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Dental Employee Enrollment Packet

Dental Plan Options Available for

The Employees and Dependents of

Weld County

(303) 744-3007 or 1-800-807-0706 FAX (303) 369-1051

www.betadental.com

(Plan Options Effective January 1, 2018)

http://www.betadental.com/

WHAT ARE THE THREE DENTAL PLAN OPTIONS? Weld County allows each employee the choice of enrolling in the Alpha Dental Plan, the Companion Life Dental Plan, or a Self-Funded Dental Plan. There are

many advantages to this flexible arrangement.

Option #1 Option #2 Option #3

Three Plans to Select From

Alpha Dental Network

Plan

Self-Funded Dental Plan

Companion Life Insurance

Plan

Important Notice!

All employees MUST enroll in one of the above three dental plans or decline coverage. You can only enroll again at the next open enrollment

period (one year from now).

Employee Dental Plan Costs (per pay period)

Beginning January 1, 2018 Full Three Qtr. Half Option #1 Alpha Dental Plan Time Time Time

Employee only $ 0 $ 0 $ 5.50 Employee + 1 $11.00 $11.00 $16.50 Employee + 2 or more $18.00 $18.00 $23.50 Option #2 Companion Life Employee only $23.76 $23.76 $29.26 Employee + 1 $58.18 $58.18 $63.68 Employee + 2 or more $110.07 $110.07 $115.57 Option #3 Self-funded Plan Employee only $ 0 $ 0 $ 5.50 Employee + 1 $11.00 $11.00 $16.50 Employee + 2 or more $18.00 $18.00 $23.50 Dental Plan Enrollment Guidelines

1. If an employee takes employee only Health Coverage: - Employees have choice of all three dental plans. - Employees who take Alpha or Companion Dental can add dependents even

though they are enrolled in County employee only medical. Cost for adding dependents to Alpha or Companion dental is at employee’s expense.

2. If an employee takes Health Coverage and adds dependents:

- Employees have choice of all three dental plans. - Employees and all dependents must be on the same dental plan option.

3. If an employee takes no medical at all:

- Employees can take the Alpha or Companion dental options for employee or employee and dependent coverage and the County will contribute towards the cost of either plan as outlined above.

Dental Plan Comparison Effective January 1, 2018

Option #1 Option #2 Option #3 Benefit Alpha Dental Companion Life * Self-Funded Plan *

Dentist Selection Network Dentist Only See any Dentist See any Dentist Deductible No deductibles $100 lifetime No deductibles (Per person) Annual Maximum None (unlimited) $1,700 per person $1,000 combined per calendar year per calendar year Claim Forms None DDS submits Employee submits Cleanings $15 copay 100% 100% Twice per year Once per year Fillings Save Approximately 100% 50% 75% Cosmetic Services Save Approximately Not Covered Not Covered (Bleaching & 50% veneer bonding etc.) Crowns Save Approximately 50% 50% 60% Root Canals Save Approximately 50% 50% 60% Periodontal Services Save Approximately 50% 50% 55% Dentures Save Approximately 50% 50% 63% Extractions Save Approximately 50% 50% 60% Orthodontic Services Yes Not Covered Not Covered (Braces) (For Children and Adults) This comparison is intended for general use only. Please reference each options specific coverage sheets for specific benefit information. * Claims that are paid on both the Companion Life and Self-funded dental plan options are based upon the Usual and

Customary Fee (UCR) for dentists in the specific zip code for which the submitting dentist is located. If a dentist has higher fees than other dentists in their Zip Code, then you will pay the difference between UCR and the dentists billed charges.

Check out these Free NationalDiscount Programs!

All members and their families enrolling in one of our products can use any of the attached FREE programs at no additional cost. It is our thanks to you for working with us!

To get started, please go to the website at the end of this paragraph to request your I.D. cards….it’s that easy. Please feel free to photocopy and give one to each family member, your dependents, or anyone who can benefit from using these FREE plans. If you have questions, please call us at 303-744-3007 or 1-800-807-0706. For more information or to download your free cards please visit us online at www.AlphaDentalPlans.com/dcards/715.

Copyright © Beta Health Association, Inc.

Our Prescription Drug discount card offers savings of up to 75% on prescription drugs, depending on the pharmacy and medication, allowing you to save each time you fill your prescription. You get easy access to 54,000 pharmacies nationwide that provide discount pricing on FDA approved brand name or generic drugs.

How It Works - Print your card - Call the customer service/pharmacist helpline at 888-593-4445 - Visit an accepting pharmacy near you to save

Our free Pet Prescription discount card provides savings of up to 75% on pet medications each time you use your Pet Prescription card, depending on the pharmacy and medication. Our four-legged friends sometimes need medications and prescription drugs just like humans. You can now get pet meds for less!

How It Works - Print your card - Call the customer service/pharmacist helpline at 888-593-4445 - Visit an accepting pharmacy near you to save

EyeMed Vision Discount Plan Epic Hearing Discount Plan

Prescription Drug Discount Plan Pet Prescription Discount Plan

We have teamed up with EyeMed Vision Care to offer easy access to over 43,000 national, conveniently located vision care providers including optometrists, ophthalmologists, opticians and many leading optical retailers, such as LensCrafters®, Target Optical®, and most Sears Optical® and Pearl Vision® locations. This benefit is free of charge for Dental Plan members.

How It Works - Print your card - Find an EyeMed provider near you by calling 1-866-723-0596 - Show your card to save

Our free Epic Hearing discount card allows you to receive savings of up to 50% off MSRP on hearing aids, tests, and other hearing care related products and services! Get easy access to a national network of hearing professionals and audiologists who can help maximize your hearing potential and support your hearing care needs.

How It Works - Print your card - Call 1-866-956-5400 for ID card information - Follow the instructions to get hearing discounts

Note: These plans are not insurance. They are discount plans to save you and your family members money as needed!

