plan brochure 2019

Transcript

1 Delt nt al’s Fed eral Employee s Dental a De ® m Progra deltadentalins.com/fedvip 201 9 A PPO Plan Na tionwide Dental may enroll in this Plan: All Federal employees, annuitants, and certain TRICARE beneficiaries Who in the United States and overseas who are eligible to enroll in the Federal Employees Dental and Vision Insurance Program ons for this P lan: Enrollment Opti Hig h Opt io n • – Self Only • Hig h Op tion – Self Plus One • Hi gh Opt io n – Self and Fam ily Standard Option – Self Only • Standard Option – Self Pl • us One • Standard Option – Self and Family This Plan has five enrollment re gions, includi ng inter na tional; plea se see t he end of this broch ure to det your region and corresponding rat es. er mine Autho rized for distributi on by the:

2 Intr oduction ge W V ision Benefits Enhancement On December 23, 2004, President Geor . Bush signed the Federal Employee Dental and fice of Personnel Management (OPM) to establish supplemental The law directed the Of Act of 2004 (Public Law 108-496). dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members. In response to the legislation, OPM established the Federal Employees Dental and V ision Insurance Program (FEDVIP). OPM has contracted with dental and vision insurers to of fer an array of choices to Federal employees and annuitants. Section Act for Fiscal 715 of the National Defense ear 2017 (FY 2017 NDAA), Public Law 1 14-38, expanded Authorization Y eligibility to certain TRICARE-eligible individuals. FEDVIP This brochure describes the benefits of Delta Dental’ s Federal Employees Dental Program under Delta Dental of California law contract OPM01-FEDVIP-01AP-3 with OPM, as authorized by the FEDVIP The address for our administrative of fice . is: Delta Dental of California Federal Employees Dental Program PO Box 537007 Sacramento, CA 95853-7007 855-410-3255 deltadentalins.com/fedvip ficial statement of benefits. No oral statement can modify or otherwise af fect the benefits, limitations, This brochure is the of and exclusions of this brochure. It is your responsibility to be informed about your benefits. If you are enrolled in this plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage, each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage. ou and your Y family members do not have a right to benefits that were available before January 1, 2019, unless those benefits are also shown in this brochure. . Rates are shown at the end of this brochure. OPM negotiates benefits and rates with each carrier annually Delta Dental maintains the network of providers available to enrollees in the Federal Employees Dental Program. Y ou may view the most current network provider directory on our website at deltadentalins.com/fedvip , or you may contact us at 855-410-3255 (TDD 866-847-1264) to request a list of participating providers in your area. Continued participation of any specific provider cannot be guaranteed. Thus, you should choose your plan based on the benefits provided and not for a ’ When you phone for an appointment, please remember to verify that the provider is specific provider s participation. currently in Delta Dental's network for the Federal Employees Dental Program. Y ou cannot change plans because of changes to the provider network. If your provider is not currently participating in the provider network, you may nominate him or her to join at .deltadentalca.or http://www . Nomination forms are available on our g/enrollee/forms/Nominatedentist.asp?DPO website, or call us and we will have a form sent to you. Please note that Delta Dental of fers various dental plans in the U.S. and not all Delta Dental network dentists are considered "in-network" for the Federal Employees Dental Program. Provider networks may be more extensive in some areas than others. W e cannot guarantee the availability of every specialty in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance. Delta Dental’ s Federal Employees Dental Pr ogram and all other FEDVIP plans ar e not a part of the Federal Employees Health Benefits (FEHB) Pr ogram. e want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost W T o review full details about our privacy practices, our legal duties, and your rights, please visit our website importance to us. at . If you do not have access to the Internet or would like further information, please contact us by deltadentalins.com/fedvip calling 855-410-3255. Discrimination is Against the Law Delta Dental's Federal Employees Dental Program complies with all applicable Federal civil rights laws, to include both T itle VII of the Civil Rights Af fordable Care Act. Pursuant to Section 1557, Delta Dental's Act of 1964 and Section 1557 of the Federal Employees Dental Program does not discriminate, exclude people, or treat them dif ferently on the basis of race, color , national origin, age, disability , or sex. 1 2019

3 T able of Contents able of Contents ...2 T e Have Changed for 2019 W ...4 How FEDVIP ...5 Program Highlights A Choice of Plans and Options ...5 Enroll Through BENEFEDS ...5 Dual Enrollment ...5 fective Date Coverage Ef ...5 ...5 Pre-tax Salary Deduction for Employees Annual Enrollment Opportunity ...5 Continued Group Coverage After Retirement ...5 aiting Period W ...5 Section 1 Eligibility ...6 ...6 Federal Employees ...6 Federal Annuitants ...6 Annuitants Survivor ...6 Compensationers Family Members ...6 Not Eligible ...7 Section 2 Enrollment ...8 Through BENEFEDS ...8 Enroll Enrollment ypes ...8 T Dual Enrollment ...8 Opportunities to Enroll or Change Enrollment ...8 When Coverage Stops ...10 ...10 Continuation of Coverage FSAFEDS/High Deductible Health Plans and FEDVIP ...10 ou Obtain Care ...12 Y Section 3 How Identification Cards/Enrollment Confirmation ...12 Where Y ou Get Covered Care ...12 Plan Providers ...12 In-Network ...12 ...12 Out-of-Network Emer gency Services ...12 Plan Allowance ...13 Precertification/Predetermination Notice ...13 Alternate Benefit ...13 Dental Review ...13 ...13 FEHB First Payor Coordination of Benefits ...13 ...14 Right of Recovery Rating Areas ...14 Limited Access Area ...14 Section 4 our Cost For Covered Services ...15 Y Deductible ...15 Coinsurance ...15 Annual Benefit Maximum ...15 2 2019 Enroll at www .BENEFEDS.com

4 Lifetime Benefit Maximum ...15 ...16 In-Network Services Out-of-Network Services ...16 ...16 Allowance Plan Calendar Y ...16 ear T ooth Missing but Not Replaced Rule ...16 Section 5 Dental Services and Supplies Class Basic ...17 A Class B Intermediate ...20 ...25 Class C Major Class D Orthodontic ...33 General Services ...35 Section 6 International Services and Supplies ...39 Section 7 General Exclusions – Things W e Do Not Cover ...40 Section 8 Claims Filing and Disputed Claims Processes ...44 ...44 How to File a Claim for Covered Services International Claims ...44 Deadline for Filing our Claim ...44 Y Disputed Claims Process ...44 Section 9 Definitions of T erms W e Use in This Brochure ...50 Stop Health Care Fraud! ...52 Summary of Benefits ...53 Notes ...55 Rate Information ...58 3 2019 Enroll at www .BENEFEDS.com

5 How W 2019 e Have Changed for ollees Newly eligible enr has expanded eligibility to include certain TRICARE eligible individuals. The TRICARE Retire FEDVIP Dental Program e (TRDP) will no longer be available after December 31, 2018. Those who were previously eligible for the TRDP are now eligible to enroll in a FEDVIP dental plan. If enrolled in a TRICARE health plan, TRICARE eligible individuals may also enroll in a FEDVIP vision plan. Delta Dental has made the following changes for 2019: • Added adult orthodontic coverage into the High Option • Added a third covered cleaning for enrollees with diagnosis of T ype 1 or T ype 2 Diabetes 4 2019 Enroll at www .BENEFEDS.com

6 FEDVIP Pr ogram Highlights Choice of Plans and A ou can select from several nationwide, and in some areas, regional dental Preferred Y Provider Or ganization (PPO) or Health Maintenance Or Options ganization (HMO) plans, and high ou can also select from several nationwide vision plans. Y and standard coverage options. ou may enroll in a dental plan or a vision plan, or both. Some Y TRICARE beneficiaries or www .opm.gov/ V isit may not be eligible to enroll in both. .opm.gov/dental www for more information. vision ou enroll online at www .BENEFEDS.com . Please see Section 2 Enrollment for more Y Enr oll Thr ough BENEFEDS information. plan, that ollment If you or one of your family members is enrolled in or covered by one FEDVIP Dual Enr plan person cannot be enrolled in or covered as a family member by another FEDVIP fering the same type of coverage; i.e., you (or covered family members) cannot be of dental plans or two FEDVIP vision plans. covered by two FEDVIP If you sign up for a dental and/or vision plan during the 2018 Open Season, your coverage Coverage Effective Date will begin on January 1, 2019. Premium deductions will start with the first full pay period ou may use your benefits as soon as your beginning on/after January 1, 2019. Y enrollment is confirmed. Employees automatically pay premiums through payroll deductions using pre-tax dollars. e-tax Salary Deduction Pr for Annuitants automatically pay premiums through annuity deductions using post-tax Employees TRICARE enrollees automatically pay premiums through payroll deduction or dollars. automatic bank withdrawal (ABW) using post-tax dollars. ollment Annual Enr , an Open Season will be held, during which you may enroll or change your Each year , Open Season runs from November 12, This year Opportunity dental and/or vision plan enrollment. December 10, 2018. 2018 through midnight EST ou do not need to re-enroll each Open Y Season unless you wish to change plans or plan options; your coverage will continue from the previous year . In addition to the annual Open Season, there are certain events that . Please see allow you to make specific types of enrollment changes throughout the year Section 2 Enrollment for more information. Y our enrollment or your eligibility to enroll may continue after retirement. Y ou do not oup Continued Gr After Coverage need to be enrolled in FEDVIP for any length of time to continue enrollment into retirement. Retir ement Y our family members may also be able to continue enrollment after your death. Please see Section 1 Eligibility for more information. W o meet this requirement, the person aiting Period The only waiting period is for orthodontic services. T receiving the services must be enrolled in this plan for the entire waiting period of 12 members who enrolled in FEDVIP during the 2018 Open months. For those TRDP Season, in-progress coverage will be allowed and there will be no waiting period. 5 2019 Enroll at www .BENEFEDS.com

7 Section 1 Eligibility Federal Employees If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP , if you are eligible for the Federal Employees Health Benefits (FEHB) Program or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you are eligible to enroll in FEDVIP . Enrollment in the FEHB Program or a Health Insurance Marketplace (Exchange) plan is not required. Annuitants Federal Y ou are eligible to enroll if you: • retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government; • retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government. enrollment will continue into retirement if you retire on an immediate our FEDVIP Y annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee. There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB Program. Age (MRA) + 10 Y our FEDVIP coverage will end if you retire on a Minimum Retirement ou may enroll in FEDVIP Y . retirement and postpone receipt of your annuity again when you begin to receive your annuity . Annuitants If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and Survivor , you may enroll or continue the existing enrollment. you are receiving an annuity compensationer is someone receiving monthly compensation from the Department of Compensationers A s Of ’ W orkers’ Compensation Programs (OWCP) due to an on-the-job injury/ Labor fice of . Y ou are illness who is determined by the Secretary of Labor to be unable to return to duty or continue FEDVIP enrollment into compensation status. eligible to enroll in FEDVIP TRICARE eligible individuals. FEDVIP The has expanded eligibility to include certain Newly eligible enr ollees TRICARE Retir ee Dental Program (TRDP) will no longer be available after December 31, 2018. TRDP are now eligible to enroll in Those who were previously eligible for the . FEDVIP TRICARE-eligible individuals, family members include your Except with respect to Family Members spouse and unmarried dependent children under age 22. This includes legally adopted children and recognized natural children who meet certain dependency requirements. This also includes stepchildren and foster children who live with you in a regular parent- child relationship. Under certain circumstances, you may also continue coverage for a rules disabled child 22 years of age or older who is incapable of self-support. FEDVIP NOT and FEHB rules for family member eligibility are the same. For more information .opm.gov/healthcare-insurance/ on family member eligibility visit the website at www dental-vision/ or contact your employing agency or retirement system. W ith respect to TRICARE-eligible individuals, family members include your spouse, , unremarried widower , unmarried child, an unremarried former spouse unremarried widow who meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibility requirements, and certain unmarried persons placed in your legal custody by a court. Children include legally adopted children, stepchildren, and pre-adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a . mental or physical incapacity 6 2019 Enroll at www .BENEFEDS.com

8 Not Eligible The following persons are not eligible to enroll in FEDVIP , regardless of FEHB eligibility or receipt of an annuity or portion of an annuity: Deferred annuitants • Note: Former spouses of TRICARE- Former spouses of employees or annuitants. • eligible individuals may enroll in a FEDVIP vision plan. • FEHB T emporary Continuation of Coverage (TCC) enrollees Anyone receiving an insurable interest annuity who is not also an eligible family • member • Note: If you are an active duty uniformed Active duty uniformed service members. service member , your dental and vision coverage will be provided by TRICARE. our family members will still be eligible to enroll in the TRICARE Dental Plan Y (TDP). 7 2019 Enroll at www .BENEFEDS.com

