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[A LM d DELTA DENTAL Delta Dental of Ohio Renewal Rates for Mayfield Village #0421 Effective April 1, 2022 Rates - Rates per enrollee per month Current Rate(s) April 1, 2021 through March 31, 2022 Renewal Rate(s) Aril 1, 2022 through March 31, 2024 Enrollee only $30.99 $32.87 $66.51 Enrollee and spouse $62.70 $78.05 Enrollee and child(ren) $73.58 $121.82 Enrollee, use and child(ren) $114.85 Overall Percent Change 6.07% Minimum client contributions: 98 percent for employee and 97 percent for Tied to medical: No Covered Persons choosing this dental plan are required to remain enrolled for a period of 12 months. Should a Covered Person choose to drop coverage after that time, he or she may not re -enroll prior to the date on which 12 months have elapsed. 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 for the 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 https-//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 age 18 and under. > 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 first permanent molars for people age eight and under and second permanent molars for people age 13 and under. The surface must be free from decay and restorations. > Composite resin (white) restorations are payable on posterior teeth. > Porcelain and resin facings on crowns are optional treatment on posterior teeth. > Implants are payable once per tooth in any five-year period. Implant related services are Covered Services. > Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. > People with special health care needs may be eligible for additional services including exams, hygiene visits, dental case management, and silver diamine fluoride treatment. February 2. 2022 0421-0001