PRESCRIPTION DISCOUNT CARD Accepted at over 60,000pharmacies nationwide

PRESCRIPTION DISCOUNT CARD Accepted at over 60,000pharmacies nationwide

PET PRESCRIPTION DISCOUNT CARD Accepted at over 60,000pharmacies nationwide

PET PRESCRIPTION DISCOUNT CARD Accepted at over 60,000pharmacies nationwide

VISION DISCOUNT CARDVISION DISCOUNT CARDAccepted at over 40,000

vision providers nationwide

HEARING DISCOUNT CARD HEARING DISCOUNT CARD

SAVE UP TO 75% ONYOUR PRESCRIPTIONS

SAVE UP TO 75% ONYOUR PRESCRIPTIONS

SAVE UP TO 75% ONPET PRESCRIPTIONS

SAVE UP TO 75% ONPET PRESCRIPTIONS

SAVE UP TO 35% ON GLASSES GET DISCOUNTS ON EYE CARE

SAVE FROM 35% TO 50%ON HEARING CARE

SAVE FROM 35% TO 50%ON HEARING CARE

SAVE UP TO 35% ON GLASSES GET DISCOUNTS ON EYE CARE

Accepted at over 40,000vision providers nationwide

MEMBER: 23456789GROUP: HDRX520BIN: 015284PCN: CRX

www.AlphaDentalPlans.com/dcards/715

Customer Service / Pharmacist Helpline: 888-593-4445

This card is free. This is not insurance. Discounts only.Process all claims electronically.









EyeMed Group #: 9235409Group Name: Beta Health Association, Inc.


Call 1-866-723-0596 to locate the nearest EyeMed Provider.This is a discount program and not insurance.

EyeMed Group #: 9235409Group Name: Beta Health Association, Inc.


Call 1-866-723-0596 to locate the nearest EyeMed Provider.This is a discount program and not insurance.

Epic Hearing: Call 1-866-956-5400 for ID card information.Group Name: Beta Health Association, Inc.

______________________________________________________________________Member Name

www.AlphaDentalPlans.com/dcards/715This is a discount program and not insurance.





Epic Hearing: Call 1-866-956-5400 for ID card information.Group Name: Beta Health Association, Inc.

______________________________________________________________________Member Name

www.AlphaDentalPlans.com/dcards/715This is a discount program and not insurance.

Thank you for choosing us as your dental partner. We are proud to offer you, free of charge, access to savings on prescription drugs, pet meds, vision, and hearing using the free cards below. Please feel free to photocopy and give one to each family member, your dependents, or anyone who can benefit from using these FREE plans. Follow the instructions on each card or visit www.AlphaDentalPlans.com/dcards/715 for more details. We appreciate our relationship!

Copyright © Beta Health Association, Inc.

Dental Option #1

The Alpha Dental Plan

The Alpha Dental Plan

Plan Highlights:

* The copayments listed on the schedule of benefits (next four pages) are pre-negotiated in advance with the providers in the network and represent a substantial savings off of the provider's normal fee. You pay the provider these amounts directly at the time services are rendered. They are your only financial responsibility on the Alpha plan. You will save an average of 70% off of ALL your dental expenses.

* Cosmetic Dentistry Included (Implants, Bleaching, Veneer Bonding, etc.) * Immediate Services for all Dental Procedures (No benefit waiting periods) * Orthodontic (braces) available for Children and Adults

* Unlimited Services each year…use the plan as much as you like

* No pre-existing condition limitations * No deductibles to satisfy * No claim forms to complete * No age limits

* Select from over 875 dentists across Colorado (including Grand Junction)

* Contracted providers credentials are reviewed annually to ensure excellent, quality care when you visit the dental office

* Change dentists any time you like by calling our office in Denver at

1-800-807-0706 The above highlights are only considered a sample of the services provided. Please

reference the attached Schedule of Benefits for more complete benefit information.

Form 040115

Average You Pay AverageCode Description Regular Cost Only SavingsDiagnostic and Preventive Services (x-rays and cleanings)D0999 Routine office visit $35 $5 86%D0120 Periodic Oral Evaluation - Established Patient $58 $0 100%D0140 Limited Oral Evaluation - Problem Focused $88 $17 81%D0150 Comprehensive Oral Evaluation - New Or Established Patient $102 $13 88%D0160 Detailed And Extensive Oral Evaluation - Problem Focused, By Report $178 $39 78%D0170 Re-Evaluation - Limited, Problem Focused (Established Patient) $83 $21 75%D0180 Comprehensive Periodontal Evaluation - New Or Established Patient $110 $25 77%D0210 Intraoral - Complete Series Of Radiographic Images $152 $33 78%D0220 Intraoral - Periapical First Radiographic Image $33 $6 81%D0230 Intraoral - Periapical Each Additional Radiographic Image $29 $6 81%D0240 Intraoral - Occlusal Radiographic Image $48 $5 90%D0250 Extraoral - First Radiographic Image $73 $5 93%D0260 Extraoral - Each Additional Radiographic Image $61 $5 92%D0270 Bitewing - Single Radiographic Image $33 $0 100%D0272 Bitewings - Two Radiographic Images $52 $0 100%D0273 Bitewings - Three Radiographic Images $64 $0 100%D0274 Bitewings - Four Radiographic Images $74 $0 100%D0277 Vertical Bitewings - 7 To 8 Radiographic Images $113 $0 100%D0330 Panoramic Radiographic Image $128 $54 58%D0340 Cephalometric Radiographic Image $140 $61 56%D0460 Pulp Vitality Tests $66 $0 100%D0470 Diagnostic Casts $132 $53 60%D0999 Emergency Visit - Same Day $90 $25 72%D1110 Prophylaxis - Adult (once every 6 months) $104 $15 86%D1120 Prophylaxis - Child (once every 6 months) $78 $15 81%D1206 Topical Application Of Fluoride Varnish $42 $12 72%D1330 Oral Hygiene Instructions $62 $0 100%D1351 Sealant - Per Tooth $62 $13 79%D1510 Space Maintainer - Fixed - Unilateral $366 $187 49%D1515 Space Maintainer - Fixed - Bilateral $500 $271 46%D1520 Space Maintainer - Removable - Unilateral $444 $226 49%D1525 Space Maintainer - Removable - Bilateral $556 $262 53%D1550 Re-Cement Or Rebond Space Maintainer $97 $18 81%D1999 Additional Prophy (for perio maintenance) $105 $45 57%