9 Section 2 Enr ollment oll or change enr ollment in a FEDVIP plan. BENEFEDS is a oll Thr ough Enr Y ou must use BENEFEDS to enr secur ed by OPM. www BENEFEDS ollment website ( If you do not have ) sponsor e enr .BENEFEDS.com access to a computer number 1-877-889-5680 to TTY , call 1-877-888-FEDS (1-877-888-3337), enroll or change your enrollment. your enr ollment will If you are currently enrolled in FEDVIP and do not want to change plans, emiums may change for 2019. plan's pr our Y . continue automatically Please Note: Y ou cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Note: Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, , or Employee Personal Page. However EBIS, MyPay , those sites may provide a link to BENEFEDS. A Self Only enrollment covers only you as the enrolled employee or annuitant. Y ou T ollment Enr ypes Self Only: may choose a Self Only enrollment even though you have a family; however , your family members will not be covered under FEDVIP . A Self Plus One enrollment covers you as the enrolled employee or annuitant plus Self Plus One: ou may choose a Self Plus One enrollment even Y . one eligible family member whom you specify though you have additional eligible family members, but the additional family members will not be covered under FEDVIP . Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant Y ou must list all eligible family members when enrolling. and all of your eligible family members. If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person ollment Dual Enr fering the same plan of cannot be enrolled in or covered as a family member by another FEDVIP dental type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP vision plans. plans or two FEDVIP Open Season oll Opportunities to Enr • or Change Enr ollment If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a December 10, 2018, dental and/or vision plan during the November 12, through midnight EST fective January 1, 2019. Open Season. Coverage is ef During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental fective date of these Open Season enrollments and changes will The ef and/or vision coverage. be set by OPM. If you want to continue your curr ollment, do nothing. Y our ent enr , unless you change it. enr ollment carries over fr om year to year e/Newly eligible New hir ou may enroll within 60 days after you become eligible as: Y a new employee; - - a previously ineligible employee who transferred to a covered position; - a survivor annuitant if not already covered under FEDVIP; or an employee returning to service following a break in service of at least 31 days. - a TRICARE-eligible individual - fective the first day of the pay period following the one in which our enrollment will be ef Y BENEFEDS receives and confirms your enrollment. Qualifying Life Event qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, A allows you to change your enrollment outside of an Open Season. 8 2019 Enroll at www .BENEFEDS.com

10 The following chart lists the QLEs and the enrollment actions you may take: Qualifying Fr om Not om Change fr Cancel Incr ease ease Decr Life Event Enr Enr ollment olled to Enr One Plan to ollment Enr ype T ype olled T Another Y es Y es No No Y es Marriage No No No No Acquiring an Y es eligible family member (non-spouse) Losing a No No No Y es No ed cover family member Losing other No No es Y No Y es dental/vision coverage (eligible or ed cover person) No es Moving out Y No No No of r egional plan's service ea ar Going on No es Y No No No active , military duty non- paystatus ollee or (enr spouse) Y No No No No es Returning to pay status om active fr military duty (enr ollee or spouse) Returning to es (if Y es (if Y No No No ollment pay status ollment enr enr fr cancelled om Leave cancelled without pay during during WOP) L WOP) L Annuity/ No No es Y Y es Y es compensation ed r estor T ransferring No es No No No Y to an eligible position* *Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer -paid premium. The timeframe for requesting a QLE change is from 31 days before to 60 days after the event. There are two exceptions: • There is no time limit for a change based on moving from a regional plan’ s service area and 9 2019 Enroll at www .BENEFEDS.com

11 • Y ou cannot request a new enrollment based on a QLE before the QLE occurs, except for ou must make the change no later enrollment because of loss of dental or vision insurance. Y than 60 days after the event. Generally , enrollments and enrollment changes made based on a QLE are ef fective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change. BENEFEDS will send you confirmation of your new coverage ef fective date. Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed. That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next Open Season, unless you experience a QLE that allows such a change or cancellation. Canceling an enr ollment ou may cancel your enrollment only during the annual Open Season. An eligible family Y ’ fective date of the cancellation. s coverage also ends upon the ef member Y our cancellation is ef fective at the end of the day before the date OPM sets as the Open Season ef fective date. TRICARE-eligible When Coverage Stops Coverage ends for active and retired Federal, U.S. Postal employees, and individuals when you: no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible • individual; • as a Retired Reservist you begin active duty; • as sponsor or primary enrollee leaves active duty begin a period of non-pay status or pay that is insuf ficient to have your FEDVIP premiums • withheld and you do not make direct premium payments to BENEFEDS; • are making direct premium payments to BENEFEDS and you stop making the payments; cancel the enrollment during Open Season • Coverage for a family member ends when: • you as the enrollee lose coverage; or • . the family member no longer meets the definition of an eligible family member FEDVIP , ther e is no 31-day extension of coverage. The following ar e also NOT Continuation of Coverage Under the FEDVIP plans: available under T emporary Continuation of Coverage (TCC); • spouse equity coverage; or • right to convert to an individual policy (conversion policy). • If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) FSAFEDS/High Deductible or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider Health Plans and FEDVIP fect your annual expenses, and thus the amount that how coverage under a FEDVIP plan will af you should allot to an FSAFEDS account. Please note that insurance premiums are not eligible expenses for either type of FSA. 10 2019 Enroll at www .BENEFEDS.com

12 If you have an HCFSA or LEX HCFSA t exhausted your FSAFEDS account and you haven’ , FSAFEDS can automatically carry over up to $500 of funds by December 31st of the plan year T o be unspent funds into another health care or limited expense account for the subsequent year . , you must be employed by an agency that participates in FSAFEDS and eligible for carryover actively making allotments from your pay through December 31. ou must also actively reenroll Y Open Season to be carryover in a health care or limited expense account during the NEXT Y our reenrollment must be for at least the minimum of $100. If you do not reenroll, or eligible. if you are not employed by an agency that participates in FSAFEDS and actively making . allotments from your pay through December 31st, your funds will not be carried over provides, the IRS requires that you forfeit any money for Because of the tax benefits an FSA This is which you did not incur an eligible expense and file a claim in the time period permitted. -Lose-it” rule. Carefully consider the amount you will elect. known as the “Use-it-or For a health care or limited expense account, each participant must contribute a minimum of $100 to a maximum of $2,650. . See Current FSAFEDS participants must re-enroll to participate next year .fsafeds.com or www call 1-877-FSAFEDS (372-3337) or TTY : 1-866-353-8058. Note: FSAFEDS is not open to r etir ed employees, or to TRICARE-eligible individuals. If you are enrolled in an FSAFEDS HCFSA, you can take advantage of the Paperless Reimbursement option, which allows you to be reimbursed from your HCFSA without When Delta Dental receives a Federal Employees Dental submitting an FSAFEDS claim. Program claim for payment, we forward information about your out-of-pocket expenses (such as copayment and deductible amounts) to FSAFEDS for processing. FSAFEDS then reimburses you for your eligible out-of-pocket costs without the need for a claim form or receipt. Reimbursement is made directly to your bank from your HCFSA account via electronic funds transfer Y ou may need to file a paper claim to FSAFEDS in certain situations. V isit www . . FSAFEDS.com for more information. If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or HRA to pay for qualified or health reimbursement arrangement (HRA), you can use your HSA dental/vision costs not covered by your FEHB and FEDVIP plans. Y ou will be required to submit your claim on behalf of Delta Dental's Federal Employees Dental Program to the FSAFEDS Health Care Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA). 1 1 2019 Enroll at www .BENEFEDS.com

13 Section 3 How Y ou Obtain Car e When you enroll for the first time, you will receive a welcome letter along with an Identification Cards/ identification card ("ID Card"). It is important to bring your FEDVIP and FEHB ID cards ollment Enr Confirmation to every dental appointment. Because most FEHB plans of fer some level of dental benefits separate from your FEDVIP coverage, presenting both ID cards can ensure that you receive the maximum allowable benefit under each program along with accurate and timely claims processing. If you require a replacement ID card, you will be able to print your ID card through the ® An ID card is neither a guarantee of T Consumer oolkit at deltadentalins.com/fedvip . Y benefits nor is it required in order for you to obtain dental services. our provider may call 855-410-3255 to confirm your enrollment in the plan and the benefits available to you. If you were enrolled in Delta Dental's Federal Employees Dental Program in 2018 and deltadentalins.com/fedvip where you can view continue coverage for 2019, please visit and print the Plan Brochure, find network dentists and much more. Plan benefits are available, subject to plan provisions, from any licensed dentist in the 50 Wher e Y ou Get Cover ed Car e United States, the District of Columbia and Puerto Rico as well as overseas. oviders Plan Pr The provider network for Delta Dental's Federal Employees Dental Program consists of : Note there are ANT independently credentialed and contracted providers. IMPOR T dif ferent dentist networks for other Delta Dental plans—so be sure to use the Dentist deltadentalins.com/fedvip Search function at to find a dentist who participates in the network for Delta Dental’ s Federal Employees Dental Program. Contact your dentist to Y ou verify he/she is participating in Delta Dental’ s Federal Employees Dental Program. may also contact Customer Service at 855-410-3255 for a list of Federal Employees Dental Program network providers near you. s Federal Employees Dental Program network dentists are available in the 50 In-Network Delta Dental’ U.S. states, the District of Columbia and Puerto Rico. Our list of participating network . dentists is updated daily When you make your appointment, please advise the dental of fice that you are enrolled in the Federal Employees Dental and V ision Insurance Program (FEDVIP) and wish to use your in-network benefits; be sure to confirm that the dentist is a participating network provider for Delta Dental's Federal Employees Dental Program. Delta Dental's Federal Employees Dental Program network does not require an enrollee to . When you use a Delta Dental Federal Employees Dental select a primary care provider Program network provider , you are responsible only for billable char ges up to our negotiated plan allowance per procedure. Y ou are not responsible for treatment service ges in excess of the in-network negotiated per -procedure maximum unless you char ges. consent in writing to additional treatment char Y ou may obtain care from any licensed dentist. If the dentist is not part of our network, Out-of-Network benefits will be considered out-of-network. When you see a dentist who is outside of Delta Dental's participating network for the Federal Employees Dental Program, you will have a lower annual maximum benefit and we pay for services based on an out-of- Y ou are responsible for any dif ference between the plan payment network plan allowance. and the amount submitted/approved. Emer gency services are defined as those dental services needed to relieve pain or prevent Emergency Services the worsening of a condition that would be caused by a delay . 12 2019 Enroll at www .BENEFEDS.com

14 All expenses for emer gency services are payable as any other expense and are subject to plan limitations such as deductibles, frequencies and maximums. If you use an out-of- network provider for emer gency services, benefits will be paid under the out-of-network ou are responsible for the dif plan provisions. ference between the plan payment and the Y amount submitted/approved. Plan The plan allowance is the amount we allow for a specific procedure. When you use a Allowance participating Delta Dental Federal Employees Dental Program provider , your out-of- pocket cost is limited to the dif ference between the plan allowance and our payment. ference between When you use an out-of-network dentist, you are responsible for the dif ference up to the submitted/approved the plan allowance and our payment plus the dif char ges. Y ecertification/ Pr ou and your provider may request us to predetermine benefits for dental procedures that edetermination Notice Pr your dentist has planned. This is especially recommended for more complex and/or major procedures. e will provide both you and your dentist with a non-binding, written Pre- W treatment Estimate indicating if the procedures are covered and, if so, an estimate of what we will pay for those specific procedures. When the treatment is complete, the provider will fill in the date(s) of service on the Pre- treatment Estimate, sign and date the notice, and return it to Delta Dental at the address provided for claims submission (see Section 9 Claims Filing and Disputed Clams Processes). Pre-treatment Estimates submitted for payment will be processed in The final determination of accordance with Delta Dental's claims processing policies. , maximums, program benefits, limitations and allowable fees will be made by eligibility Delta Dental when the Pre-treatment Estimate is processed for payment. If more than one service or procedure can be used to treat the dental condition, Delta Alternate Benefit Dental reserves the right to authorize an alternate, less costly covered service as deemed by a dental professional to be appropriate and to meet broadly accepted national standards of dental practice. our Some dental services submitted on a claim may be reviewed if deemed appropriate. Dental Review Y provider should submit radiographic images with crowns and periodontal charting with periodontal sur geries. There may be situations resulting from the dental review in which an alternate benefit is recommended. For more extensive and costly services, we reatment Estimate request be submitted so you have an estimate recommend that a Pre-T of your coverage before the services are rendered. requirements, the FEHB plan will always be the It is important to know that, per FEDVIP FEHB First Payor first payor when you are also covered under Delta Dental's Federal Employees Dental Program. Therefore, it is important to provide your dental of fice with both your FEHB ID card and your Delta Dental Federal Employees Dental Program enrollment card at each appointment. When you visit a provider who participates with both, your FEHB plan and your FEDVIP The FEDVIP plan allowance will be the plan, the FEHB plan will pay benefits first. ge in these cases. Y ference between the FEHB prevailing char ou are responsible for the dif plan allowance. benefit payments and the FEDVIP e are responsible for and FEDVIP W facilitating the process with the primary FEHB payor . W e will coordinate benefit payments with the payment of benefits under other group Coordination of Benefits health benefits coverage (non-FEHB) you may have and the payment of dental/vision costs under no-fault insurance that pays benefits without regard to fault. If you are covered under a non-FEHB plan, Delta Dental’ s Federal Employees Dental Program dental benefits will be coordinated using traditional COB provisions for determining payment. 13 2019 Enroll at www .BENEFEDS.com

15 If your other dental coverage is part of your FEHB plan, it is important to note that by law , our dentist must submit your claim to your FEHB carrier Y your FEHB plan must pay first. first and then to Delta Dental. It is your responsibility to let the dentist know if you have both FEHB and FEDVIP coverage so the claim is submitted and processed correctly . If the amount we pay is more than we should have paid under the First Payor provision or Right of Recovery when benefits are coordinated, we may recover the excess from one or more of: the person we have paid; • • insurance companies; or ganizations. • other or , the member will never be held responsible for a greater out-of-pocket amount However than he/she would have been responsible for had there been no overpayment. Y our rates are determined based on where you live. This is called a rating area. If you eas Ar Rating or by move, you must update your address through BENEFEDS at www .BENEFEDS.com our rates might change because of the move. phone at 877-888-3337. Y ficient access (based on contractual standards) to a Delta Access Ar If you live in an area with insuf ea Limited Dental Federal Employees Dental Program network provider and you receive covered services from an out-of-network dentist, we will pay the same benefit level as if you used the services of an in-network dentist. Y our responsibility is limited to any dif ference between the amount billed and our payment. 14 2019 Enroll at www .BENEFEDS.com

