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<br />SCHEDULE OF BENEFITS (CONTINUED) <br /> <br />Plan 2 - All Active Full-time Employees located outside a PPO service area <br /> <br />BENEFITS FOR CLASS 2 <br /> <br />Elil:ible Class: <br /> <br />All Full-Time Employees located outside a PPO service area <br /> <br />Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are <br />required to contribute to the cost for Dependent Dental Coverage. <br /> <br />BenefIt Waitinl: Period: <br />Type II Procedures: <br />Type III Procedures: <br /> <br />None <br />6 Months <br /> <br />The BenefIt Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the <br />Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the <br />Policy Effective Date. <br /> <br />Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes <br /> <br />Late Entrant Limitation (when lij)J)licablc:): <br />Type II Procedures: 12 Months <br />Type III Procedures: 12 Months <br /> <br />DENTAL BENEFITS <br /> <br />CALENDAR YEAR DEDUCTIBLE <br />for Type II and III Procedures (combined) <br />INDMDUAL <br />F AMIL Y <br /> <br />$50 <br />$150 <br /> <br />PERCENT PAYABLE <br />Type I - Diagnostic & Preventive Services <br />Type II - Basic Services <br />Type III - Major Services <br /> <br />100% <br />80% <br />50% <br /> <br />CALENDAR YEAR MAXIMUM <br />for Type I, II and III Procedures (combined) <br /> <br />$2,000 <br /> <br />GL 11-3-88 <br /> <br />3-3 <br /> <br />09/01/01 <br />