Restorative Services (fillings and crowns)D2140 Amalgam - One Surface, Primary Or Permanent $166 $37 78%D2150 Amalgam - Two Surfaces, Primary Or Permanent $209 $47 77%D2160 Amalgam - Three Surfaces, Primary Or Permanent $252 $59 77%D2161 Amalgam - Four Or More Surfaces, Primary Or Permanent $300 $69 77%D2330 Resin-Based Composite - One Surface, Anterior $188 $50 73%D2331 Resin-Based Composite - Two Surfaces, Anterior $233 $64 73%D2332 Resin-Based Composite - Three Surfaces, Anterior $289 $84 71%D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior) $367 $139 62%D2390 Resin-Based Composite Crown, Anterior $527 $290 45%D2391 Resin-Based Composite - One Surface, Posterior $207 $108 48%D2392 Resin-Based Composite - Two Surfaces, Posterior $270 $150 44%D2393 Resin-Based Composite - Three Surfaces, Posterior $332 $187 44%D2394 Resin-Based Composite - Four Or More Surfaces, Posterior $400 $207 48%D2510 Inlay - Metallic - One Surface $1,000 $330 67%D2520 Inlay - Metallic - Two Surfaces $1,053 $348 67%D2530 Inlay - Metallic - Three Or More Surfaces $1,125 $371 67%D2542 Onlay - Metallic-Two Surfaces $1,160 $383 67%D2543 Onlay - Metallic-Three Surfaces $1,181 $391 67%D2544 Onlay - Metallic-Four Or More Surfaces $1,228 $404 67%D2610 Inlay - Porcelain/Ceramic - One Surface $1,068 $352 67%

Please call (800) 807-0706for Customer Service

Please visit www.betadental.com/alpha19 to locate a provider near you. There are many providers all across Colorado to select from!

Alpha Dental - Plan 19 Fee Schedule

Average You Pay AverageCode Description Regular Cost Only SavingsRestorative Services (fillings and crowns) ContinuedD2620 Inlay - Porcelain/Ceramic - Two Surfaces $1,067 $363 66%D2630 Inlay - Porcelain/Ceramic - Three Or More Surfaces $1,120 $392 65%D2642 Onlay - Porcelain/Ceramic - Two Surfaces $1,155 $393 66%D2643 Onlay - Porcelain/Ceramic - Three Surfaces $1,235 $432 65%D2644 Onlay - Porcelain/Ceramic - Four Or More Surfaces $1,278 $447 65%D2650 Inlay - Resin-Based Composite - One Surface $1,016 $335 67%D2651 Inlay - Resin-Based Composite - Two Surfaces $1,050 $346 67%D2652 Inlay - Resin-Based Composite - Three Or More Surfaces $1,095 $362 67%D2662 Onlay - Resin-Based Composite - Two Surfaces $1,116 $435 61%D2663 Onlay - Resin-Based Composite - Three Surfaces $1,147 $447 61%D2664 Onlay - Resin-Based Composite - Four Or More Surfaces $1,197 $455 62%D2710 Crown - Resin-Based Composite (Indirect) $1,085 $359 67%D2720 Crown - Resin With High Noble Metal $1,232 $406 67%D2721 Crown - Resin With Predominantly Base Metal $1,167 $384 67%D2722 Crown - Resin With Noble Metal $1,193 $394 67%D2740 Crown - Porcelain/Ceramic Substrate $1,333 $440 67%D2750 Crown - Porcelain Fused To High Noble Metal $1,318 $435 67%D2751 Crown - Porcelain Fused To Predominantly Base Metal $1,210 $362 70%D2752 Crown - Porcelain Fused To Noble Metal $1,239 $420 66%D2780 Crown - 3/4 Cast High Noble Metal $1,257 $503 60%D2781 Crown - 3/4 Cast Predominantly Base Metal $1,167 $467 60%D2782 Crown - 3/4 Cast Noble Metal $1,208 $483 60%D2783 Crown - 3/4 Porcelain/Ceramic $1,287 $502 61%D2790 Crown - Full Cast High Noble Metal $1,329 $422 68%D2791 Crown - Full Cast Predominantly Base Metal $1,167 $361 69%D2792 Crown - Full Cast Noble Metal $1,222 $398 67%D2910 Recement Or Rebond Inlay, Onlay, Or Partial Coverage Restoration $128 $17 87%D2920 Recement Or Rebond Crown $128 $34 73%D2930 Prefabricated Stainless Steel Crown - Primary Tooth $314 $109 65%D2931 Prefabricated Stainless Steel Crown - Permanent Tooth $379 $131 65%D2932 Prefabricated Resin Crown $411 $172 58%D2933 Prefabricated Stainless Steel Crown With Resin Window $417 $188 55%D2940 Protective Restoration $143 $40 72%D2950 Core Buildup, Including Any Pins $317 $89 72%D2951 Pin Retention - Per Tooth, In Addition To Restoration $86 $24 72%D2952 Post And Core In Addition To Crown, Indirectly Fabricated $495 $145 71%D2953 Each Additional Indirectly Fabricated Post - Same Tooth $400 $110 73%D2954 Prefabricated Post And Core In Addition To Crown $389 $114 71%D2955 Post Removal $343 $150 56%D2957 Each Additional Prefabricated Post - Same Tooth $239 $96 60%D2960 Labial Veneer (Resin Laminate) - Chairside $778 $204 74%D2999 Complex Rehabilitation On Crown And Bridge Procedures (6 or more) Per Unit In The

Same Treatment Plan$135

PLEASE NOTE - Any procedures listed under restorative services that require lab work do not include an allowable $155 lab fee (per unit). If gold is used, then there is also an additional cost based on the billed cost the provider is paying the lab for the gold. Doctors, please make sure that all members fully understand what their fees will be and what the savings are from your normal full fees before treatment begins. Temporary crowns are included with the permanent crown preparation.