16 Section 4 Cover ed Services Y our Cost For This is what you will pay out-of-pocket for covered care: Deductible A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services. There is no family deductible limit. ges credited to the deductible are also counted towards the Plan maximum Covered char and limitations. In-Network Out-of- In-Network Out-of- Network Network High Option Standard High Option Standard Option Option A Class $0 $0 $0 $0 $0 $50 $75 Class B $0 $0 $75 $0 Class C $50 Orthodontics $0 $0 $0 $0 Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you meet your deductible, if applicable. In-Network Out-of- In-Network Out-of- Network Network High Option Standard Standard High Option Option Option A 0% 0% 10% 40% Class 30% 45% 40% Class B 60% 60% 80% 65% 50% Class C 50% 50% 50% 50% Orthodontics ges. The Annual Annual Benefit Once you reach this amount, you are responsible for all additional char Maximum Benefit Maximums within each option are combined between in and out of network services. The total Annual Benefit Maximum will never be greater than the In-Network Maximum Annual Benefit. In-Network In-Network Out-of- Out-of- Network Network High Option Standard Standard High Option Option Option Maximum $30,000 $1,500 $3,000 $600 Annual Benefits The Lifetime Maximum is applicable to Orthodontia benefits only . There are no other Lifetime Benefit lifetime maximums under this Plan. Maximum 15 2019 Enroll at www .BENEFEDS.com

17 In-Network In-Network Out-of-Network Out-of-Network Standard High Option Standard High Option Option Option $3,500 for $3,500 for Lifetime $2,000 $1,000 Orthodontic children; $2,000 children; $2,000 for adults Maximum for adults ou pay the coinsurance percentage of our network allowance for covered services. Y Y In-Network Services ou ges above that allowance. are not responsible for char Out-of-Network Services If the dentist you use is not part of our network, benefits will be considered out-of- network. Because these providers are not part of our network, we pay for services rendered by an out-of-network provider based on an out-of-network plan allowance. The plan allowance is the amount we allow for a specific procedure. When you use a Allowance Plan participating provider , your out-of-pocket cost is limited to the dif ference between the , you are When you use an out-of-network provider plan allowance and our payment. responsible for the dif ference between our payment and the submitted/approved amount. The calendar year refers to the plan year , which is defined as January 1, 2019 to December ear Calendar Y 31, 2019. The installation of complete or partial removable dentures, fixed partial dentures ooth Missing but Not T Replaced Rule (bridges), implants and other prosthodontic services will be covered when replacing or repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior fective date under the Delta Dental Federal Employees Dental to your coverage ef Program. Initial prosthodontic services to replace natural teeth that were missing prior to your Delta Dental Federal Employees Dental Program date of coverage are not covered. TRDP enrollees will be covered for the 2019 plan In-Pr ogr ess T r eatment In-progress treatment for incoming year; regardless of any current plan exclusion for care initiated prior to the enrollee's fective date. ef This requirement includes assumption of payments for covered orthodontia services up to policy limits, and full payment where applicable up to the terms of FEDVIP the FEDVIP policy for covered services completed (but not initiated) in the 2019 plan year such as crowns and implants. This is not a requirement for carriers to provide in-progress coverage for orthodontia in a plan where an enrollee must meet a waiting period. Unless otherwise stated, FEDVIP carriers will not cover in-progress treatment if you plan that has a waiting period, or does not cover the service. Several enroll in a FEDVIP fer orthodontia coverage without a 12-month dental plans have options that of FEDVIP waiting period, and without age limits. 16 2019 Enroll at www .BENEFEDS.com

18 Section 5 Dental Services and Supplies Class A Basic Important things you should keep in mind about these benefits: • All benefits are subject to the definitions, limitations, and exclusions in this plan brochure and are payable only when determined to be necessary for the prevention, diagnosis, care, or treatment of a covered condition and if they are determined to meet generally accepted dental protocols. • The calendar year deductible is $0 under both the High and Standard options when services are rendered by an in-network provider . • If an out-of-network provider renders the services, there is a $50.00 deductible per person per calendar year for the High Option and a $75.00 deductible per person per calendar year for the Standard Option. Each enrolled covered person must satisfy his/her own deductible; there is no family deductible in either option. • The annual benefit maximum in the High Option is $30,000 for non-orthodontic services when the services are rendered by an in-network provider and $3,000 when services are rendered by an out- . of-network provider The annual benefit maximum in the Standard Option is $1,500 when services are rendered by an in-network provider and $600 when services are rendered by an out-of-network . provider Under no circumstances will Delta Dental's Federal Employees Dental Program allow more than • $30,000 in combined benefits under the High Option in any plan year or more than $1,500 in combined benefits under the Standard Option in any plan year . • Also see Any dental service or treatment not listed as a covered service is not eligible for benefits. Section 7, General Exclusions – Things W e Do Not Cover , for a list of exclusions and limitations. Y ou Pay: • High Option In-Network: - $0 for covered services as defined by the plan and subject to plan limitations and maximums. Out-of-Network: 10% of the plan's out-of-network allowance and any dif ference between that - allowance and the billed/approved amount. • Standard Option - In-Network: $0 for covered services as defined by the plan and subject to plan limitations and maximums. - Out-of-Network: 40% of the plan's out-of-network allowance and any dif ference between that allowance and the billed/approved amount. Diagnostic Services D0120 Periodic oral evaluation – established patient - Limited to two in a calendar year D0140 Limited oral evaluation - problem-focused – Limited to one in a calendar year D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation – new or established patient - Limited to one in a calendar year D0180 Comprehensive periodontal evaluation – new or established patient - Limited to one in a calendar year D0210 Intraoral - complete set of radiographic images – Limited to one every 48 months D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0240 Intraoral - occlusal radiographic image D0250 Extraoral - 2D projection radiographic images created using a stationary radiation source, and detector D0251 Extraoral - posterior dental radiographic image D0270 Bitewing - single radiographic image – Limited to one in a calendar year Diagnostic Services - continued on next page 17 2019

19 Diagnostic Services (cont.) D0272 Bitewings - two radiographic images – Limited to one in a calendar year D0273 Bitewings - three radiographic images – Limited to one in a calendar year D0274 Bitewings - four radiographic images – Limited to one in a calendar year ertical bitewings - 7 to 8 radiographic images – Limited to one in a calendar year D0277 V D0330 Panoramic radiographic images – Limited to one every 48 months D0425 Caries susceptibility tests Benefit Limitations for Class Diagnostic Services A 1. Pulp vitality tests are considered integral to all services. Examinations/evaluations by specialists are payable as comprehensive or periodic examinations/evaluations and are 2. counted towards the two-in-a-calendar -year limitation on examinations/evaluations. A full-mouth series (complete series) of radiographs includes bitewings. Any additional radiographic image taken with a 3. complete radiographic series is considered integral to the complete series. 4. If the total fee for individually listed radiographs equals or exceeds the fee for a complete series, these radiographs are paid as a complete series and are subject to the same benefit limitations. 5. Payment for more than one of any category of full-mouth radiographs within a 48-month period is the patient's responsibility . A panoramic radiograph taken with any other radiographic image is considered a full-mouth series and is paid as such, 6. A panoramic radiograph is not a benefit for patients under six years of age. and is subject to the same benefit limitation. 7. Payment for periapical radiographic images (other than as part of a complete series) is limited to four within a calendar year except when done in conjunction with emer gency services and submitted by report. 8. Payment for a bitewing survey , whether single, two, three, four or vertical radiographic image(s), including those taken as part of a complete series, is limited to one within a calendar year . eventive Services Pr 1 10 Prophylaxis - Adult – Limited to two in a calendar year (or three if enrollee is a T ype 1 or T D1 ype 2 diabetic) D1 120 Prophylaxis - Child – Limited to two in a calendar year (or three if enrollee is a T ype 1 or T ype 2 diabetic) D1206 T opical application of fluoride varnish - limited to two in a calendar year D1208 opical application of fluoride - excluding varnish – Limited to two in a calendar year T D1351 Sealant - per tooth - permanent molars free from caries to patients under 19 – Limited to one in 36 months D1352 Preventive resin restoration in a moderate-to-high-caries-risk patient - permanent tooth D1510 Space maintainer - fixed - unilateral – For dependent children under age 19 D1516 Space maintainer - fixed - bilateral – maxillary - For dependent children under age 19 D1517 Space maintainer – fixed – bilateral – mandibular – For dependent children under age 19 D1520 Space maintainer - removable - unilateral – For dependent children under age 19 D1526 Space maintainer - removable - bilateral – maxillary For dependent children under age 19 D1527 Space maintainer – removable – bilateral – mandibular For dependent children under age 19 D1550 Recement or rebond space maintainer – Payable once in a calendar year D1575 Distal shoe space maintainer – fixed – unilateral – For dependent children under age 19 Preventive Services - continued on next page 18 2019

20 Pr eventive Services (cont.) A Preventive Services Benefit Limitations for Class T ype 1 or 1. ype 2 Diabetes are covered in a calendar year . A Three prophylaxes for adults and children diagnosed with T statement from the patient’ s medical condition must be provided. s physician documenting the patient’ 2. Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and is paid as such. Participating dentists may not bill the patient for any dif ference in fees. 3. There are no provisions for special consideration for a prophylaxis based on degree of dif ficulty . Scaling or polishing to remove plaque, calculus and stains from teeth is considered to be part of the prophylaxis procedure. 4. T opical fluoride applications are covered only when performed as independent procedures. Use of a prophylaxis paste containing fluoride is payable as a prophylaxis only . Routine oral hygiene instructions are considered integral to a prophylaxis service. 5. 6. The tooth number of the space to be maintained is required when requesting payment for space maintainers. The fee for a stainless steel crown or band retainer is considered to be included in the total fee for the space maintainer . 7. 8. Sealants provided on the same date of service and on the same tooth as a restoration of the occlusal surface are considered integral procedures. Basic Services Additional Pr es Cover ed as Class A ocedur D91 10 Palliative (emer gency) treatment of dental pain - minor procedure 19 2019

21 Class B Intermediate Important things you should keep in mind about these benefits: All benefits are subject to the definitions, limitations and exclusions in this plan brochure and are • payable only when determined to be necessary for minor restorative care or treatment of a covered condition and if they are determined to meet generally accepted dental protocols. The calendar year deductible is $0 under both the High and Standard options when services are • . provided by an in-network provider • If an out-of-network provider renders the services, there is a $50.00 deductible per person per calendar year for the High Option and a $75.00 deductible per person per year for the Standard Option. Each enrolled covered person must satisfy his/her own deductible; there is no family deductible in either option. The annual benefit maximum in the High Option is $30,000 for non-orthodontic services when the • services are rendered by an in-network provider and $3,000 when services are rendered by an out- of-network provider . The annual benefit maximum in the Standard Option is $1,500 for non- orthodontic services when services are rendered by an in-network provider and $600 when services are rendered by an out-of-network provider . • Under no circumstance will Delta Dental's Federal Employees Dental Program allow more than $30,000 in combined benefits under the High Option in any plan year or more than $1,500 in combined benefits under the Standard Option in any plan year . • Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see Things W Section 7, General Exclusions – , for a list of exclusions and limitations. e Do Not Cover • In-progress treatment for transitioning TRDP enrollees will be covered for the 2019 plan year . This is regardless of any current plan exclusions for care initiated prior to the enrollee’ s ef fective date. Y ou Pay: High Option • In-Network: 30% of the network allowance for covered services as defined by the plan and - subject to plan limitations and maximums. - Out-of-Network: 40% of the plan's out-of-network allowance along with a $50 deductible and ference between that allowance and the billed/approved amount. any dif Standard Option • - In-Network: 45% of the network allowance for covered services as defined by the plan subject to plan limitations and maximums. - Out-of-Network: 60% of the plan's out-of-network allowance along with a $75 deductible and any dif ference between that allowance and the billed/approved amount. Minor Restorative Services D2140 Amalgam – one surface, primary or permanent D2150 Amalgam – two surfaces, primary or permanent D2160 Amalgam – three surfaces, primary or permanent D2161 Amalgam – four or more surfaces, primary or permanent D2330 Resin-based composite – one surface, anterior D2331 Resin-based composite – two surfaces, anterior D2332 Resin-based composite – three surfaces, anterior D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) D2391 Resin-based composite – one surface, posterior D2392 Resin-based composite – two surfaces, posterior Minor Restorative Services - continued on next page 20 2019 Enroll at www .BENEFEDS.com

22 Minor Restorative Services (cont.) D2393 Resin-based composite – three surfaces, posterior D2394 Resin-based composite – four or more surfaces, posterior , veneer or partial coverage restorations D2910 Recement or rebond inlay , onlay D2920 Recement or rebond crown D2930 Prefabricated stainless steel crown – primary tooth - One per patient, per tooth, per lifetime D2931 Prefabricated stainless steel crown – permanent tooth - One per patient, per tooth, per lifetime D2951 Pin retention – per tooth, in addition to restoration Benefit Limitations for Class B Minor Restorative Services 1. Pin retention is covered only when reported in conjunction with an eligible restoration. 2. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits. 3. Repair or replacement of restorations by the same dentist/dental of fice and involving the same tooth surfaces performed within 24 months of the original restoration are considered integral procedures, and a separate fee is not char geable to the member by a participating dentist regardless of the number of combinations of restorations placed. However , payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy . 4. The payment for restorations includes all related services including but not limited to etching, bases, liners, dentinal adhesives, local anesthesia, polishing caries removal, preparation of gingival tissue, occlusal/contact adjustments and detection agents. 5. . Restorations are covered benefits only when necessary to replace tooth structure loss due to fracture or decay 6. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth up to age 14, or when placed as a result of accidental injury . 7. Payment for a resin restoration will be made when a laboratory-fabricated porcelain or resin veneer is used to restore an anterior tooth due to tooth fracture or caries. Endodontic Services 10 Pulp cap - direct (excluding final restoration) D31 D3120 Pulp cap - indirect (excluding final restoration) - Payable once per tooth D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament - Payable once per tooth on primary teeth only D3221 Pulpal debridement, primary and permanent teeth D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development, per tooth, per lifetime D3230 Pulpal therapy (resorbable filling) – anterior , primary tooth (excluding final restoration) - For dependent children to age 6 D3240 Pulpal therapy (resorbable filling) – posterior , primary tooth (excluding final restoration) - For dependent children to age 1 1 and limited to once per tooth per lifetime Benefit Limitations for Class B Endodontic Services 1. Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of root canal therapy . 2. Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable if root canal therapy is not and will not be provided on the same tooth. 3. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed. 4. An indirect pulp cap is payable only when a near exposure of the pulp is evident and when the final restoration is not completed for at least 60 days. 5. Payment for gross pulpal debridement is limited to the relief of pain prior to conventional root canal therapy and when performed by a dentist not completing the endodontic therapy . 21 2019 Enroll at www .BENEFEDS.com

