Orthodontia- for Adult and Children
Paid at 50% UCR* with a $1,000 lifetime maximum per person. No deductible applies.

Annual Maximum Benefit
• Type I (A)(B) and Type II Procedures - $1,000 per calendar year per person.
• Orthodontia Procedures - $1,000 Lifetime per person.

This plan includes a maximum carryover for dental. Each insured (employee and/or dependent) will qualify for a dental maximum carryover if they:

1. Visit a dentist between January 1 and December 31 of the plan year.
2. Submit a claim for payment prior to March 1 of the following year.
3. Total benefits paid for the Calendar Year must be less than $500.

If you meet all 3 requirements you will have an additional $250 available in the Annual Dental Maximum for the next plan year. In future years if you have benefits paid of less than $500, additional amounts of $250 will be added to the carryover. However, the most you can accumulate in the maximum carryover is $1,000. Therefore, the maximum annual benefit may never exceed $2,000 in any one year.

LATE ENTRANT CLAUSE
There is a 12 month waiting period on all services except for cleanings, exams, and fluoride applications for employees who do not enroll when first eligible for coverage. The waiting period will be waived for employees who enroll when first eligible.

Dental Exclusions (deferment Period)
During the first 36 months following your or your dependent's Dental Coverage Effective Date, the initial placement of dentures, partial dentures, or bridges, if it includes the replacement of teeth all of which are missing prior to the effective date. (For currently covered insureds, Ameritas will use the employees Date of Hire to determine the 36 month period.) This exclusion will not apply if the prosthesis replaces a sound natural tooth which is extracted while the patient is insured under this Dental Coverage and which is replaced within 12 months of the extraction. During the first 36 months of coverage, the replacement of bridges, partial dentures, dentures, inlays or crowns is excluded. Exceptions to this exclusion will be made if the replacement is made necessary by: a) accidental bodily injury to sound natural teeth (chewing injuries are not considered accidental bodily injuries), or b) the extraction of a sound natural tooth provided the replacement is completed within 12 months of the date of the injury or extraction.

Eligible Employees
You are eligible for insurance if you are a full-time active employee working at least 30 hours per week.

Eligible Dependents
Provides Coverage On:
• Your Spouse
• Children up to age 24 and unmarried if wholly dependent upon you for maintenance and support.

PREDETERMINATION OF BENEFITS
A treatment plan MAY be filed if a proposed course of treatment will exceed $200.00. With this information, Ameritas can determine the benefits payable under this policy prior to the work actually being done. It will give the insured the amount payable, along with an idea of the out of pocket expense.

Coordination of Benefits
If you or any of your dependents incur charges which are covered by any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the charges incurred.

Certificate of Insurance
The Certificate of Insurance issued to you describes in detail the benefits and limitations of this plan. This brochure is for general information only.

Section 125
This policy is provided as part of the Policyholder's Section 125 Plan. Each member has the option under the Section 125 Plan of participating or not participating in this policy.

A member may change their election only during an annual election period, except for a change in family status. Examples of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination of employment. Please see your plan administrator for details.

Orthodontia Limitations
(This is not a complete list)
• No benefit is payable for expenses incurred:
• In connection with a Treatment Program which was begun before the individual became insured for orthodontic benefits.
• During any quarter of a Treatment Program if the individual was not continuously insured for orthodontic benefits for the entire quarter.
• After the individual's insurance for orthodontic benefits terminates.

Limitations/Exclusions
(This is not a complete List)
• For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2nd bicuspid are considered cosmetic.
• Charges incurred prior to the date the individual became insured under this plan, or following the date of termination of coverage.
• Services which are not recommended by a dentist or which are not required for necessary care and treatment.
• Expenses incurred to replace lost or stolen appliances.
• Expenses incurred by an insured because of a sickness for which he /she is eligible for benefits under Worker's Compensation Act or similar laws.

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