Endodontic Services (root canals)D3110 Pulp Cap - Direct (Excluding Final Restoration) $97 $28 71%D3120 Pulp Cap - Indirect (Excluding Final Restoration) $98 $28 71%D3220 Therapeutic Pulpotomy (Excluding Final Restoration) - Removal Of Pulp Coronal To

The Dentinocemental Junction And Application Of Medicament$233 $77 67%

D3221 Pulpal Debridement, Primary And Permanent Teeth $273 $93 66%D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth (Excluding Final

Restoration) $324 $101 69%

D3240 Pulpal Therapy (Resorbable Filling) - Posterior, Primary Tooth (Excluding Final Restoration)

$361 $110 69%

D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) $860 $304 65%D3320 Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration) $992 $363 63%D3330 Endodontic Therapy, Molar (Excluding Final Restoration) $1,200 $454 62%D3331 Treatment Of Root Canal Obstruction; Non-Surgical Access $717 $308 57%D3332 Incomplete Endodontic Therapy; Inoperable, Unrestorable Or Fractured Tooth $527 $216 59%D3333 Internal Root Repair Of Perforation Defects $416 $171 59%D3346 Retreatment Of Previous Root Canal Therapy - Anterior $998 $399 60%D3347 Retreatment Of Previous Root Canal Therapy - Bicuspid $1,139 $444 61%D3348 Retreatment Of Previous Root Canal Therapy - Molar $1,355 $528 61%

Alpha Dental Plan 19 Fee Schedule - Page 2 of 6

Average You Pay AverageCode Description Regular Cost Only SavingsEndodontic Services (root canals) ContinuedD3351 Apexification/Recalcification – Initial Visit (Apical Closure/Calcific Repair Of

Perforations, Root Resorption, Etc.)$417 $167 60%

D3352 Apexification/Recalcification/Pulpal Regeneration - Interim Medication Replacement (Apical Closure/Calcific Repair Of Perforations, Root Resorption, Pulp Space

$304 $125 59%

D3353 Apexification/Recalcification - Final Visit (Includes Completed Root Canal Therapy - Apical Closure/Calcific Repair Of Perforations, Root Resorption, Etc.)

$628 $251 60%

D3410 Apicoectomy/Periradicular Surgery - Anterior $816 $361 56%D3421 Apicoectomy/Periradicular Surgery - Bicuspid (First Root) $911 $414 55%D3425 Apicoectomy/Periradicular Surgery - Molar (First Root) $1,036 $462 55%D3426 Apicoectomy/Periradicular Surgery (Each Additional Root) $478 $171 64%D3430 Retrograde Filling - Per Root $327 $120 63%D3450 Root Amputation - Per Root $560 $213 62%D3470 Intentional Reimplantation (Including Necessary Splinting) $938 $356 62%D3910 Surgical Procedure For Isolation Of Tooth With Rubber Dam $279 $64 77%D3920 Hemisection (Including Any Root Removal), Not Including Root Canal Therapy $550 $253 54%D3950 Canal Preparation And Fitting Of Preformed Dowel Or Post $299 $135 55%

Periodontic Services (gum disease)D4210 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded

Spaces Per Quadrant$719 $340 53%

D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

$352 $194 45%

D4240 Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

$858 $368 57%

D4241 Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

$728 $306 58%

D4245 Apically Positioned Flap $945 $406 57%D4249 Clinical Crown Lengthening - Hard Tissue $882 $379 57%D4260 Osseous Surgery (Including Elevation Of Full Thickness Flap And Closure) - Four Or

More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant$1,249 $572 54%

D4261 Osseous Surgery (Including Elevation Of Full Thickness Flap And Closure) - One to Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

$1,033 $465 55%

D4263 Bone Replacement Graft - First Site In Quadrant $819 $369 55%D4264 Bone Replacement Graft - Each Additional Site In Quadrant $617 $271 56%D4266 Guided Tissue Regeneration - Resorbable Barrier, Per Site $940 $404 57%D4267 Guided Tissue Regeneration - Nonresorbable Barrier, Per Site (Includes Membrane

Removal)$1,103 $496 55%

D4268 Surgical Revision Procedure, Per Tooth $947 $417 56%D4270 Pedicle Soft Tissue Graft Procedure $945 $416 56%D4320 Provisional Splinting - Intracoronal $599 $280 53%D4321 Provisional Splinting - Extracoronal $556 $260 53%D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant $294 $124 58%D4342 Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant $212 $89 58%D4355 Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis $213 $106 50%D4910 Periodontal Maintenance $161 $63 61%D4920 Unscheduled Dressing Change (By Someone Other Than Treating Dentist) $117 $55 53%D4999 Periodontal Screening And Scoring $34 $11 67%

Prosthodontic Services - Removable (dentures) D5110 Complete Denture - Maxillary $2,000 $593 70%D5120 Complete Denture - Mandibular $2,000 $593 70%D5130 Immediate Denture - Maxillary $2,154 $857 60%D5140 Immediate Denture - Mandibular $2,160 $858 60%D5211 Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And

Teeth)$1,570 $493 69%

D5212 Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)

$1,569 $479 69%

D5213 Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)

$2,068 $600 71%

D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)