23 Periodontic services D4341 Periodontal scaling and root planing – four or more teeth per quadrant - Payable once per quadrant in 24 months D4342 Periodontal scaling and root planing – one to three teeth, per quadrant - Payable once per quadrant in 24 months D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation 10 and D4346 D4910 Periodontal maintenance – Limited to four in a calendar year combined with D1 1 D7921 Collection and application of autologous blood concentrate product - Limited to one in 36 months Benefit Limitations for Class B Periodontic Services 1. Documentation of the need for periodontal treatment includes periodontal pocket charting, case type, prognosis, amount of existing attached gingiva, etc. Periodontal pocket charting should indicate the area/quadrants/teeth involved and is required for most procedures. routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to 2. A periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty , gingival flap procedure gery . or osseous sur A 3. combination of up to four D4910 (periodontal maintenance procedures) or D4346 (scaling in the presence of 1 . generalized moderate or severe gingival inflammation) or D1 10 (adult prophylaxis) may be paid within a calendar year Note: Adult prophylaxis, including D4346, is limited to two in a calendar year (refer to Preventive Services section). Periodontal maintenance is only covered when performed following active periodontal treatment. 4. An oral evaluation reported in addition to periodontal maintenance will be processed as a separate procedure subject to 5. the policies and limitations applicable to oral evaluation. Pr osthodontic services D5410 Adjust complete denture – maxillary D541 1 Adjust complete denture – mandibular D5421 Adjust partial denture – maxillary Adjust partial denture – mandibular D5422 1 Repair broken complete denture base, mandibular D551 D5512 Repair broken complete denture base, maxillary D5520 Replace missing or broken teeth – complete denture (each tooth) 1 Repair resin partial denture base, mandibular D561 D5612 Repair resin partial denture base, maxillary D5621 Repair cast partial framework, mandibular D5622 Repair cast partial framework, maxillary D5630 Repair or replace broken retentive clasping materials - per tooth D5640 Replace broken teeth – per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture - per tooth D5670 Replace all teeth and acrylic on cast metal framework (maxillary) D5671 Replace all teeth and acrylic on cast metal framework (mandibular) D5710 Rebase complete maxillary denture – Limited to once in 36 months D571 1 Rebase complete mandibular denture – Limited to once in 36 months D5720 Rebase maxillary partial denture – Limited to once in 36 months D5721 Rebase mandibular partial denture – Limited to once in 36 months D5730 Reline complete maxillary denture (chairside) – Limited to once in 36 months D5731 Reline complete mandibular denture (chairside) – Limited to once in 36 months D5740 Reline maxillary partial denture (chairside) – Limited to once in 36 months D5741 Reline mandibular partial denture (chairside) – Limited to once in 36 months D5750 Reline complete maxillary denture (laboratory) – Limited to once in 36 months Prosthodontic services - continued on next page 22 2019 Enroll at www .BENEFEDS.com

24 Pr osthodontic services (cont.) D5751 Reline complete mandibular denture (laboratory) – Limited to once in 36 months D5760 Reline maxillary partial denture (laboratory) – Limited to once in 36 months D5761 Reline mandibular partial denture (laboratory) – Limited to once in 36 months issue conditioning, maxillary D5850 T T issue conditioning, mandibular D5851 D6930 Recement or rebond fixed partial denture D6980 Fixed partial denture repair necessitated by restorative material failure Benefit Limitations for Class B Prosthodontic Services For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. 1. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, however , the provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider , typically an oral sur geon, inserted the dentures. 2. The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures is A geable to the member by a participating dentist. included in the fee for these procedures. separate fee is not char 3. T issue conditioning is considered integral when performed on the same day as the delivery of a denture or a reline/ rebase. Recementation of crowns, fixed partial dentures, inlays, onlays, or cast posts within six months of their placement by the 4. same dentist/dental of fice is considered integral to the original procedure. 5. Adjustments to or relining or rebasing of an initial or replacement denture provided within six months of the insertion of an initial or replacement denture are integral to the denture. Oral surgery D71 1 1 Extraction coronal remnants, primary tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Extraction of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth – soft tissue D7230 Removal of impacted tooth – partially bony D7240 Removal of impacted tooth – completely bony , with unusual sur D7241 Removal of impacted tooth – completely bony gical complications D7250 Removal of residual tooth roots (cutting procedure) D7251 Coronectomy - intentional partial tooth removal D7270 T ooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7280 Exposure of an unerupted tooth – Payable once per tooth per lifetime D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant D731 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant 1 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant D7471 Removal of exostosis (maxilla or mandible) D7510 Incision and drainage of abscess – intraoral soft tissue D7910 Suture of recent small wounds up to 5 cm D7971 Excision of pericoronal gingiva D7999 Unspecified oral sur gery procedure, by report Oral sur gery - continued on next page 23 2019 Enroll at www .BENEFEDS.com

25 Oral surgery (cont.) Benefit Limitations for Class B Oral Sur gery Services Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy 1. . 2. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow-up care is considered integral to the procedure. Char ges for related services such as necessary wires and splints, adjustments, and follow-up visits are considered 3. integral to the fee for reimplantation and/or stabilization (D7270). 4. The removal of impacted teeth is paid based on the anatomical position as determined from a review of x-rays. If the degree of impaction is determined to be less than the reported degree, payment will be based on the allowance for the lesser level. 5. Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless specific documentation is provided that substantiates the need for removal and is approved by the contractor . 6. fice visits, local anesthesia and suture removal, is included in the fee for the Routine post-operative care, including of extraction. 7. The fee for root recovery is included in the fee for the extraction. 8. Incision and drainage on the same date of service with any palliative or oral sur gery procedure is not payable. The procedure is considered part of those services. 9. Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy . 24 2019 Enroll at www .BENEFEDS.com

26 Class C Major Important things you should keep in mind about these benefits: All benefits are subject to the definitions, limitations and exclusions in this plan brochure and are • payable only when determined to be necessary for the prevention, diagnosis, care or treatment of a covered condition and if they are determined to meet generally accepted dental protocols. The calendar year deductible is $0 under both the High and Standard options when services are • . rendered by an in-network provider • If an out-of-network provider renders the services, there is a $50.00 deductible per person per calendar year for the High Option and a $75.00 deductible per person per calendar year for the Standard Option. Each enrolled covered person must satisfy his/her own deductible; there is no family deductible in either option. • The annual benefit maximum in the High Option is $30,000 for non-orthodontic services when the services are rendered by an in-network provider and $3,000 when services are rendered by an out- . The annual benefit maximum in the Standard Option is $1,500 for non- of-network provider orthodontic services when services are rendered by an in-network provider and $600 when services are rendered by an out-of-network provider . Under no circumstances will Delta Dental’ • s Federal Employees Dental Program allow more than $30,000 in combined benefits under the High Option in any plan year or more than $1,500 in combined benefits under the Standard Option in any plan year . Alternate benefits: If more than one service can be used to treat the dental condition, an alternate • benefit may be authorized for a less costly service as deemed appropriate by a dental professional. Prior to receiving major services, we recommend that a precertification be submitted so you are aware of your coverage before the services are rendered. • Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see Section 7, General Exclusions – Things W e Do Not Cover , for a list of exclusions and limitations. • In-progress treatment for transitioning enrollees will be covered for the 2019 plan year . This TRDP s ef is regardless of any current plan exclusions for care initiated prior to the enrollee’ fective date. ou Pay: Y • High Option - In-Network: 50% of the network allowance for covered services as defined by the plan and subject to plan limitations and maximums. - Out-of-Network: 60% of the plan's out-of-network allowance along with a $50.00 deductible and any dif ference between that allowance and the billed/approved amount. • Standard Option - In-Network: 65% of the network allowance for covered services as defined by the plan and subject to plan limitations and maximums. - Out-of-Network: 80% of plan's out-of-network allowance along with a $75.00 deductible and any dif ference between that allowance and the billed/approved amount. 25 2019 Enroll at www .BENEFEDS.com

27 Major Restorative Services D0160 Detailed and extensive oral evaluation – problem-focused, by report D2510 Inlay – metallic – one surface D2520 Inlay – metallic – two surfaces D2530 Inlay – metallic – three or more surfaces D2542 Onlay – metallic – two surfaces D2543 Onlay – metallic – three surfaces D2544 Onlay – metallic – four or more surfaces D2740 Crown – porcelain/ceramic D2750 Crown – porcelain fused to high noble metal D2751 Crown – porcelain fused to predominantly base metal D2752 Crown – porcelain fused to noble metal D2780 Crown – 3/4 cast high noble metal D2781 Crown – 3/4 cast predominantly base metal D2782 Crown – 3/4 cast noble metal D2783 Crown – 3/4 porcelain/ceramic D2790 Crown – full cast high noble metal – Limited to once in five years D2791 Crown – full cast predominantly base metal – Limited to once in five years D2792 Crown – full cast noble metal – Limited to once in five years D2794 Crown – titanium – Limited to once in five years D2950 Core buildup, including any pins when required D2954 Prefabricated post and core in addition to crown D2980 Crown repair necessitated by restorative material failure D2981 Inlay repair necessitated by restorative material failure D2982 Onlay repair necessitated by restorative material failure D2983 V eneer repair necessitated by restorative material failure D2990 Resin infiltration of incipient smooth surface lesions Major Restorative Services - continued on next page 26 2019 Enroll at www .BENEFEDS.com

28 Major Restorative Services (cont.) Benefit Limitations for Class C Major Restorative Services 1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral 2. Pin retention is covered only when reported in conjunction with an eligible restoration. 3. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin buildup (D2950). 4. The char ge for a crown or onlay should include all char ges for work related to its placement including, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try- in visits, and cementations of both temporary and permanent crowns. Onlays, permanent single-crown restorations, and posts and cores for members 12 years of age or younger are excluded 5. from coverage unless specific rationale is provided indicating the reason for such treatment (e.g., fracture, endodontic therapy , etc.) and if approved by the contractor . Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core. 6. The patient is responsible for the dif ge for the cast post and core and the amount paid by the ference between the dentist's char contractor for the prefabricated post and core. 7. , buildup, or Replacement of crowns, onlays, buildups, and posts and cores is covered only if the existing crown, onlay post and core was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing crown, onlay , buildup, or post and core is not and cannot be made serviceable. Satisfactory evidence must show , buildup, or post and core is not and cannot be made serviceable. that the existing crown, onlay The five-year service date is measured based on the actual date (day and month) of the initial services versus the first day of the initial service month. 8. Onlays, crowns, and posts and cores are payable only when necessary due to decay or tooth fracture. However , if the tooth can be adequately restored with amalgam or composite (resin) filling materials, payment will be made for that service. This payment can be applied toward the cost of the onlay , crown, or post and core. 9. When performed as an independent procedure, the placement of a post is not a covered benefit. Posts are only eligible when provided as part of a buildup for a crown and are considered integral to the buildup. 10. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to ef fective date of coverage are not eligible for coverage. Endodontic Services D3310 Endodontic therapy , anterior tooth (excluding final restoration) D3320 Endodontic therapy , premolar tooth (excluding final restoration) D3330 Endodontic therapy , molar tooth (excluding final restoration) D3346 Retreatment of previous root canal therapy – anterior D3347 Retreatment of previous root canal therapy – premolar D3348 Retreatment of previous root canal therapy – molar D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) – For permanent teeth only D3352 Apexification/recalcification – interim medication replacement – For permanent teeth only D3353 Apexification/recalcification – final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) – For permanent teeth only D3410 Apicoectomy – anterior D3421 Apicoectomy – premolar (first root) D3425 Apicoectomy – molar (first root) D3426 Apicoectomy (each additional root) D3427 Periradicular sur gery without apicoectomy D3430 Retrograde filling – per root D3450 Root amputation – per root Endodontic Services - continued on next page 27 2019 Enroll at www .BENEFEDS.com

