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.' SCHEDULE OF BENEFITS (CONTINUED) Plan 1 - All Active Full-time Employees located in a PPO service area BENEFITS FOR CLASS 1 Eli~ible Class: All Full-Time Employees located in a PPO service area Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are required to contribute to the cost for Dependent Dental Coverage, BenefIt Waitin~ Period: Type II Procedures: Type III Procedures: None 6 Months The BenefIt Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the Policy Effective Date. Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes Late Entrant Limitation (when lij)plicable): Type II Procedures: 12 Months Type III Procedures: 12 Months DENTAL BENEFITS PPO PLAN In-Network Services PPO PLAN Out-of-Network Services CALENDAR YEAR DEDUCTIBLE for these Procedure Types (combined) INDIVIDUAL FAMILY Types II & III $50 $150 Types II & III $50 $150 PERCENT PAYABLE Type I - Diagnostic & Preventive Services Type II - Basic Services Type III - Major Services 100% 85% 55% 100% 75% 45% CALENDAR YEAR MAXIMUM for these Procedure Types (combined) $2,000 Types I, II & III , $2,000 Types I, II & III Under the CLAIMS PROCEDURES provision, the paragraph captioned "TO WHOM PAYABLE" is amended to read as follows. TO WHOM PAYABLE. Dental Expense BenefIts generally will be paid to the Covered Employee; unless the Covered Employee has assigned such benefIts to the Dentist, or an overpayment has been made. However, if services are provided by a Participating Dentist, benefIts are automatically assigned to that Dentist, unless the bill has been paid, GL 11-3-SB 3-2 09/01/01