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<br />DENTAL CLADM PROCEDURE <br />for <br />PREDETERMINATION OF BENEFITS <br /> <br />If a Covered Person is advised to have non-emergency dental treatment which will cost $300 or more, he or she should fmd out in <br />advance what charges may be considered Covered Expenses under this Policy. <br /> <br />To use this procedure: <br />(1) the Covered Employee should request a claim form and take it to the Dentist; <br />(2) the Dentist will list the proposed procedures and fees on the claim form and return it to the Company; and <br />(3) the Company will verify current eligibility and determine what benefIts would be payable for the procedures <br />listed. <br /> <br />GL11-19B-PD <br /> <br />')7 <br /> <br />OQ/01/01 <br />