29 Endodontic Services (cont.) D3920 Hemisection (including any root removal), not including root canal therapy Benefit Limitations for Class C Endodontic Services 1. T reatment of a root canal obstruction is considered an integral procedure. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed. 2. 3. Placement of a final restoration following endodontic therapy is eligible as a separate procedure. 4. gery or root canal therapy by the same dentist or group practice within 24 months is Retreatment of apical sur considered part of the original procedure. 5. Apexification is payable only on permanent teeth with incomplete root development or for repair of perforation. Otherwise, the fee is included in the fee for the root canal. Periodontic Services D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant 1 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant D421 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant D4249 Clinical crown lengthening – hard tissue – Payable once per tooth, per lifetime D4260 Osseous sur gery (including elevation of a full thickness flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous sur gery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant D4268 Sur gical revision procedure, per tooth D4270 Pedicle soft tissue graft procedure D4273 Autogenous connective tissue graft procedure (including donor and recipient sites), first tooth, implant or edentulous tooth position in graft D4275 Non-autogenous connective tissue graft (including recipient site and donor material), first tooth, implant or edentulous tooth position in graft D4276 Combined connective tissue and double pedicle graft, per tooth gery), first tooth or edentulous tooth position D4277 Free soft tissue graft procedure (including recipient and donor site sur in graft D4278 Free soft tissue graft procedure (including recipient and donor site sur gery), each additional contiguous tooth or edentulous tooth position in same graft site D4283 gical sites) - each additional Autogenous connective graft tissue procedure (including donor and recipient sur contiguous tooth, implant or edentulous tooth position in same graft site D4285 Non-autogenous connective tissue graft procedure (including recipient sur gical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position in same graft site D4355 Full mouth debridement to enable comprehensive oral evaluation and diagnosis on subsequent visit D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth Periodontic Services - continued on next page 28 2019 Enroll at www .BENEFEDS.com

30 Periodontic Services (cont.) Benefit Limitations for Class C Periodontic Services Documentation of the need for periodontal treatment includes periodontal pocket charting, case type, prognosis, amount 1. of existing attached gingiva, etc. Periodontal pocket charting should indicate the area/quadrants/teeth involved and is required for most procedures. Gingivectomy or gingivoplasty , gingival flap procedures, guided tissue regeneration, soft tissue grafts, bone replacement 2. grafts and osseous sur gery provided within 36 months of the same sur gical periodontal procedure in the same area of the mouth are not covered. 3. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, onlays, crown buildups, post and cores or basic restorations are considered integral to the restoration. Gingival flap procedure is considered integral when provided on the same date of service by the same dentist in the 4. same area of the mouth as periodontal sur gical procedures, endodontic procedures and oral sur gery procedures. 5. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater) or surfaces involved. Another site on the same tooth is considered integral to the first site reported. Non-contiguous areas involving dif ferent teeth may be reported as additional sites. Osseous sur gery in the same area of the mouth. 6. gery is not covered when provided within 36 months of osseous sur 7. Osseous sur gery performed in a limited area and in conjunction with crown lengthening on the same date of service by the same dentist and in the same area of the mouth will be processed as crown lengthening. Guided tissue regeneration is covered only when provided to treat Class II furcation involvement or interbony defects. It 8. is not covered when provided to obtain root coverage, or when provided in conjunction with extractions, cyst removal or procedures involving the removal of a portion of a tooth, e.g, apicoectomy or hemisection. 9. One crown lengthening per tooth per lifetime is covered. 10. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty , gingival flap procedure or osseous sur gery . 1 1. gical procedures (except soft tissue grafts, osseous grafts, and guided tissue Payment for multiple periodontal sur regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the greater sur The lesser procedure is considered integral and its allowance is included in the allowance for gical procedure. the greater procedure. Sur gical revision procedure (D4268) is considered integral to all other periodontal procedures. 12. 13. Subepithelial connective tissue grafts and combined connective tissue and double pedical grafts are payable at the level of free soft tissue grafts. The dif ference between the allowance for the soft tissue graft and the dentist's char ge is the patient's responsibility . 14. Up to two tissue grafts are payable per quadrant per visit. Additional tissue grafts performed in a quadrant are not covered benefits. Pr osthodontic Services 10 Complete denture – maxillary D51 D5120 Complete denture – mandibular D5130 Immediate denture – maxillary D5140 Immediate denture – mandibular D521 1 Maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth) D5212 Mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth) D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5221 Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth) D5222 Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Prosthodontic Services - continued on next page 29 2019 Enroll at www .BENEFEDS.com

31 Pr osthodontic Services (cont.) D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5282 Removable unilateral partial denture – one-piece cast metal (including clasps and teeth), maxillary D5283 Removable unilateral partial denture – one-piece cast metal (including clasps and teeth), mandibular gical placement of implant body: endosteal implant D6010 Sur D6013 Sur gical placement of mini implant D6055 Connecting Bar - implant supported or abutment supported D6056 Prefabricated abutment - includes modification and placement D6057 Custom fabricated abutment - includes placement D6058 Abutment supported porcelain/ceramic crown D6059 Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal) D6060 Abutment supported porcelain fused to metal crown (noble metal) D6061 Abutment supported cast metal crown (high noble metal) D6062 Abutment supported cast metal crown (predominantly base metal) D6063 D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain/ceramic crown D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy , high noble metal) D6067 Implant supported metal crown (titanium, titanium alloy , high noble metal) D6068 Abutment supported retainer for porcelain/ceramic FPD D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 Abutment retainer for porcelain fused to metal FPD (predominantly base metal) D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) D6072 Abutment supported retainer for cast metal FPD (predominantly base metal) D6073 D6074 Abutment supported retainer for cast metal FPD (noble metal) D6075 Implant supported retainer for ceramic FPD , or high noble metal) D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy , or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments D6090 Repair implant supported prosthesis, by report D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment D6094 Abutment supported crown (titanium) D6095 Repair implant abutment D6096 remove broken implant retaining screw D6100 Implant removal, by report D61 10 Implant/abutment supported removable denture for edentulous arch - maxillary D61 1 1 Implant/abutment supported removable denture for edentulous arch - mandibular D61 12 Implant/abutment supported removable denture for partially edentulous arch - maxillary D61 13 Implant/abutment supported removable denture for partially edentulous arch - mandibular D61 14 Implant/abutment supported fixed denture for edentulous arch - maxillary Prosthodontic Services - continued on next page 30 2019 Enroll at www .BENEFEDS.com

32 Pr osthodontic Services (cont.) 15 Implant/abutment supported fixed denture for edentulous arch - mandibular D61 D61 16 Implant/abutment supported fixed denture for partially edentulous arch - maxillary 17 Implant/abutment supported fixed denture for partially edentulous arch - mandibular D61 D6194 Abutment supported retainer crown for FPD (titanium) D6210 Pontic – cast high noble metal D621 1 Pontic – cast predominantly base metal D6212 Pontic – cast noble metal D6214 Pontic – titanium D6240 Pontic – porcelain fused to high noble metal D6241 Pontic – porcelain fused to predominantly base metal D6242 Pontic – porcelain fused to noble metal D6245 Pontic – porcelain/ceramic D6545 Retainer - cast metal for resin bonded fixed prosthesis D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis D6549 Resin retainer - for resin-bonded fixed prosthesis D6600 Retainer inlay – porcelain/ceramic, two surfaces D6601 Retainer inlay – porcelain/ceramic, three or more surfaces D6604 Retainer inlay - indirectly fabricated predominantly base metal, two surfaces D6605 Retainer inlay - indirectly fabricated predominantly base metal, three or more surfaces D6608 Retainer onlay – porcelain/ceramic, two surfaces D6609 Retainer onlay - porcelain/ceramic, three or more surfaces D6612 Retainer onlay - indirectly fabricated predominantly base metal, two surfaces D6613 Retainer onlay - indirectly fabricated predominantly base metal, three or more surfaces D6740 Retainer crown – porcelain/ceramic D6750 Retainer crown – porcelain fused to high noble metal D6751 Retainer crown – porcelain fused to predominantly base metal D6752 Retainer crown – porcelain fused to noble metal D6780 Retainer crown – 3/4 cast high noble metal D6781 Retainer crown – 3/4 cast predominantly base metal D6782 Retainer crown – 3/4 cast noble metal D6783 Retainer crown – 3/4 porcelain/ceramic D6790 Retainer crown – full cast high noble metal D6791 Retainer crown – full cast predominantly base metal D6792 Retainer crown – full cast noble metal D6794 Retainer crown – titanium D9999 Unspecified adjunctive procedure, by report Prosthodontic Services - continued on next page 31 2019 Enroll at www .BENEFEDS.com

33 Pr osthodontic Services (cont.) Benefit Limitations for Class C Prosthodontic Services 1. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital fective date of coverage are not eligible for coverage. defects, prior to ef Replacement of implants is covered only if the existing implant was placed at least five years prior to the replacement 2. and the implant has failed. 3. Replacement of removable and/or fixed prostheses (i.e., partial and/or complete denture, fixed bridge) is covered when The month and the existing removable and/or fixed prostheses was provided at least five years prior to the replacement. year of the initial placement of the prostheses is required for coverage and claims payment. If the existing removable and/or fixed prostheses cannot be repaired, satisfactory evidence (narrative, radiographic images) is required for coverage of the replacement prostheses. Replacement of implant prostheses is covered only if the existing prostheses were placed at least five years prior to the 4. replacement and satisfactory evidence is presented that demonstrates they are not, and cannot be made, serviceable. Implant procedures, including applicable restorations and repairs, are a covered benefit once in five years. For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. 5. , the The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, however provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider , typically an geon, inserted the dentures. oral sur The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures are 6. included in the fee for these procedures. A separate fee is not char geable to the member by a participating dentist. 7. Removable cast-base partial dentures for members under 12 years of age are excluded from coverage unless specific rationale is provided indicating the necessity for that treatment and is approved by the contractor . Adjustments provided within six months of the insertion of an initial or replacement denture or implant are integral to 8. the denture or implant. 9. The relining or rebasing of a denture is considered integral when performed within six months following the insertion of that denture. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are not covered unless specific 10. . rationale is provided indicating the necessity for such treatment and is approved by the contractor 1 1. Payment for a denture or an overdenture made with precious metals is based on the allowance for a conventional denture. Specialized procedures performed in conjunction with an overdenture are not covered. Any additional cost is the member's responsibility . 12. fixed partial denture and removable partial denture are not covered in the same arch. Payment will be made for a A removable partial denture to replace all missing teeth in the arch. 13. T emporary fixed partial dentures are not a covered benefit and, when done in conjunction with permanent fixed partial dentures, are considered integral to the allowance for the fixed partial dentures. 14. Implants and related prosthetics may be covered and may be reimbursed as an alternative benefit as a three-unit fixed partial denture. 15. Replacement of dentures that have been lost, stolen or misplaced is not a covered service. 32 2019 Enroll at www .BENEFEDS.com

34 Class D Orthodontic Important things you should keep in mind about these benefits: All benefits are subject to the definitions, limitations, and exclusions in this plan brochure and are • payable only when determined to be necessary for the prevention, diagnosis, care, or treatment of a covered orthodontic condition and if they are determined to meet generally accepted dental protocols. • The calendar year deductible for orthodontic services is $0 per eligible enrollee under both the High and Standard options. Orthodontic services are only for dependent children up to age 19 in the Standard option, and for children and adults enrolled in the High option. T • The waiting period for orthodontic services is 12 months. o meet this requirement, the enrollee receiving orthodontic services must be covered under the same plan for the entire 12 month waiting period and continue orthodontic benefits in that same orthodontia-vested plan option. In-progress treatment will be allowed for those enrollees who came to FEDVIP from the TRICARE Retiree Dental Program. • The lifetime maximum for orthodontic services depends on the option in which you enroll and if you chose to receive services from a network provider . If you are covered by the High Option, the lifetime maximum is $3,500 for children regardless of the participating status of the provider and $2,000 for adults. In the Standard Option, services rendered by an in-network provider will be subject to a $2,000 lifetime maximum and services rendered by an out-of-network provider will be subject to a $1,000 lifetime maximum. • Covered services are limited to the maximum allowable char ge as determined by Delta Dental and are subject to alternative benefits, coinsurance, maximum benefit limits, waiting periods and the other limitations described in this plan brochure. Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see • Section 7, General Exclusions – Things W e Do Not Cover , for a list of exclusions and limitations. • In-progress treatment for transitioning TRDP enrollees will be covered for the 2019 plan year . This is regardless of any current plan exclusions for care initiated prior to the enrollee’ s ef fective date. This requirement includes assumption of payments for covered orthodontia services up to the • policy limits, and full payment where applicable up to the terms of FEDVIP policy for FEDVIP covered services completed (but not initiated) in the 2019 plan year such as crowns and implants. Y ou Pay: • High Option - In-Network: 50% of the network allowance up to the lifetime maximum. Y ou are responsible for all char ges that exceed the lifetime maximum. - Out-of-Network: 50% of the plan's out-of-network allowance and any dif ference between that allowance and the billed amount. Standard Option • - In-Network: 50% of the network allowance up to the lifetime maximum. Y ou are responsible for all char ges that exceed the lifetime maximum. - Out-of-Network: 50% of the plan's out-of-network allowance and any dif ference between that allowance and the billed amount. 33 2019 Enroll at www .BENEFEDS.com

35 Orthodontic Services D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition D8040 Limited orthodontic treatment of the adult dentition (by report) D8050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition D8070 Comprehensive orthodontic treatment of the transitional dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition D8210 Removable appliance therapy D8220 Fixed appliance therapy D8660 Pre-orthodontic treatment examination to monitor growth and development D8670 Periodic orthodontic treatment visit D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) D8690 Orthodontic treatment (alternative billing to a contract fee) Benefit Limitations for Class D Orthodontic Services Orthodontic treatment in the Standard Plan is available only for dependent children up to, but not including, 19 years of 1. age. Orthodontic services for adults and for dependent children age 19 and older are only covered in the High Plan, subject to a 12-month waiting period. Payment for diagnostic services performed in conjunction with orthodontics is applied to the member's annual 2. maximum. 3. Orthodontic consultations will be processed as comprehensive or periodic evaluations and are subject to the same time limitations. 4. Initial payment for orthodontic services will not be made until a banding date has been submitted to the contractor . 5. All retention and case-finishing procedures are integral to the total case fee. Observations and adjustments are integral to the payment for retention appliances. 6. Repair of damaged, lost or missing orthodontic appliances is not covered. Recementation of an orthodontic appliance by the same dentist who placed the appliance and/or who is responsible for 7. , recementation by a dif ferent dentist will be considered for the ongoing care of the patient is not covered. However payment as palliative emer gency treatment. 8. Orthodontic treatment (alternative billing to the contract fee) will be reviewed for individual consideration with any allowance being applied to the orthodontic lifetime maximum. It is only payable for services rendered by a dentist other than the dentist rendering complete orthodontic treatment. 9. Periodic orthodontic treatment visits (as part of the contract) are considered an integral part of a complete orthodontic treatment plan and are not reimbursable as a separate service. It is the dentist's and the member's responsibility to notify the carrier if orthodontic treatment is discontinued or 10. completed sooner than anticipated. 1 1. When an enrollee becomes eligible for orthodontic coverage after orthodontic treatment has already begun (known as “in-progress orthodontic treatment”), the Plan’ s total amount payable is prorated according to the banding date and the remaining portion of active treatment scheduled as of the patient’ s date of eligibility for orthodontic coverage. 34 2019 Enroll at www .BENEFEDS.com

