Appeals Coordinator ofArkansas Blue Cross and Blue Shield, 601 S. Gaines Street, Little Rock, Arkansas 72203.Your request must be made within sixty (60) days after you have been notified of the denialof benefits.

2. In preparing your request for review, you or your duly authorized representative will have theright to examine documents pertinent to your claim. However, medical information can bereleased to you only upon the written authorization of your physician. You or yourrepresentative may submit, with your request for review, any additional information relevant toyour claim and may also submit issues and comments in writing. A complete review will thenbe made of all information relating to your claim. You will receive a final decision in writingwithin sixty (60) days after the receipt of your review request, except where specialcircumstances require extensive review. A final decision will be sent to you after no longerthan one hundred twenty (120) days.

3. The Company acting on behalf of the Plan shall have authority and full discretion todetermine all questions arising in connection with your insurance benefits, including but notlimited to eligibility, interpretation of Plan language, and findings of fact with regard to anysuch questions. The actions, determinations and interpretations of the Company acting onbehalf of the Plan with respect to all such matters, and with respect to any other matterswithin the scope of its authority, shall be conclusive and binding on you and the Plan.

P. Despite our best efforts, we may make a claim payment which is not for a benefit provided under thisPolicy, or we may make payment to you when payment should have gone directly to the Provider oftreatment or services instead. In the event of an erroneous or mistaken payment, you agree to refund

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the full amount of such payment to us promptly upon our request. The Company will have the right tooffset future payments made to you or your Provider if prompt refund of such payment is notreceived.

ARTICLE VII. POLICY PROVISIONS RELATIVE TO MEMBERSHIP, MEETINGS AND VOTINGA. Membership

By virtue of ownership of this Policy, the Policyholder is a member of Arkansas Blue Cross and BlueShield. This Policy is a non-participating policy. This means that the Policyholder does not receivedistribution of any premium, revenues, savings or assets of the Company.

B. Annual MeetingAn annual meeting of the members shall be held each and every calendar year in the State ofArkansas for the purpose of electing directors, receiving and considering reports as to the businessand affairs of the Company and transacting such other business as may properly come before themeeting. The meeting shall be held between January 1 and April 1 of each year at such place, dateand time as shall be fixed by the Board of Directors or the Chief Executive Officer. The Board ofDirectors may, from time to time, provide that the place, date and time of the annual meeting shall beset forth in the Policy of members as set out in Section D. below.

“THE ANNUAL MEETING OF THE MEMBERS SHALL BE HELD EACH YEAR ATTHE HOME OFFICE, LOCATED AT 601 GAINES STREET, LITTLE ROCK,ARKANSAS, ON THE THIRD MONDAY IN MARCH AT 1:00 P.M. (PROVIDED, IFSUCH DAY SHALL BE A LEGAL HOLIDAY, THEN AT THE SAME TIME ANDPLACE ON THE NEXT SUCCEEDING DATE WHICH IS NOT A LEGAL HOLIDAY).”

C. Special MeetingsA special meeting of members for any purpose may be called by the Board of Directors or ChiefExecutive Officer, and shall be called by the Chief Executive Officer of the Secretary at the request ofmembers holding one-third (1/3) of the voting power entitled to vote thereat. Such request shall statethe purpose or purposes of the meeting, and no other business outside the scope of the statepurpose or purposes shall be transacted. Unless ordered by the Board of Directors, the time andplace of each special meeting of members shall be determined by the Chief Executive Officer.

D. Notice of MeetingsSo long as each insurance Policy issued by the Company sets forth the place, date and hour of theannual meeting of members, no notice of any annual meeting shall be required to be given to anymember, regardless of the number or nature of proposals to be considered and voted upon at theannual meeting. If notice of the annual meeting is not set forth in each insurance Policy, written orprinted notice of the annual meeting and every special meeting of the members, stating the place,date, time and the purpose or purposes of such meeting shall be given to the members entitled tovote at such meeting not less than ten (10), nor more than sixty (60), days before the date of themeeting. All such notices shall be given, either personally or by the mail, by or at the direction of theChief Executive Officer or Secretary unless ordered by the Board of Directors. Notices which shall bemailed shall be deemed to be "given" when deposited in the United States Mail addressed to themember at the member's address as it appears on the records of the Company, with postage prepaid[first class mail], if the notice is mailed thirty (30) days or less before the date of the meeting], andany notice transmitted other than by mail shall be deemed to have been "given" when delivered tothe member.