$2,084 $601 71%

D5281 Removable Unilateral Partial Denture - One Piece Cast Metal (Including Clasps And Teeth

$1,139 $364 68%

D5410 Adjust Complete Denture - Maxillary $104 $39 63%D5411 Adjust Complete Denture - Mandibular $104 $39 62%D5421 Adjust Partial Denture - Maxillary $104 $39 62%D5422 Adjust Partial Denture - Mandibular $104 $39 62%D5510 Repair Broken Complete Denture Base $247 $94 62%


Average You Pay AverageCode Description Regular Cost Only SavingsProsthodontic Services - Removable (dentures) Continued D5520 Replace Missing Or Broken Teeth - Complete Denture (Each Tooth) $217 $68 69%D5610 Repair Resin Denture Base $238 $87 64%D5620 Repair Cast Framework $333 $148 56%D5630 Repair Or Replace Broken Clasp $309 $113 63%D5640 Replace Broken Teeth - Per Tooth $214 $73 66%D5650 Add Tooth To Existing Partial Denture $262 $101 61%D5660 Add Clasp To Existing Partial Denture $316 $131 59%D5710 Rebase Complete Maxillary Denture $678 $297 56%D5711 Rebase Complete Mandibular Denture $672 $295 56%D5720 Rebase Maxillary Partial Denture $656 $248 62%D5721 Rebase Mandibular Partial Denture $656 $249 62%D5730 Reline Complete Maxillary Denture (Chairside) $433 $188 56%D5731 Reline Complete Mandibular Denture (Chairside) $433 $188 56%D5740 Reline Maxillary Partial Denture (Chairside) $424 $178 58%D5741 Reline Mandibular Partial Denture (Chairside) $432 $179 58%D5750 Reline Complete Maxillary Denture (Laboratory) $553 $170 69%D5751 Reline Complete Mandibular Denture (Laboratory) $555 $171 69%D5760 Reline Maxillary Partial Denture (Laboratory) $540 $170 69%D5761 Reline Mandibular Partial Denture (Laboratory) $540 $169 69%D5810 Interim Complete Denture (Maxillary) $1,010 $374 63%D5811 Interim Complete Denture (Mandibular) $1,018 $377 63%D5820 Interim Partial Denture (Maxillary) $807 $299 63%D5821 Interim Partial Denture (Mandibular) $807 $291 64%D5850 Tissue Conditioning, Maxillary $240 $69 71%D5851 Tissue Conditioning, Mandibular $240 $67 72%

PLEASE NOTE - In addition to the fees listed above in prosthodontist Services - Removable (dentures), additional fees may be charged for upgraded teeth and enhanced cosmetics, personalization beyond the norm or techniques involving precision dentures. Doctors, please make sure that all members understand what their fees will be and what the savings are from your normal full fees before treatment begins.

Implant / Abutment Supported Prosthetic Services (where available)D6000 through D6199PLEASE NOTE - Doctors, please make sure that all members understand what their fees will be and what the savings are from your normal full fees before treatment begins.

Prosthodontic Services - Fixed (dentures)D6210 Pontic - Cast High Noble Metal $1,278 $405 68%D6211 Pontic - Cast Predominantly Base Metal $1,196 $349 71%D6212 Pontic - Cast Noble Metal $1,218 $363 70%D6240 Pontic - Porcelain Fused To High Noble Metal $1,316 $434 67%D6241 Pontic - Porcelain Fused To Predominantly Base Metal $1,210 $357 71%D6242 Pontic - Porcelain Fused To Noble Metal $1,245 $380 69%D6245 Pontic - Porcelain/Ceramic $1,327 $425 68%D6250 Pontic - Resin With High Noble Metal $1,263 $402 68%D6251 Pontic - Resin With Predominantly Base Metal $1,222 $379 69%D6252 Pontic - Resin With Noble Metal $1,222 $380 69%D6545 Retainer - Cast Metal For Resin Bonded Fixed Prosthesis $1,000 $370 63%D6548 Retainer - Porcelain/Ceramic For Resin Bonded Fixed Prosthesis $1,101 $396 64%D6720 Crown - Resin With High Noble Metal $1,253 $413 67%D6721 Crown - Resin With Predominantly Base Metal $1,220 $403 67%D6722 Crown - Resin With Noble Metal $1,225 $404 67%D6740 Crown - Porcelain/Ceramic $1,339 $469 65%D6750 Crown - Porcelain Fused To High Noble Metal $1,326 $437 67%D6751 Crown - Porcelain Fused To Predominantly Base Metal $1,202 $360 70%D6752 Crown - Porcelain Fused To Noble Metal $1,222 $379 69%D6780 Crown - 3/4 Cast High Noble Metal $1,256 $414 67%D6781 Crown - 3/4 Cast Predominantly Base Metal $1,199 $396 67%D6782 Crown - 3/4 Cast Noble Metal $1,222 $415 66%D6783 Crown - 3/4 Porcelain/Ceramic $1,288 $425 67%D6790 Crown - Full Cast High Noble Metal $1,278 $405 68%D6791 Crown - Full Cast Predominantly Base Metal $1,195 $370 69%D6792 Crown - Full Cast Noble Metal $1,217 $370 70%D6930 Recement Or Rebond Fixed Partial Denture $200 $75 63%

PLEASE NOTE - Any procedures listed under restorative services that require lab work do not include an allowable $155 lab fee (per unit). If gold is used, then there is also an additional cost based on the billed cost the provider is paying the lab for the gold. Doctors, please make sure that all members fully understand what their fees will be and what the savings are from your normal full fees before treatment begins.