36 General Services Important things you should keep in mind about these benefits: All benefits are subject to the definitions, limitations, and exclusions in this plan brochure and are • payable only when determined to be necessary for the prevention, diagnosis, care, or treatment of a covered condition and if they are determined to meet generally accepted dental protocols. The calendar year deductible is $0 under both the High and Standard options when services are • . provided by an in-network provider • If an out-of-network provider renders services, there is a $50.00 deductible per person per calendar year for the High Option and a $75.00 deductible per person per calendar year for the Standard Option. Each enrolled covered person must satisfy his/her own deductible; there is no family deductible in either option. • The annual benefit maximum in the High Option is $30,000 for non-orthodontic services when the services are rendered by an in-network provider and $3,000 when the services are rendered by an . out-of-network provider The annual benefit maximum in the Standard Option is $1,500 when the services are rendered by an in-network provider and $600 when the services are rendered by an out- of-network provider . Under no circumstance will Delta Dental’ s Federal Employees Dental Program allow more than • $30,000 in combined benefits under the High Option in any plan year or more than $1,500 in . combined benefits under the Standard Option in any plan year • Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see Section 7, General Exclusions – Things W e Do Not Cover , for a list of exclusions and limitations. Y ou Pay: High Option • In-Network: 30% of the network allowance for covered services as defined by the plan and - subject to plan deductibles and maximums. - 40% of the plan's out-of-network allowance along with a $50.00 deductible and Out-of-Network: any dif ference between that allowance and the billed/approved amount.. • Standard Option - In-Network: 45% of the network allowance for covered services as defined by the plan and subject to plan deductibles and maximums. Out-of-Network: 60% of the plan's out-of-network allowance along with a $75.00 deductible and - any dif ference between that allowance and the billed/approved amount. Anesthesia Services D9222 Deep sedation/general anesthesia – first 15 minutes D9223 Deep sedation/general anesthesia - each subsequent 15-minute increment Intravenous Sedation D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment 35 2019 Enroll at www .BENEFEDS.com

37 Consultations D9310 Consultation (diagnostic service provided by dentist or physician other than the requesting dentist or physician) V Office isits D9440 Of fice visit – after regular scheduled hours Medications D9610 Therapeutic drug injection, by report D9612 Therapeutic parenteral drugs, two or more administrations, dif ferent medications Post-Surgical Services D9930 T reatment of complications (post-sur gical) unusual circumstances, by report Miscellaneous Services D9941 Fabrication of athletic mouth guard -- Limited to one in a 12-consecutive-month period D9944 Occlusal guard – hard appliance, full arch D9945 Occlusal guard – soft appliance, full arch D9946 Occlusal guard – hard appliance, partial arch D9974 Internal bleaching, by report - per tooth -- Limited to once per tooth per three-year period Miscellaneous Services - continued on next page 36 2019 Enroll at www .BENEFEDS.com

38 Miscellaneous Services (cont.) Benefit Limitations for General Services Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when provided in 1. connection with a covered procedure(s) and when rendered by a dentist or other professional provider licensed and approved to provide anesthesia in the state where the service is rendered. 2. Deep sedation/general anesthesia and intravenous sedation are covered only by report when determined to be medically or dentally necessary for documented/handicapped or uncontrollable patients or justifiable medical or dental conditions. 3. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the procedure for which it was provided must be submitted. For palliative (emer gency) treatment to be covered, the dentist must provide treatment to alleviate a problem or 4. symptom that occurred suddenly and unexpectedly and that requires immediate attention. If the only service provided is to evaluate the patient and refer the patient to another dentist and/or prescribe medication, it would be considered a "Limited oral evaluation - problem-focused" (D0140). 5. Consultations are covered only when provided by a dentist other than the practitioner requesting the treatment. 6. Consultations reported for a non-covered benefit, such as temporomandibular joint dysfunction (TMJD), are not covered. -hours visits are covered only when the dentist must return to the of fice after regularly scheduled hours to treat the 7. After patient in an emer gency situation. Therapeutic drug injections are only payable in unusual circumstances, which must be documented by report. They are 8. not benefits if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation or premedication. 9. Occlusal guards are covered for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMJD). Limited to one every 5 years and for patients 13 years of age and older . 10. Internal bleaching of discolored teeth (D9974) is covered by report for endodontically treated anterior teeth. A postoperative endodontic x-ray is required for consideration if the endodontic therapy has not been submitted to the contractor for payment. Adjunctive Services Adjunctive Services - continued on next page .BENEFEDS.com 37 2019 Enroll at www

39 Adjunctive Services (cont.) 1. Adjunctive dental care is dental care that is: Medically necessary in the treatment of an otherwise covered medical (not dental) condition • An integral part of the treatment of such medical condition • • Essential to the control of the primary medical condition • Required in preparation for , or as the result of, dental trauma which may or may not be caused by medically necessary treatment of an injury or disease (iatrogenic). The Federal Employees Dental Program does not cover adjunctive care services. 2. These are medical services that may be covered under the FEHB medical policy even when provided by a general dentist or oral sur geon. The following diagnoses or conditions may fall under this category: • T reatment for relief of Myofacial Pain Dysfunction Syndrome or T emporomandibular Joint Dysfunction (TMJD) • Orthodontic treatment for cleft lip or cleft palate, or when required in preparation for , or as a result of, trauma to teeth and supporting structures caused by medically necessary treatment of an injury or disease. • Procedures associated with preventive and restorative dental care when associated with radiation therapy to the head or neck unless otherwise covered as routine preventive procedures under this plan • T otal or complete ankyloglossia • Intraoral abscesses which extend beyond the dental alveolus • Extraoral abscesses • Cellulitis and osteitis which is clearly exacerbating and directly af fecting a medical condition currently under treatment • Removal of teeth and tooth fragments in order to treat and repair facial trauma resulting from an accidental injury • Prosthetic replacement of either the maxilla or mandible due to reduction of body tissues associated with traumatic injury (such as a gunshot wound) in addition to services related to treating neoplasms or iatrogenic dental trauma .BENEFEDS.com 38 2019 Enroll at www

40 Section 6 International Services and Supplies e will pay benefits, subject to plan provisions, in an amount equal to the covered International Claims W percentage for the char ges incurred by you. All payments will be made in U.S. currency . Payment International employees and their dependents may contact Delta Dental’ s international International Finding an Pr ovider referral service for referral to dental providers outside of the continental United States, the District of Columbia and Puerto Rico or may use the dentist of their choice. Plan participants may call 312-356-5971 (collect from outside the U.S.) or 888-558-2705 (toll- . International participants free if inside the U.S.) to find a local provider in their country will receive out-of-network benefits when services are performed by an internationally . located provider The plan participant will be responsible for paying the dentist and submitting the claims to Filing International Delta Dental’ s Federal Employee Dental Program for reimbursement. Mail completed Claims claim forms to: Delta Dental of California Federal Employees Dental Program PO. Box 537007 95853-7007 Sacramento, CA There is one international region. Please see the rate table for the actual premium amount. International Rates 39 2019 enroll at www .BENEFEDS.com

41 Section 7 General Exclusions – Things e Do Not Cover W Although we may list a specific service as a benefit, we will not cover it The exclusions in this section apply to all benefits. unless it is determined necessary for the prevention, diagnosis, care, or treatment of a covered condition. All out-of-network ges as defined by Delta services listed in Section 5 are subject to the usual and customary maximum allowable fee char Dental’ The member is responsible for all remaining char ges that exceed the allowable s Federal Employees Dental Program. maximum. Additionally , any dental service or treatment not listed in Section 5 as a covered service is not eligible for benefits. W e do not cover the following: • Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law; • Services and treatment which are experimental or investigational; • Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or This compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. exclusion applies whether or not you claim the benefits or compensation; • Services and treatment received from a dental or medical department maintained by or on behalf of an employer , mutual V benefit association, labor union, trust, hospital or similar person or group; A • Services and treatment performed prior to your ef fective date of coverage; • Services and treatment incurred after the termination date of your coverage unless otherwise indicated; • Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice. • Services and treatment resulting from your failure to comply with professionally prescribed treatment; • T elephone consultations; Any char • ges for failure to keep a scheduled appointment; • Any services that are considered strictly cosmetic in nature including, but not limited to, char ges for personalization or characterization of prosthetic appliances; • Services related to the diagnosis and treatment of emporomandibular Joint Dysfunction (TMJD); T • Services or treatment provided as a result of intentionally self-inflicted injury or illness; • Services or treatment provided as a result of injuries suf fered while committing or attempting to commit a felony , engaging in an illegal occupation, or participating in a riot, rebellion or insurrection; • Of fice infection control char ges; • Char ges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays; • State or territorial taxes on dental services performed; • Those services submitted by a dentist, which are the same services performed on the same date for the same member by another dentist; • Those services provided free of char ge by any governmental unit, except where this exclusion is prohibited by law; • Those services for which the member would have no obligation to pay in the absence of this or any similar coverage; • Those services which are for specialized procedures and techniques; 40 2019 Enroll at www .BENEFEDS.com

42 • Those services performed by a dentist who is compensated by a facility for similar covered services performed for members; • Duplicate, provisional and temporary devices, appliances, and services; • Plaque control programs, oral hygiene instruction, and dietary instructions; • Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth; • Gold foil restorations; • Char ges for sterilizing instruments; T reatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is • paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan; T reatment of services for injuries resulting from war or act of war • , whether declared or undeclared, or from police or military service for any country or or ganization; ges for treatment at the hospital (inpatient or • Hospital costs or any additional fees that the dentist or hospital char outpatient); • Char ges by the provider for completing dental forms; • Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it; • Use of material or home health aids to prevent decay , such as toothpaste, fluoride gels, dental floss and teeth whiteners; • Cone Beam Imaging and Cone Beam MRI procedures; • Sealants for teeth other than permanent molars; • Precision attachments, personalization, precious metal bases and other specialized techniques; • Replacement of dentures that have been lost, stolen or misplaced; • Orthodontic services provided to an enrolled member who has not been credited with meeting the 12-month waiting period requirement; • Repair of damaged orthodontic appliances; • Replacement of lost or missing appliances; • External bleaching; • Nitrous oxide; • Oral sedation; • T opical medicament center; • Bone grafts when done in connection with extractions, apicoectomies or non-covered/non eligible implants; • When two or more services are submitted and the services are considered part of the same service to one another the Plan will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by Delta s Federal Employees Dental Program. Dental’ • When two or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), the Plan will pay for the service that represents the final treatment as determined by this plan. 41 2019 Enroll at www .BENEFEDS.com

43 General Policies ed services ar e subject to the following general policies: All cover 1. Services must be necessary to preserve functionality and maintenance of oral health to the teeth and supporting structures and must meet accepted standards of dental practice. Services determined to be unnecessary or which do not meet accepted standards of practice are not billable to the patient by a participating dentist unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the treatment. Participating dentists shall document such notification in their records. 2. The plan must provide an alternate benefit provision for benefits beyond the least expensive professionally accepted ference between the covered benefit and the more expensive treatment standard of care, whereby the patient pays the dif option. 3. An appeal is not available when the services are determined to be unnecessary or do not meet accepted standards of dental practice unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the This is because such services are not billable to the patient, and there would be no amount to dispute to consider treatment. an appeal. Procedures should be reported using the American Dental 4. Association's (ADA) current dental procedure codes and terminology . 5. Claims submitted for payment more than 12 months after the month in which a service is provided are not eligible for payment. A participating dentist may not bill the enrollee for services that are denied for this reason. 6. Services, including evaluations, which are routinely performed in conjunction with or as part of another service, are considered integral. Participating dentists may not bill members for services denied if they are considered integral to another service. Char ges for the completion of claim forms and submission of required information for determination of benefits are not 7. payable to participating dentists by either the contractor or enrollee. Local anesthesia is considered integral to the procedure(s) for which it is provided. 8. 9. Payment for diagnostic services performed in conjunction with orthodontics may be applied to the member's annual maximum. Class A Pr eventive Services • Space maintainers for missing permanent teeth or primary anterior teeth (except primary cuspids) • Repair of a damaged space maintainer; Class B Minor Restorative Services • Sedative restorations; • Restorations performed after the placement of any type of crown or onlay on the same tooth and by the same dentist; • Restorations placed due to abrasion, attrition, erosion, congenital or developmental malformations or to restore vertical dimension; • Glass ionomer restorations; Class B Periodontic Services 42 2019 Enroll at www .BENEFEDS.com

