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<br />
<br />Cleveland Regional Group Sales Office
<br />6480 Rockside Woods Blvd. South, Suite 220
<br />Independence, OH, 44131
<br />Phone: (216) 654-1908 ;Toll Free: (800) 222-0447
<br />Fax: (216)654-1912
<br />Mayfield Village
<br />397379
<br />DENTAL PLAN DESIGN CHANGE SUMMARY
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<br />Current Plan Design Alternative Plan Design
<br />Contract Type DG 2000 Contract Type DG 2000
<br />Plan Type PPO Plan - W t Plan Type Split Maximum Plan - B t
<br />Participation 75-100% Participation 75-100%
<br /> In-Network Out-of-Network In-Network Out-of-Network
<br />Reimbursement Based On Fee Schedule R & C - 90th °/Wile Reimbursement Based On Fee Schedule R & C - 90th %ile
<br />Coinsurance Coinsurance
<br />Preventive 100% 100% Preventive 100% 100%
<br />Basic 100%a 80% Basic 100°/a 80%
<br />Major 60°/a 50% Major 60% 50%
<br />Deductible Deductible
<br />Amount $25 $25 Amount $50 $50
<br />Waived for Prev. Srvcs7 Yes Yes Waived for Prev. Srvcs7 Yes Yes
<br />Maximum $1,500 $1,500 Maximum $1,500 $1,000
<br /> Maximum Rollover Detail:
<br /> Threshold: $500
<br /> Rollover amount: $250
<br /> In-network Only Rollover amount: $350 ,
<br /> Maximum Rollover Account Limit: $1,000
<br /> -- If a member submits a claim and does nut exceed the $500 paid claims threshold
<br /> during the benefit year, Guardian will roll over $250 into their Maximum Rollove
<br /> Account (MRA) for use in future years.
<br /> - If a member uses Guardian Preferred Providers exclusively during the benefit year, the
<br /> amount is increased to $350.
<br /> -- Each employee and dependent maintain separate MRAs based on their own claim
<br /> activity.
<br /> -- Each member's MRA may not exceed the $1000 Maximum Rollover Account Limit.
<br /> - For calendar year accumulation cases with a plan anniversary date in Oct, Nov, o
<br /> Dec, the Maximum Rollover feature starts as of the first full benefit year.
<br /> (For example, if a plan renews in November of 2005, claims activity in 2006 will be used
<br /> to determine rollover amounts for use in 2007.)
<br /> - For all other cases, we will use claims activity from the entire current benefit year to
<br /> determine rollover amounts for use in the next benefit year.
<br />DentalGuard Options: DentalGuard Options (changes from the current plan design):
<br />None None
<br />Dependent Age Limits 20/26 Dependent Age Limits 20/26
<br />Current Plan Design Rates Alternative Plan Design Rates
<br /> Monthly Monthly
<br /> . Premium .Count Month/ Rate Premium Count Ivfonthl Rate
<br />Employee $285.84 8` $35.73 Employee $256:32 8 $32.04'
<br />Employee+Spouse $1,139.18 14 $81.37 Employee+Spouse $1,021.58 14 $72.97
<br />Employee + Child $411.08 4 $102.77 Employee + Child $368.64 4 $92.16
<br />Family $4,452.90 30 $148.43 Family $3,993.00 30 $133.10
<br />Total $6,289.00 56 Total $5,639.54 56
<br /> (585)
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<br />Plalmholder Signature
<br />GP-I-DG2000
<br />authorive Guardian to change eur compan}1s Dental plan design to the Alternative Plan Design shovm above.
<br />Authorized Signature: Title: Date:
<br />All plan change ragouts must be ro-eived in the Guardian Home O~ir< IS days prior to the eRocuve date of change.
<br />Date Prepared: 6(25/2007
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