30% Discount From Plan Providers Normal Full Fee

Average You Pay AverageCode Description Regular Cost Only SavingsOral Surgery Services (extractions) D7111 Extraction, Coronal Remnants - Deciduous Tooth $156 $51 67%D7140 Extraction, Erupted Tooth Or Exposed Root (Elevation And/or Forceps Removal) $206 $51 75%D7210 Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of

Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated$322 $88 73%

D7220 Removal Of Impacted Tooth - Soft Tissue $362 $97 73%D7230 Removal Of Impacted Tooth - Partially Bony $457 $178 61%D7240 Removal Of Impacted Tooth - Completely Bony $557 $223 60%D7241 Removal Of Impacted Tooth - Completely Bony, With Unusual Surgical Complications $662 $259 61%D7250 Surgical Removal Of Residual Tooth Roots (Cutting Procedure) $350 $128 63%D7270 Tooth Reimplantation And/Or Stabilization Of Accidentally Evulsed Or Displaced Tooth $639 $255 60%D7272 Tooth Transplantation (Includes Reimplantation From One Site To Another And

Splinting And/Or Stabilization)$889 $468 47%

D7280 Surgical Access Of An Unerupted Tooth $555 $242 56%D7285 Incisional Biopsy Of Oral Tissue - Hard (Bone, Tooth) $516 $225 56%D7286 Incisional Biopsy Of Oral Tissue - Soft $379 $165 56%D7310 Alveoloplasty In Conjunction With Extractions – Four Or More Teeth Or Tooth Spaces,

Per Quadrant$343 $131 62%

D7320 Alveoloplasty Not In Conjunction With Extractions –Four Or More Teeth Or Tooth Spaces, Per Quadrant

$515 $190 63%

D7450 Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm $710 $256 64%D7451 Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25

Cm$972 $360 63%

D7460 Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm $666 $240 64%D7461 Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Greater Than

1.25 Cm$1,050 $389 63%

D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue $276 $107 61%D7910 Suture Of Recent Small Wounds Up To 5 Cm $346 $0 100%D7911 Complicated Suture - Up To 5 Cm $583 $292 50%D7912 Complicated Suture - Greater Than 5 Cm $918 $459 50%D7960 Frenulectomy – Also Known As Frenectomy Or Frenulectomy – Separate Procedure Not

Incidental To Another Procedure$517 $133 74%

D7970 Excision Of Hyperplastic Tissue - Per Arch $593 $211 64%D7971 Excision Of Pericoronal Gingiva $308 $165 46%

Orthodontic Services (braces for children and adults) D8660 Pre-Orthodontic Treatment Examination To Monitor Growth And Development $595 $0 100%D8670 Periodic Orthodontic Treatment Visit (child) $371 $155 58%D8670 Periodic Orthodontic Treatment Visit (adult) $371 $155 58%D8680 Orthodontic Retention $728 $382 48%D8693 Recement Or Rebond Fixed Retainer $398 $204 49%D8999 Orthodontic Treatment Plan And Records $360 $211 41%D0330 Panoramic Radiographic Image $128 $54 58%Other Orthodontic Procedure Guidelines1. Services not listed will be discounted 30% off of the participating providers normal full fee. 2. Invisalign procedures and treatment are to be discounted 20% off of the participating providers normal full fee.

Miscellaneous Services D9110 Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure $147 $51 65%D9210 Local Anesthesia Not In Conjunction with Operative Or Surgical Procedures $83 $42 50%D9230 Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia $89 $25 72%D9241 Intravenous Moderate (conscious) Sedation/Analgesia - First 30 Minutes $467 $250 46%D9242 Intravenous Moderate (conscious) Sedation/Analgesia - Each Additional 15 Minutes $189 $100 47%D9310 Consultation - Diagnostic Service Provided By Dentist Or Physician Other Than

Requesting Dentist Or Physician$156 $0 100%

D9430 Office Visit For Observation (During Regularly Scheduled Hours) - No Other Services Performed

$89 $39 56%

D9440 Office Visit - After Regularly Scheduled Hours $210 $90 57%D9910 Application Of Desensitizing Medicament $75 $6 92%D9911 Application Of Desensitizing Resin For Cervical And/Or Root Surface, Per Tooth $89 $37 58%D9941 Fabrication Of Athletic Mouth guard $320 $108 66%D9950 Occlusion Analysis - Mounted Case $416 $187 55%D9951 Occlusal Adjustment - Limited $211 $77 64%D9952 Occlusal Adjustment - Complete $797 $296 63%D9970 Enamel Microabrasion $237 $92 61%D9972 External Bleaching-Per Arch - Performed In Office $359 $180 50%D9973 External Bleaching-Per Tooth $250 $125 50%D9974 Internal Bleaching-Per Tooth $311 $156 50%


Average You Pay AverageCode Description Regular Cost Only SavingsMiscellaneous Services (Continued)D9975 External Bleaching For Home Application, Per Arch; Includes Materials And Fabrication $350 $175 50%D9986 Missed Appointment (without 24 hour notice) $74 $41 44%D9987 Cancelled Appointment (without 24 hour notice) $63 $35 44%