44 • Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or periodontal sur gical procedures in the same area of the mouth; osthodontic Services Class B Pr • For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The , the provider completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, however who fabricated the dentures may be reimbursed for the dentures after insertion if another provider , typically an Oral Sur geon, inserted the dentures. Class B Oral Surgery Services • Unsuccessful extractions; • Removal of impacted third molars in patients under age 15 and over age 30 unless specific documentation is provided that . substantiates the need for removal and it is approved by the contractor Restorative Services Class C Major • Sedative restorations; • Cast crowns with resin facings; • Protective restoration; • Composite resin inlays; • Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to the ef fective date of coverage are not eligible for coverage. Class C Endodontic Services • Incomplete endodontic therapy due to the patient's discontinuation of treatment; • paste-type root canal filling incorporating formaldehyde or paraformaldehyde; A • Endodontic procedures in conjunction with overdentures; • Incompletely filled root canals, other than for reason of an inoperable or fractured tooth; Class C Pr osthodontic Services • Implants, when placed for a removable denture; • Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects, prior to the ef fective date of coverage are not eligible for coverage. Class D Orthodontic Services • Myofunctional therapy is integral to orthodontic treatment and is not payable as a separate benefit; • Orthodontic services for dependent children age 19 and older are not covered in the Standard Plan; • Orthodontic services for adults are only covered in the High Plan; General Services • Deep sedation/general anesthesia and intravenous conscious sedation without a report; Adjunctive Services • Adjunctive dental services, except as described in the General Services section of this plan brochure. 43 2019 Enroll at www .BENEFEDS.com

45 Section 8 Claims Filing and Disputed Claims Pr ocesses How to File a Claim for o avoid delay in the payment of your claims please have your dental provider submit T ed Services Cover your claims directly to Delta Dental’ s Federal Employees Dental Program for payment. s Federal Employees Dental Program network providers will submit your Delta Dental’ claims directly to Delta Dental’ s Federal Employees Dental Program. If you would like to submit a paper claim, you may download a claim form from the website at deltadentalins. com/fedvip . Mail completed claim forms to: Delta Dental of California Federal Employees Dental Program PO Box 537007 95853-7007 Sacramento, CA When a claimant files a claim for dental insurance benefits described in this plan brochure, the claim should be sent to us within 12 months of the date of service. If the claim is not submitted within the time limits described in this section, the delay may cause a claim to be denied or reduced. International Claims For services you receive outside of the 50 United States, the District of Columbia or Puerto Rico, send itemized bills/receipts that include an English translation and the date the services were rendered. Benefits will be calculated using the daily rate of exchange . International participants for the date of service and reimbursed in United States currency will receive out-of-network benefits when services are performed by an internationally . All international claims should be submitted to Delta Dental of located provider California, Federal Employees Dental Program, PO Box 537007, Sacramento, CA 95853-7007. W e may It is to your benefit to reply promptly when we ask for additional information. delay processing or deny your claim if you do not respond. See Section 6 International Services and Supplies for more information. Send us all of the documents for your claims as soon as possible. Y ou must submit your our Y Filing Deadline for claim to us within 12 months following the delivery of the services in order for them to be Claim considered for plan benefits, unless timely filing was prevented by administrative , provided the claim was submitted as operations of the Government or legal incapacity soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks. e may require, at our option, supporting documentation such as clinical reports, charts, W and/or x-rays. ocess Disputed Claims Pr Follow this disputed claims process if you disagree with our decision on your claim or ovide a r ole for OPM to r eview law does not pr request for services. The FEDVIP disputed claims. Disputed Claim Steps: Y ou must include any pertinent 1. Ask us in writing to reconsider our initial decision. information omitted from the initial claim filing and mail your additional proof to us within 90 days from the date of receipt of our decision. 2. Send your request for reconsideration to: Delta Dental of California Federal Employees Dental Program Claims Appeals PO Box 537015 Sacramento, CA 95853-7015 44 2019 Enroll at www .BENEFEDS.com

46 W e will review your request and provide you with a written or electronic explanation of benefit determination within 30 days of the receipt of your request. 3. If you disagree with the decision regarding your request for reconsideration, you may Y request a second review of the denial. ou must submit your request to us in writing to the address shown above along with any additional information you or your dentist can provide to substantiate your claim so that we can reconsider our decision. Failure to do so will disqualify the appeal of your claim. 4. If you do not agree with our final decision, under certain circumstances you may request an independent third party , mutually agreed upon by Delta Dental's Federal o qualify for this Employees Dental Program and OPM, to review the decision. T , the reason for denial must be based on our determination independent third-party review that the rationale for the procedure did not meet our dental necessity criteria or our administration of the plan's alternate benefit provision; for example, a bridge being given an alternate benefit of a partial denture. The decision of the independent third party is binding and constitutes the final review of your claim. CONFIDENTIALITY OF YOUR HEAL TH INFORMA TION AA Notice of Privacy HIP Practices ABOUT YOU MA Y BE THIS NOTICE DESCRIBES HOW MEDICAL INFORMA TION THIS T O YOU CAN GET USED AND DISCLOSED AND HOW ACCESS . CAREFULL IT TION. PLEASE REVIEW INFORMA Y This notice is required by law to inform you of how Delta Dental and its af filiates ("Delta Dental") protect the confidentiality of your health care information in our possession. Protected Health Information (PHI) is defined as individually identifiable information , mental or physical condition or treatment. Some regarding a patient's health care history , electronic examples of PHI include your name, address, telephone and/or fax number mail address, social security number or other identification number , date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives, uses and discloses your PHI to administer your benefit plan or as permitted or required by Any other disclosure of your PHI without your authorization is prohibited. . law e follow the privacy practices described in this notice and federal and state privacy W requirements that apply to our administration of your benefits. Delta Dental reserves the e will update this W fective for all PHI maintained. right to change our privacy practice ef notice if there are material changes and redistribute it to you within 60 days of the change W e will also promptly post a revised notice on our website. to our practices. copy may A be requested anytime by contacting the address or phone number at the end of this notice. ou should receive a copy of this notice at the time of enrollment in a Delta Dental Y program and will be informed on how to obtain a copy at least every three years. PERMITTED USES AND DISCLOSURES OF YOUR PHI eatment, payment or Uses and disclosur es of your PHI for tr e operations health car PHI to r example, Delta Dental may use and disclose your For eview the quality of oviders . car e pr ovided by our network of pr 45 2019 Enroll at www .BENEFEDS.com

47 Y our explicit authorization is not required to disclose information about yourself for purposes of health care treatment, payment of claims, billing of premiums, and other health care operations. If your benefit plan is sponsored by your employer or another party , we may provide PHI to your employer or plan sponsor to administer your benefits. filiates that perform services , we may disclose PHI to third-party af As permitted by law for Delta Dental to administer your benefits, and who have signed a contract agreeing to protect the confidentiality of your PHI, and have implemented privacy policies and procedures that comply with applicable federal and state law . Some examples of disclosure and use for treatment, payment or operations include: processing your claims, collecting enrollment information and premiums, reviewing the quality of health care you receive, providing customer service, resolving your grievances, and sharing payment information with other insurers. Some other examples are: • Uses and/or disclosures of PHI in facilitating treatment. For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested by your . provider Uses and/or disclosures of PHI for payment. • For example, Delta Dental may use and . disclose your PHI to bill you or your plan sponsor Uses and/or disclosures of PHI for health care operations. For example, Delta Dental • may use and disclose your PHI to review the quality of care provided by our network of providers. permitted uses and disclosur Other es without an authorization W e are permitted to disclose your PHI upon your request or to your authorized personal representative (with certain exceptions) when required by the U. S. Secretary of Health and Human Services to investigate or determine our compliance with law , and when otherwise required by law . Delta Dental may disclose your PHI without your prior authorization in response to the following: • Court order; Order of a board, commission, or administrative agency for purposes of adjudication • pursuant to its lawful authority; • Subpoena in a civil action; • Investigative subpoena of a government board, commission, or agency; • Subpoena in an arbitration; • Law enforcement search warrant; or • Coroner's request during investigations. Some other examples include: to notify or assist in notifying a family member , another person, or a personal representative of your condition; to assist in disaster relief ef forts; to report victims of abuse, neglect or domestic violence to appropriate authorities; for or gan donation purposes; to avert a serious threat to health or safety; for specialized government functions such as military and veterans activities; for workers' compensation purposes; and, with certain restrictions, we are permitted to use and/or disclose your PHI for underwriting, provided it does not contain genetic information. Information can also be de-identified or summarized so it cannot be traced to you and, in selected instances, for research purposes with the proper oversight. Disclosur es Delta Dental makes with your authorization Delta Dental will not use or disclose your PHI without your prior written authorization unless permitted by law . Y ou can later revoke that authorization, in writing, to stop the future use and disclosure. The authorization will be obtained from you by Delta Dental or by a person requesting your PHI from Delta Dental. 46 2019 Enroll at www .BENEFEDS.com

48 YOUR RIGHTS REGARDING PHI Y ou have the right to request an inspection of and obtain a copy of your PHI. ou may access your PHI by contacting Delta Dental at the address at the bottom of this Y ou must include (1) your name, address, telephone number and identification notice. Y ge a reasonable fee for , and (2) the PHI you are requesting. Delta Dental may char number providing you copies of your PHI. Delta Dental will only maintain that PHI that we obtain or utilize in providing your health care benefits. Most PHI, such as treatment records or x- rays, is returned by Delta Dental to the dentist after we have completed our review of that ou may need to contact your health care provider to obtain PHI that Delta information. Y Dental does not possess. ou may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, Y criminal, or administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or state law . In some circumstances, you may have a right to have this decision reviewed. Please contact Delta Dental as noted below if you have questions about access to your PHI. ou have the right to r Y estriction of your PHI. equest a r Y , you ou have the right to ask that we limit how we use and disclose your PHI, however While we will may not restrict our legal or permitted uses and disclosures of PHI. consider your request, we are not legally required to accept those requests that we cannot reasonably implement or comply with during an emer gency . If we accept your request, we will put our understanding in writing. ou have the right to corr Y update your PHI. ect or Y ou may request to make an amendment of PHI we maintain about you. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. If your PHI was sent to us by another , we may refer you to that person to amend your PHI. For example, we may refer you to your dentist to amend your treatment chart or to your employer , if applicable, to amend your enrollment information. Please contact the privacy of fice as noted below if you have questions about amending your PHI. ou have rights r elated to the use and disclosur e of your PHI for Y marketing. Delta Dental agrees to obtain your authorization for the use or disclosure of PHI for marketing when required by law . Y ou have the opportunity to opt out of marketing that is permitted by law without an authorization. Delta Dental does not use your PHI for fundraising purposes. Y ou have the right to r equest or r eceive confidential communications fr om us by alternative means or at a differ ess. ent addr Alternate or confidential communication is available if disclosure of your PHI to the address on file could endanger you. ou may be required to provide us with a statement of Y possible danger , as well as specify a dif ferent address or another method of contact. Please make this request in writing to the address noted at the end of this notice. Y eceive an accounting of certain disclosur es we have made, if ou have the right to r any , of your PHI. 47 2019 Enroll at www .BENEFEDS.com

49 Y ou have a right to an accounting of disclosures with some restrictions. This right does not apply to disclosures for purposes of treatment, payment, or health care operations or for information we disclosed after we received a valid authorization from you. Additionally , we do not need to account for disclosures made to you, to family members e do not need to account W or friends involved in your care, or for notification purposes. for disclosures made for national security reasons, certain law enforcement purposes or disclosures made as part of a limited data set. Please contact us at the number at the end of this notice if you would like to receive an accounting of disclosures or if you have questions about this right. Y ou have the right to get this notice by email. Y ou may also request an email copy of this notice is posted on the Delta Dental website. A copy or paper copy of this notice by calling our Customer Service number listed at the bottom of this notice. ou have the right to be notified following a br Y ed pr otected health each of unsecur information. Delta Dental will notify you in writing, at the address on file, if we discover we compromised the privacy of your PHI. COMPLAINTS Y ou may file a complaint to Delta Dental and/or to the U. S. Secretary of Health and Human Services if you believe Delta Dental has violated your privacy rights. Complaints . to Delta Dental may be filed by notifying the contact below e will not retaliate against W you for filing a complaint. CONT ACTS Y ou may contact Delta Dental at 866-530-9675, or you may write to the address listed below for further information about the complaint process or any of the information contained in this notice. Delta Dental PO Box 997330 Sacramento, CA 95899-7330 This notice is ef fective on and after January 1, 2016. Note: Delta Dental's privacy practices r eflect applicable federal law as well as known egulations. If applicable state law is mor e pr state law and r otective of information than the federal privacy laws, Delta Dental pr otects information in accordance with the state law . LANGUAGE ASSIST ANCE IMPOR T ANT : Can you read this letter? If not, we can have somebody help you read it. Y ou may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Delta Dental ID card, or 1-866-530-9675. IMPOR T ANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. T ambién puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Delta Dental o al 1-866-530-9675. (Spanish) Last Significant Changes to this Notice: 48 2019 Enroll at www .BENEFEDS.com