E. QuorumExcept as otherwise provided by applicable law, a majority of the members of the Company (presentin person or by proxy) shall be necessary to constitute a quorum for the transaction of business atany annual or special meeting of the members of the Company.

F. Voting RightsEach member shall be entitled to one vote for each policy held by him upon each matter coming to avote at meetings of members provided, a group policyholder shall be entitled to a number of votesequal to the number of certificate holders insured under this Group Policy. Such vote may beexercised in person or by written proxy.

G. Vote Required

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A majority of the voting power represented at any meeting of members shall be necessary andsufficient to approve any given matter. There shall be no cumulative voting.

H. ProxyAt all meetings of members a member may vote by proxy executed in writing by the member or bythe member's duly authorized attorney in fact. Such proxy shall be filed with the Secretary beforecommencement of the meeting or at such late time as shall be expressly permitted by the Corporateofficer presiding at such meeting. Once a Policy is issued by the Company, the Policyholder shallreceive a proxy form for the Policyholder's signature. The proxy form shall contain a provisionpursuant to which the Policyholder thereof grants a revocable proxy to the Board of Directors withrespect to all matters to be considered and voted upon by members at any meeting occurring whilesuch insurance Policy is in force.

P. Mark White, President and Chief Executive Officer

ARKANSAS BLUE CROSS AND BLUE SHIELD601 S. Gaines Street

Little Rock, Arkansas 72201

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Arkansas Consumers Information Notice

For additional information regarding your Arkansas Blue Cross and Blue Shield benefits, please feel free tocontact us at:

Arkansas Blue Cross and Blue ShieldCustomer Service

Post Office Box 2181Little Rock, Arkansas 72203

Telephone (501) 378-2010 or toll free (800) 421-1112

If we at Arkansas Blue Cross and Blue Shield fail to provide you with reasonable and adequate service, youshould feel free to contact:

Arkansas Insurance DepartmentConsumer Services Division

1200 West Third StreetLittle Rock, Arkansas 72201

Telephone (501) 371-2640 or toll free (800) [email protected].

mailto:[email protected]

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LIMITATIONS AND EXCLUSIONS UNDERTHE ARKANSAS LIFE AND HEALTH INSURANCE

GUARANTY ASSOCIATION ACT

Residents of this state who purchase life insurance, annuities or health and accident insurance should knowthat the insurance companies licensed in this state to write these types of insurance are members of theArkansas Life and Health Insurance Guaranty Association ("Guaranty Association"). The purpose of theGuaranty Association is to assure that policy and contract owners will be protected, within certain limits, in theunlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen,the Guaranty Association will assess its other member insurance companies for the money to pay the claimsof policy owners who live in this state and, in some cases, to keep coverage in force. The valuable extraprotection provided by the member insurers through the Guaranty Association is not unlimited, however. And,as noted in the box below, this protection is not a substitute for consumers' care in selecting insurancecompanies that are well managed and financially stable.

DISCLAIMERThe Arkansas Life and Health Insurance Guaranty Association ("Guaranty Association") maynot provide coverage for this policy. If coverage is provided, it may be subject to substantiallimitations or exclusions and require continued residency in this state. You should not rely oncoverage by the Guaranty Association in purchasing an insurance policy or contract.

Coverage is NOT provided for your policy or contract or any portion of it that is not guaranteedby the insurer or for which you have assumed the risk, such as non-guaranteed amounts heldin a separate account under a variable life or variable annuity contract.

Insurance companies or their agents are required by law to provide you with this notice.However, insurance companies and their agents are prohibited by law from using the existenceof the Guaranty Association to induce you to purchase any kind of insurance policy.

The Arkansas Life and Health Insurance Guaranty Associationc/o The Liquidation Division1023 West Capitol, Suite 2

Little Rock, Arkansas 72201

Arkansas Insurance Department1200 West Third Street

Little Rock, Arkansas 72201-1904

The state law that provides for this safety-net is called the Arkansas Life and Health Insurance GuarantyAssociation Act ("Act"). Below is a brief summary of the Act's coverages, exclusions and limits. This summarydoes not cover all provisions of the Act; nor does it in any way change anyone's rights or obligations underthe Act or the rights or obligations of the Guaranty Association.