General Plan Limitations and Exclusions1. All procedures listed above do not include any specific lab fees or precious metal costs that are required. Members must agree in writing to all upgraded materials used before treatment begins and what the savings are off of your participating providers normal full fee. See each section for specific details.2. Members are responsible for paying all amounts due to plan providers at the time services are rendered unless mutually agreed upon by all parties.3. The above fees are for General Dentist use only. Plan specialist lists are available by calling 1(800) 807-0706 or emailing [email protected]. All contracted plan specialists offer members up to a 25% discount off of their normal full fees depending on the provider and location.4. Any procedure not listed will be discounted 30% off of the participating providers normal full fee.5. Medical costs associated with any dental procedure are not covered on this plan.6. Dentures or appliances will be replaced only after 3 years have elapsed since such dentures or appliances were provided under this program, unless the denture or appliance becomes unserviceable due to illness. 7. Any dental treatment started prior to members eligibility to receive services under this plan or started after a members termination are not covered.8. Failure to follow the prescribed treatment or accidents occurring during the course of treatment may result in additional charges by your plan provider.9. Failure to pay scheduled fees at the time services are rendered may prevent future dental services from being received until all past fees have been paid in full.10. Services provided by non-participating providers are not covered on this plan.11. Services which, in the opinion your plan provider, are not necessary for the members dental health, or are contrary to established dental ethics are not covered. 12. Cosmetic dental procedures are covered only if the attending dentist and member agree on the procedure and cost.13. Services that are compensable under workmen's compensation or employer liability laws are not covered.14. Myofunctional therapy procedures for training, treating, or developing muscles in and around the jaw or mouth including TMJ are not covered except by plan participating specialists (where available).15. Any dental procedures or services that cannot be performed in the dental office due to the physical limitations of the member are not covered.16. Any services that a participating General Dentist recommends be performed by a specialist are covered only if members sees a participating specialist.17. The liability of Beta Health Association, Inc. is limited to the return of the members membership fees paid for one year by the member.18. Members enrolled in this Beta Health Association, Inc. dental plan agree that neither it or it's employees are liable for dentistry or services provided by any contracted or non-contracted plan providers.19. Members understand that plan providers are independent contractors and are not employed by Beta Health Association, Inc.20. Extractions for asymptomatic third molars (wisdom teeth) are not covered unless they are causing movement of the teeth. 21. This dental program is in no way to be considered insurance. It is a discount fee-for-service dental plan.22. Fees are subject to change on an as needed basis. Please contact Beta Health at 1-(800) 807-0706 for current fees.


ThreeEasyWays

TofindanAlphaDentalPlanProvider(ADP)

1. Please use the Provider Directory given to you with your enrollmentmaterials.YoumustselectaproviderwhenenrollingontheAlphaPlan.Onthedirectoryincolumnnumber3(Provider#)thisiswhereyouwillselect your dental provider. Find the ADP number and then put thatnumber on the enrollment form next to where it states Alpha DentalPlan.

2. Gotowww.betadental.com/alpha19/andenterthezipcodeofwhereyouwishtoseeaparticipatingAlphaDentalPlanprovider.

3. Callourofficeat(303)744‐3007or1(800)807‐0706forassistance.Weareheretohelp!

Important:

AllservicesreceivedwhileyouareenrolledintheAlphaDentalPlanMUSTbeprovidedbyaparticipatingAlphaDentalPlanprovideror

dentaloffice.ThereareNOOutofNetworkbenefitsontheAlphaDentalPlan.Youcanchangeprovidersatanytime,bycontactingouroffice.Pleasenoteallfamilymembersmustseethesameproviderfor

treatment

Dental Option #2

The Companion Life

Dental Plan

The Companion Life

Dental Plan

Plan Highlights:

* See any Dentist you wish * $100 lifetime deductible applies per person..…most are calendar year - Deductible is combined between both basic and major services * Orthodontic Services (braces) not covered

* Two Cleanings per person per year covered at 100% after deductible

* Pre-existing condition exclusions apply

* $1,700 calendar year maximum benefit for each family member

* Fillings covered at 100% after deductible

* Major services covered at 50% after deductible * Payments are made to dentists by predetermined Usual, Reasonable, and

Customary (UCR) fees

* Excellent claims service The above highlights are only considered a sample of the coverage’s provided.

Please reference the attached Companion Life Schedule of Benefits and the Certificate of Coverage for more complete benefit information.

A Dental Plan For Groups of Three or More

Covered Services Description SELECT ANY DENTIST Preventive, Basic, and Major services are subject to a combined lifetime deductible of $100 per covered person. The Companion Life Dental Plan must be offered with one of the Beta Health Association, Inc. Network Dental Plans as an option for all eligible employees. A minimum of three employees must enroll in the Companion Life Dental Plan to start coverage. 30% of all eligible employees must be enrolled between all plans. Preventive Services Plan B (without ortho)

No waiting periods before benefits begin Routine exams, cleanings (once every 6 months) Fluoride treatments for dependent children under age 19 (once every 12 months) Bitewing x-rays (once every 12 months) Emergency exams for dental pain (minor procedures)

Basic Services No waiting periods before benefits begin Periapical x-rays Full mouth or panorex x-rays (once every 36 months) Simple restorative procedures (fillings) Simple extractions Palliative treatment for dental pain and local anesthesia

Major Services 12 month waiting period before benefits begin (unless takeover applies) Replacement of prosthodontics, dentures, crowns, and inlays Endodontic procedures (Root canals) Periodontic procedures (Gum disease) Major restorative procedures (crowns and inlays) Dental implants (adult only) Prosthetic procedures (bridges and dentures) Space maintainers Oral surgery procedures (non-simple extractions) Denture relines General anesthesia (for services dentally necessary)

Plan Maximum Benefit Per covered person per calendar year Combined between Preventive, Basic, and Major Services only

Orthodontic Services 12 month waiting period before benefits begin (unless takeover applies) No deductible applies to Orthodontic procedures $1,000 lifetime maximum benefit per covered dependent For children only to age 19

Takeover Benefits (if prior plan is being replaced with like benefits) Takeover means that credit is given for waiting periods for like coverages only which were accumulated under an existing dental plan at the initial open enrollment only. No credit is given for deductibles satisfied under your existing plan. 1. For an employer group to be eligible for Takeover Benefits, at least five employees must enroll in the Companion Life plan at the initial open enrollment. 2 In order to provide Takeover Benefits, your employers current dental plan must have been in effect continuously for at least 12 months. 3. All employees covered on the effective date with continuous coverage from the prior group plan are eligible for Takeover Benefits. Waiting periods will be

reduced by the amount of time covered under the prior plan. 4. Takeover Benefits must be requested when the group is submitted for coverage and are subject to the approval of Companion Life. Benefit payments are based upon the allowable charges in the area in which the service is provided. Any Dentist charges above this allowable fee are not an eligible expense. A monthly billing fee of $1 per covered employee per month (not to exceed $10 per month) will also apply. Note: This a general outline of covered services and does not include all the covered services , limitations and exclusions of the policy. See your certificate for specific

details.

