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? <br />UARDIAN <br />? <br />Cleveland Regional Group Sales Office <br />6480 Rockside Woods Blvd. South, Suite 170 <br />Cleveland, OH, 44131 <br />Phone: (216) 447-1908 ; Toll Free: (800) 222-0447 <br />Fax: (216) 447-1912 <br />Mayfield Village <br />397379 <br />DENTAL PLAN DESIGN CHANGE SUMMARY <br /> <br /> <br />? <br />t <br />nks0????.. <br /> <br /> Current Plan Design Alternative Plan Design <br /> Conlract Type I)G 2000 Contract Type DG 2000 <br /> Plan Type PPO Plan - Wl Plan Type PPO Plan - Xl <br /> Pazticipation 1 75-100% Participation 75-100% <br /> In-Network Out-of-Nettvork In-Network Out-of-Network <br /> Reimbutsement Based On Fee Schedule R& C- 90th %ile Reimbutsement Based On Fee Schedule R& C- 90th %ile <br /> Coinsurance Coinsurance <br /> Preventive 100% 100% Preventive 100% 100% <br /> Basic 100% 80% Basic 100% 80% <br /> Major 600/o 50% Major 600/o 50% <br /> Deductible Deductible <br /> Amount $25 $25 Amount $25 $75 <br /> Waived for Prev. Srvcs7 Yes Yes Waived for Prev. Srvcs? Yes No <br /> Maximum $1,000 $1,000 Maximum $1,000 $1,000 <br /> Maximum RoRover 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 not exceed the $500 paid claims threshol <br /> during the benefit year, Guardian will roll over $250 into their Maximum Rollov <br /> Account (MIZA) for use in future years. <br /> - If a member uses Guardian Preferred Providets exclusively during the benefit year, th <br /> amount is increased to $350. <br /> - Each employee and dependent maintain separate MRAs based on their own cla' <br /> activity. <br /> - Each membees MRA may not exceed the $1000 Maximum Rollover Account Limit <br /> - For calendar year accumulation cases with a plan annivetsazy date in Oct, Nov, o <br /> Dec, the Maximum Rollover feature stuts as of the fust full benefit year. <br /> (For example, if a plan renews in November of 2005, claims activity in 2006 will be used <br /> to detennine rollover aznounts 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 currei?t 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 /> Mont}ily Monthly <br /> Premium Count Monthl Rate Premium Count Monthl Rate <br /> Employee $313.40 10 $31.34 Employee $274.20 10 $27.42 <br /> Employee,+8pouse $927.94 13 = $7138 . , Employee + Spouse $811.98 13 $62.46 <br /> , <br />Employee + Child ` $360.60 " 4 ` $90.15 Employee + Child ' $315.52 4 $78.88 <br /> Family $3,775.80 29 $130.20 Family $3,303.68 29 $113.92 <br /> Total $5,377.74 56 Total $4,705.38 56 <br /> (sas) <br /> .Cha?t <br /> <br />Planholder Signature <br />GP-1-DG2000 <br />I authorize Guardiea to change our compan}+s Dental pian design to the Alumative Plen Design shown ebwe. <br />Authoriud Signamre: Title: Date: <br />All plm cbm,ga requeats must ba received in the Guerdim Home Ogice IS deys prior W the cffxtiw dffie of cLenga <br />Date Prep : 6 19 006.