COVERAGEGenerally, individuals will be protected by the Guaranty Association if they live in this state and hold a life,annuity or health insurance contract or policy, or if they are insured under a group insurance contract issuedby a member insurer. The beneficiaries, payees or assignees of policy or contract owners are protected aswell, even if they live in another state.

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EXCLUSIONS FROM COVERAGEHowever, persons owning such policies are NOT protected by the Guaranty Association if:

• They are eligible for protection under the laws of another state (this may occur when the insolventinsurer was incorporated in another state whose guaranty association protects insureds who liveoutside that state);

• The insurer was not authorized to do business in this state;• Their policy or contract was issued by a nonprofit hospital or medical service organization, an HMO, a

fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similarplan in which the policy or contract owner is subject to future assessments, or by an insuranceexchange.

The Guaranty Association also does NOT provide coverage for:• Any policy or contract or portion thereof which is not guaranteed by the insurer or for which the

owner has assumed the risk, such as non-guaranteed amounts held in a separate account under avariable life or variable annuity contract;

• Any policy of reinsurance (unless an assumption certificate was issued);• Interest rate yields that exceed an average rate;• Dividends and voting rights and experience rating credits;• Credits given in connection with the administration of a policy by a group contract holder;• Employers' plans to the extent they are self-funded (that is, not insured by an insurance company,

even if an insurance company administers them);• Unallocated annuity contracts (which give rights to group contractholders, not individuals);• Unallocated annuity contracts issued to/in connection with benefit plans protected under Federal

Pension Benefit Corporation ("FPBC")(whether the FPBC is yet liable or not);• Portions of an unallocated annuity contract not owned by a benefit plan or a government lottery

(unless the owner is a resident) or issued to a collective investment trust or similar pooled fundoffered by a bank or other financial institution);

• Portions of a policy or contract to the extent assessments required by law for the GuarantyAssociation are preempted by State or Federal law;

• Obligations that do not arise under the policy or contract, including claims based on marketingmaterials or side letters, riders, or other documents which do not meet filing requirements, or claimsfor policy misrepresentations, or extra-contractual or penalty claims;

• Contractual agreements establishing the member insurer's obligations to provide book valueaccounting guarantees for defined contribution benefit plan participants (by reference to a portfolio ofassets owned by a nonaffiliate benefit plan or its trustees).

LIMITS ON AMOUNT OF COVERAGE

The Act also limits the amount the Guaranty Association is obligated to cover: The Guaranty Associationcannot pay more than what the insurance company would owe under a policy or contract. Also, for any oneinsured life, the Guaranty Association will pay a maximum of $300,000 - no matter how many policies andcontracts there were with the same company, even if they provided different types of coverages. Within thisoverall $300,000 limit, the Association will not pay more than $300,000 in health insurance benefits $300,000in present value of annuity benefits, or $300,000 in life insurance death benefits or net cash surrender values- again, no matter how many policies and contracts there were with the same company, and no matter howmany different types of coverages. There is a $1,000,000 limit with respect to any contract holder forunallocated annuity benefits, irrespective of the number of contracts held by the contract holder. These arelimitations for which the Guaranty Association is obligated before taking into account either its subrogationand assignment rights or the extent to which those benefits could be provided out of the assets of theimpaired or insolvent insurer.

INDEX

AArkansas Consumers InformationNotice 49. . . . . . . . . . . . . . . . . . . . . . . .

B

CCOVERED SERVICES 12. . . . . . . . . . .

DDEFINITIONS 40. . . . . . . . . . . . . . . . . .

E

G

H

I

LLIMITATIONS AND EXCLUSIONSUNDER THE ARKANSAS LIFE ANDHEALTH INSURANCE GUARANTY

ASSOCIATION ACT 50. . . . . . . . . . . . .

M

N

OOTHER PROVISIONS 44. . . . . . . . . . .

P

R

SSERVICES NOT INCLUDED 25. . . . . .SPECIFIC BENEFIT LIMITATIONS 23.SUBROGATION 44. . . . . . . . . . . . . . . .STATEMENT OF COVERAGE 40. . . . .

T

W

Y

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