50 • Clarified that Delta Dental does not used your PHI for fundraising purposes – ef fective January 1, 2016 • Clarified that Delta Dental’ s privacy policy reflect federal and state requirements – fective January 1, 2015 ef • fective July 1, Updated contact information (mailing address and phone number) – ef 2013 • Updated Delta Dental’ s duty to notify af fected individuals if a breach of their unsecured PHI occurs – ef fective July 1, 2013 Clarified that Delta Dental does not and will not sell your information without your • express written authorization – ef fective July 1, 2013 • Clarified several instances where the law requires individual authorization to use and disclose information (e.g., fundraising and marketing as noted above) – ef fective July 1, 2013 T A DENT AL AND ITS AFFILIA TES DEL fers and administers fee-for Delta Dental of California of -service dental programs for groups headquartered in the state of California. Delta Dental of New fers and administers fee-for -service programs in New Y ork. ork of Y fer and administer fee for -service dental filiates of Delta Dental of Pennsylvania and its af W est programs in Delaware, Maryland, Pennsylvania, ir ginia and the District of V Columbia. Delta Dental of Pennsylvania's af filiates are Delta Dental of Delaware; Delta W est V Dental of the District of Columbia and Delta Dental of ginia. ir Delta Dental Insurance Company of fers and administers fee-for -service dental programs to groups headquartered or located in Alabama, Florida, Geor gia, Louisiana, Mississippi, Montana, Nevada, T W est exas and Utah and vision programs to groups headquartered in ir V ginia. DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; Alabama, Inc.; VT , W A, WI, WY — Dentegra AR, CO, IA, ME, MI, NC, NH, OK, OR, RI, SC, SD, AK, CT , DC, DE, FL, GA, KS, LA, MS, MT , TN and WV — Delta Insurance Company; Dental Insurance Company; HI, ID, IL, IN, KY , MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — — Alpha Dental of Utah, Inc.; Alpha Dental of Nevada, Inc.; UT Alpha Dental of New Mexico, Inc.; NY NM — Y ork, Inc.; P A — — Delta Dental of New Delta Dental of Pennsylvania; V A — Delta Dental of V ir ginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products. Dentegra Insurance Company . 49 2019 Enroll at www .BENEFEDS.com

51 Section 9 Definitions of erms e Use in This Br ochur e T W Alternate Benefit If we determine a service less costly than the one performed by your dentist could have been performed by your dentist, we will pay benefits based upon the less costly services. Y ou Get Care for a definition of alternate benefit. See Section 3 How The maximum annual benefit that you can receive per person. Annual Benefit Maximum Annuitants Federal retirees (who retired on an immediate annuity) and survivors (of those who retired . This also includes those on an immediate annuity or died in service) receiving an annuity s Of W orkers’ receiving compensation from the Department of Labor fice of ’ Annuitants are sometimes Compensation Programs, who are called compensationers. called retirees. . BENEFEDS The enrollment and premium administration system for FEDVIP Covered services or payment for covered services to which enrollees and covered family Benefits members are entitled to the extent provided by this brochure. Also referred to as the plan year . Calendar Y ear From January 1, 2019 through December 31, 2019. A Services Class Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays. Intermediate services, which include restorative procedures such as fillings, prefabricated Class B Services stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments. Class C Services Major services, which include endodontic services such as root canals, periodontal , major restorative services such as crowns, oral sur gery , services such as gingivectomy bridges, and prosthodontic services such as complete dentures. Orthodontic services. Class D Services . Coinsurance Coinsurance is the stated percentage of covered expenses you must pay A copayment is a fixed amount of money you pay to the provider when you receive Copay/Copayment services. cosmetic procedure is any procedure or portion of a procedure performed primarily to e Cosmetic Pr ocedur A improve physical appearance or is performed for psychological purposes. Covered services shall include only those services specifically listed in Section 5 Dental ed Service Cover Services and Supplies. covered service must be incurred and completed while the A person receiving the service is a covered person. Covered services are subject to plan provisions for exclusions and limitations and meet acceptable standards of dental practice as determined by us. The calendar date on which you visit the dentist's of fice and services are rendered. Date of Service The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan. Enr ollee Federal Employees Dental and FEDVIP V ision Insurance Program. Accepted Generally Dental Necessity means that a dental service or treatment is performed in accordance with otocols Dental Pr generally accepted dental standards, as determined from multiple sources including but not limited to relevant clinical dental research from various research or ganizations including dental schools, current recognized dental school standard of care curriculums and or ganized dental groups including the American Dental Association, which is , disease or injury of teeth, or essential for the care of teeth and necessary to treat decay supporting tissues of the teeth. 50 2019 Enroll at www .BENEFEDS.com

52 Dental services that initiated in 2018 that will be completed in 2019. In-Pr T r eatment ogr ess Incur/Incurr covered service is deemed incurred on the date care, treatment or service is received. ed A Maximum Allowed Char ge means the contracted or billed amount of the dental char ge Maximum Allowable whichever is the lesser . Charge Allowance means the allowance per procedure that Delta Dental’ s Federal Network Allowance Network Employees Dental Program has negotiated with the provider and they have agreed to accept as payment in full for his/her services. s Federal Employees Dental Program Plan Delta Dental’ Plan The amount we use to determine our payment for services. If services are provided by an Allowance in-network dentist the Plan Allowance is based on the discounted fee he or she accepts as payment in full for the procedure or procedures. If services are provided by an out-of- s Federal Employees Dental network dentist the Plan Allowance is based on Delta Dental’ ges for the procedure or procedures. s determination of usual and customary char Program’ Pr e-T r eatment Estimate This is the procedure used by the plan to estimate covered services and the amount that . It is not a guarantee of payment. the plan will cover The installation of complete or partial removable dentures, fixed partial dentures ooth Missing but Not "T (bridges), implants, and other prosthodontic services will be covered when replacing or Replaced" Rule repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior fective date under the Delta Dental Federal Employees Dental to your coverage ef Program. Initial prosthodontic services to replace natural teeth that were missing prior to your Delta Dental Federal Employees Dental Program date of coverage are not covered. W aiting Period The amount of time that you must be enrolled in this plan before you can receive orthodontic services. W e/Us Delta Dental’ s Federal Employees Dental Program Y ou . Enrollee or eligible family member , a sponsor means the individual who is eligible for medical or dental benefits Generally Sponsor filiation with the uniformed under 10 U.S.C. chapter 55 based on his or her direct af services (including military members of the National Guard and Reserves). Under circumstances where a sponsor is not an enrollee, a TEI family member may accept TEI certifying family responsibility to self-certify as an enrollee and enroll TEI family members member TEI family members include a sponsor TRICARE-eligible , unremarried ’ s spouse, unremarried widow ’ , unmarried child, and certain unmarried persons placed in a sponsor widower individual (TEI) family s legal custody by a court. Children include legally adopted children, stepchildren, and pre- member adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self- . support because of a mental or physical incapacity 51 2019 Enroll at www .BENEFEDS.com

53 Stop Health Car e Fraud! Fraud increases the cost of health care for everyone and increases your Federal Employees Dental Program premium. Pr ourself Fr om Fraud – Here are some things that you can do to prevent fraud: otect Y , except to your Do not give your plan identification (ID) number over the telephone or to people you do not know • s Federal Employees Dental Program, BENEFEDS, or OPM. providers, Delta Dental’ • Let only the appropriate providers review your clinical record or recommend services. • A void using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. • Carefully review your Explanation of Benefits (EOB) statements. • Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or service. • ged you for services you did not receive, billed you twice for the same service, or If you suspect that a provider has char misrepresented any information, do the following: Call the provider and ask for an explanation. - . There may be an error - If the provider does not resolve the matter , call us at 855-410-3255 and explain the situation, you will be required to state your complaint in writing to us. • Do not maintain as a family member on your policy: - Y our former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or Y - our child over age 22 (unless he/she is disabled and incapable of self- support). If you have any questions about the eligibility of a dependent, please contact BENEFEDS. Be sure to review Section 1 Eligibility of this plan brochure prior to submitting your enrollment or obtaining benefits. intentional misr epr Fraud or ohibited under the plan. Y ou can be pr osecuted for fraud esentation of material fact is pr and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services oll in the plan when for or who is no longer enr olled in the plan, or enr someone who is not an eligible family member you ar e no longer eligible. 52 2019 Enroll at www .BENEFEDS.com

54 Summary of Benefits • ely on this chart alone. This page summarizes specific expenses we cover; for more details, please review the Do not r individual sections of this plan brochure. • www .BENEFEDS.com or call 1-877-888-FEDS If you want to enroll or change your enrollment in this plan, please visit (1-877-888-3337), TTY number 1-877-889-5680. Y ou Pay Y High Option Benefits ou Pay Page Out-of-network In-network A 10% 16 0% Class of the plan allowance Basic Services – ference between preventive and diagnostic and any dif our allowance and the billed amount. Class B Intermediate 19 of the plan allowance 30% 40% Services – includes minor and any dif ference between restorative services our allowance and the billed amount. of the plan allowance 24 Class C Major Services – 50% 60% ference between and any dif includes major restorative, our allowance and the billed endodontic, and prosthodontic services amount. of the plan allowance 31 50% 50% Class D Orthodontic Services ference between and any dif our allowance and the billed $3,500 Lifetime amount. Maximum for children/ $2,000 for adults Please Note: Class A, B, and C services in the High Option are subject to a $30,000 annual maximum benefit in-network and a $3,000 annual maximum benefit out-of-network. 53 2019 Enroll at www .BENEFEDS.com

55 Standard Option Benefits Y ou Pay Page Y ou Pay In-network Out-of-network A Basic Services – 16 0% 40% of the plan allowance Class ference between and any dif preventive and diagnostic our allowance and the billed amount. Class B Intermediate 45% 60% of the plan allowance 19 and any dif ference between Services – includes minor our allowance and the billed restorative services amount. Class C Major Services – 24 65% 80% of the plan allowance ference between includes major restorative, and any dif endodontic, and our allowance and the billed prosthodontic services amount. Class D Orthodontic 31 of the plan allowance 50% 50% and any dif ference between Services our allowance and the billed $2,000 Lifetime Maximum amount. Or a $1,000 Lifetime Maximum for out-of- network Please Note: Class A, B, and C Services in the Standard Option are subject to a $1,500 annual maximum benefit in- network and a $600 annual maximum benefit out-of-network . 54 2019 Enroll at www .BENEFEDS.com

56 Notes 55 2019

57 Notes 56 2019 Enroll at www .BENEFEDS.com

58 Notes 57 2019 Enroll at www .BENEFEDS.com

59 Rate In form ation w to find your rate Ho art bel • k up you r stat e or zip code to determi ne our ra ting area. ow, In the first ch loo ea to our e cond he f ollow ing pa ge, mat ch yo ur Rati ng Ar on t nrollm ent type and plan opt ion. he se chart • In t s by Sta te/Zip Code (first th ree digit Premium Rat ing Area s) State State State Rati ng ng Rati Rati ng Area Area Area E n ti r e st a t e a MD 2 1 9 e AK PA Res t o f s t t 2 5 4 t E r e st a t e 1 MD Res t o f s ti a t e 5 PR E nti r e a rea 1 n AL E AR ir e s t a t e 2 ME E nt ir e s t a t e 5 RI E n t i r e s t a te 5 nt E n ti r e st a t e 5 MI E n ti r e st a AZ e 4 SC E n t i r e s t a te 5 t CA En tire state 5 MN En tire state 4 SD Ent ir e state 5 En state 4 MO En tire state 4 TN Ent ir e state 1 CO tire r E ti r e a t e 5 MS E n ti n e st a t e 1 TX 739 3 CT st E n ti r e st a t e 5 MT E n ti r e st a t e DC TX Res t o f s t a t e 2 1 DE E n ti r e st a t e 4 NC E n ti r e st a t e 2 UT E n i r e s t a te 5 t FL Entir e sta te 4 ND Entir te 1 VA 200-205, 220-227 5 e sta GA E nt ir e s t a t e 2 NE E nt ir e s t a t e 1 VA R e s t o f s t a t e 3 GU nti r e a rea 5 NH E n ti r e st a t e 5 VI E nti r e a rea 5 E 4 ti r e st a t e 5 NJ 08 0 - 0 8 n 4 VT E n ti r e st a t e 5 HI E E nt ir e s t a t e 4 NJ R e s t o f s t a t e 5 WA E n t i r e s t a te 5 IA ID E n tir e st a t e 5 NM E n t i r e s t a te 4 WI 5 4 0 4 a nt ir IL s t a te 2 NV E n t i r e s t E te 5 WI R e s t o f s t a t e 5 e IN 46 3 - 4 6 4 2 NY E n t i r e s t a te 5 WV 254 5 t IN s t o f s t a t e 1 OH E n t i r e s e a te 1 WV R e s t o f s t a t e 2 R E n ti r e st a t e 4 OK E n t i r e s t a te 3 WY E n t i r e s t a te 5 KS t a t K Y 1 e O R E En t i r e s t a t e nt 5 ir I NT E R e I n te r n at i o n a l 5 s 17 s t a t e L 1 E P A nt ir 3 - 17 4 , 183 e 5 A e s t a t e A 5 ir P A E 18 9 - 1 9 6 nt 4 M Enrol 201 5 8 9 l at www .BENEFED S.c om

60 Monthly Rates n d r a d n a t S d r a d a t S Hig h tio n op d Standar tion Hig tion Hig h h op op op op tion tion and Self lf option Se Rati ng Only Self Self Plus One Plu d Self an Self s Only Family Areas m n O a i l y e F $36.27 $72.54 $108.81 $18.81 $37.59 $56.40 1 $40.97 $39.78 $119.32 $20.48 $61.43 $79.54 2 $130.85 $22.06 $43.62 $44.14 $66.21 $87.23 3 $92.80 $139.21 $46.39 $46.52 $69.79 $23.27 4 $53.95 $107.92 $161.87 $53.17 $79.76 $26.59 5 eek Bi-w ly Rates d r a d S n a t S t a n d d r a n Standar d tio op h Hig op tion tion Hig h op Hig h opti op tion on Rati ng lf and Self option Se Self Self Plus One Only an d s Self Plu Self Areas Family Only n O F a mi l y e $8.68 $16.74 $33.48 $50.22 $17.35 $26.03 1 $28.35 $18.36 $36.71 $55.07 $9.45 $18.91 2 $20.13 $40.26 $60.39 $10.18 $20.37 $30.56 3 $21.41 $42.83 $64.25 $10.74 $21.47 $32.21 4 $24.90 $49.81 $74.71 $12.27 $24.54 $36.81 5 t 20 9 5 9 Enroll a 1 w ww.B EN EFED S.c om

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