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<br />TABLE OF CONTENTS
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<br />Schedule of BenefIts "".,.,..,..,..,...",.,., ,.,.,. ",., "..,.".,...,., "." '" ..,., ,." "., "., ,., ,.,... ...."" ,.,.", ,., ,.,.......,.,.. .,."..., 3
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<br />DefIni tions ........,.."...................."",.,.............."..,.....",."",..,.",...,.,.""."..,..,..,.",.,......,.,."."". ..""".".,...., 4
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<br />General Provisions......,.,.....,.,.........,.",."".,.......""."",...""..,....,.,.,."",.,.....,....,.,.,.,.,..,.".,.,..."."".,.. ,'....., 8
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<br />Eligibility and Effective Dates for Employee Dental Coverage................................................................ 10
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<br />Termination of Employee Dental Coverage ,..............................,.................,...................,........,............... 11
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<br />Eligibility for Dependent Dental Coverage ......................,..,.............................................................,....... 13
<br />Termination of Dependent Dental Coverage.................................,..............,..,......................................... 15
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<br />Premiums and Premium Rates ....... .................. ........................................."..,.. .........., ...., ,...............,...,..... 16
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<br />Policy Termination ................. ...........,...,.,..,....., "..................,....,...,.".,.....,.. "...,..... ,.. ..,..,...,." ......,...,., ,.", 17
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<br />Dental Expense BenefIts "..... ,..,., "..."" ,.,..., "."."....,. ..,.",. "." ,'....,.,.,.,.., ,.,..,........ ,.....,.,.. ,." ........,.."".,....,. 18
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<br />Alternative Procedures ......,.,.,.,',.,.......",..".,..,."...",.,...,.,.".,."....."...,..."...,.,.,..,....".,.,....,.,.",..,.......,.,.... 19
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<br />Limitations and Exclusions .,.,... "..,..... ,.., "..,."..., ..", ..,." ,..".. .".,."" ".,.,.,..,.., ,..., ,."" ,......, ...,. ,. .,... .,..., ..,.. ,. 20
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<br />Coordination of Dental Expense BenefIts ".".."".,......,......,.,.....,.,...".,....".,..".,.......,.,.,..,...,..".,...,...,....,.23
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<br />Claims Procedures for Dental Coverage.................................................................................................... 25
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<br />Predetermination of BenefIts".,..,..,.....""."."....,..,..,.,.,.... ........,.."....,.,.".,.......,..""........".",..,.........,....... 27
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<br />Dental Coverage Continuation "" ... ........"."." ,..,............, "..,.",..."..",.....,.,....,..., ,..,.,.", ",.. .,....,.,."" ..., ..", 28
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<br />Type I Procedures "."...............",......." ......,.....,.,..... .,.. ,....,..,.."" "...,...., ,....,.......,...,.,., '.,. .., ........,..,....".., ,. 31
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<br />Type II Procedures ,.,..,.,",....".,.,.,.,.,.".,.,..,....,..........,...,.,..",...,.....,....,.,..,..,.....",..,..,.......,..,.......,.....,...... 32
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<br />Type III Procedures .. ......,.,.,.,..........., ,.....,. ...." ,.."..".., ...,."..,....,.....,.".,.....,...., ,.,..."..,..., ,......, ...,..,.....,. .... 35
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<br />Prior Carrier Credit Provision. ..,.,........ ..........,...........". ,."....,...........,...,.....,..", ....,...., ,...,.,..,....,..,.., ,.,., ,.,., 37
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<br />GL11-2-TC
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<br />2
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<br />09/01/01
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