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Delta Dental of Ohio Renewal Rates for Mayfield Village #0421 Effective Apri11, 2017 d DELTA DENTAL® Rates per subscriber per month Current Rate(s) April 1, 2015 through March 31, 2017 Renewal Rate(s) April 1, 2017 through March 31, 2019 Subscriber only $30.99 $30.99 Subscriber and spouse $62.70 $62.70 Subscriber and child(ren) $73.58 $73.58 Subscriber, spouse and child(ren) $114.85 $114.85 Overall Percent Change 0:00% Minimum client contributions: 98 percent for employee and 97 percent for dependent(s). ~ Tied to medical: No Subscribers and eligible dependents must enroll for a minimum of 12 months. If coverage is terminated after 12 months, they may not re-enroll prior to the open enrollment that occurs at least 12 months from the date of termination. Dependents may only enroll if the Subscriber is enrolled (except under COBRA) and must be enrolled in the same plan as the Subscriber. Plan changes are only allowed during operi enrollment periods, except that an election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. . . Rates do not include any applicable claims taxes. The rates are valid only forthe effective date noted above and are guaranteed for a two year non-retention contract. Self-billing is not allowed and you agree to pay as invoiced each month. Standard subscriber materials will be provided to you to distribute to your members. These include the Summary of Dental Plan Benefits, Certificate, and reference~cards. Printed dentist directories are not included. You can find participating dentists on our website at www.DeltaDentalOH.com. The plan specifications are subject to Delta Dental's standard exclusions and limitations, including: - Oral exams (including evaluations by a specialist) are payable twice per calendar year. - Prophylaxes (cleanings) are payable twice per calendar year. - People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about.treatment. - Fluoride treatments are payable twice per calendar year for people up to age 19. - Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. - Sealants are payable once per tooth per lifetime for the occlusal surface of first permanent molars up to age nine and second permanent molars up to age 14. The surface must be free from decay and restorations. - Composite resin (white) restorations are Covered Services on posterior teeth. • - Porcelain and resin facings on crowns are optional treatment on posterior teeth. - Implants and implant related services are payable once per tooth in any five-year period. January 26, 2017 0421-0001