100%

100%

50%

Not Available

$1,700

Limitations and Exclusions Covered expenses will not include and no benefits will be payable for : 1. For any treatment which is for cosmetic purposes or to correct congenital malformations, except for medically necessary care and treatment of congenial cleft

lip and palate. 2. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these items, unless

required because of an accidental bodily injury sustained while the Insured is covered. Replacement is not covered if the item can be repaired. 3. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of natural teeth during the same

period of continuous coverage. But the extraction of a third molar (wisdom tooth) will not qualify the item for payment. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. Coverage does not include the part of the cost that applies specifically to replacement of teeth extracted prior to the period of coverage.

4. For the addition of teeth to an existing prosthetic appliance or fixed bridge unless for replacement of natural teeth extracted during the same period of continuous coverage.

5. For any expense incurred or procedure started prior to the Insured’s current period of continuous coverage. 6. For any expense incurred or procedure started after the Insured’s insurance under this section terminates, except for a prosthetic appliance, fixed bridge,

crown, or inlay or onlay restoration for which both (a) the procedure begins before insurance ends and (b) the item’s final placement is within 90 days after insurance terminates.

7. To duplicate appliances or replace lost or stolen appliances. 8. For appliances, restorations or procedures to:

a. alter vertical dimension; b. restore or maintain occlusion; c. splint or replace tooth structure lost as a result of abrasion or attrition; or d. treat jaw fractures or disturbances of the temporomanbibular joint.

9. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. 10. For broken appointments or the completion of claim forms. 11. For orthodontia service or for any services associated with orthodontic therapy when this optional coverage is not elected and the additional premium is not

paid. 12. For sealants which are:

a. not applied to a permanent molar; b. applied before age 6 or after attaining age 16; or c. reapplied to a molar within three years from the date of a previous sealant application.

13. For sub gingival curettage or root planning (procedure numbers 4220 and 4321) unless both x-rays and depth summaries of each tooth confirm the presence of periodontal disease involved.

14. Because of an Insured’s injury arising out of, or in the course of, work for wage or profit. 15. For an Insured’s sickness, injury or condition for which he or she is eligible for benefits under any Worker’s Compensation Act or similar laws. 16. For charges for which the Insured is not liable or which would not have been made had no insurance been in force. 17. For service which are not recommended by a dentist, not required for necessary care and treatment, or do not have a reasonably favorable prognosis. 18. Because of war or any act of war, declared or not, or while on full-time active duty in the armed forces of any country. 19. To an Insured if payment is not legal where the Insured is living when expenses are incurred. 20. For any services related to: equilibration, bite registration or bite analysis. 21. For crowns for the purpose of periodontal splinting. 22. For charges for: over dentures, and associated precision or semi-precision attachments and any related Endodontic treatment associated with it; or other

customized attachments. 23. For charges for myofunctional therapy, orthognathic surgery or athletic mouth guards. 24. For procedures for which benefits are payable under the employer’s medical expense benefit plan for employees and their dependents. 25. Services or supplies provided by a family member or a member of the Insured’s household.

090108

Predetermination of Benefits: As a service to protect the Insured, Companion Life will provide predetermination of benefits for recommended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps insured’s better understand their coverage. The Insured or Insured’s Dentist should submit the treatment plan to Companion Life for review and predetermination of benefits before the service begins.

Designed and Marketed By Beta Health Association, Inc. 9725 East Hampden Avenue, #400, Denver, CO, 80231

303-744-3007 or 1-800-807-0706

Underwritten and Administered by Companion Life Insurance P.O. Box 100102, Columbia, SC, 29202-3102

1-800-753-0404, Fax 803-735-0736

ThreeEasyWaystofindInNetworkproviders

fortheCompanionLifePPOdentalplan

1. Gotowww.dentemax.comandclickonthe“findadentist”tabatthetopofthehomepage,enteryourzipcodeandhitthesearchlink.

2. Callyourdentalproviderandaskiftheyare“Contracted”asaninnetwork providerwith the DenteMax national network. This isthenameofthenetworkthatCompanionLifecontractswith. BespecificwhenaskingthedentalofficebecauseALLdentalofficeswill accept Companion Life. By utilizing theDenteMax networkyouwillgetthebestbenefitfromyourplan

3. Ifyouseeaproviderthatisnotinnetwork,thenCompanionLifewill pay based upon what 90% of the dentists in that zip codewouldconsidertheirnormalfullfee.Ifyourdentistchargesmorethanthat,thenyouwillhavetopaythedifference.

Dental Option #3

The Self-funded

Dental Plan

The Self-funded Dental Plan

Plan Highlights:

* See any Dentist you wish * No deductible applies on covered services * Orthodontic (braces) not covered

* One Cleaning per person per year covered at 100% Second Cleaning covered at 50%

* Pre-existing condition exclusions apply

* $1,000 calendar year maximum benefit (combined between all family members)

* Fillings and major services covered at 50% * Payments are made to dentists by predetermined Usual, Reasonable,

and Customary (UCR) fees

* Employee must pay dentist first and then submit claim for payment from Weld County

The above highlights are only considered a sample of the coverage’s provided. Please reference the attached information for specific benefit details.

1

TABLE OF CONTENTS

Claim Payments Made in Error 10 Definitions 3 Dental Definitions 3 General Definitions 3 Participation Definitions 5 Provider Definitions 5 Dental Expense Benefit 6 Class I Services 7 Class II Services 7 Dental Limitations 8 Facility of Payment 11 Legal Actions 10 Payments 10 Process in Case of Disputed Claim 11 Proof of Loss/Timely Submission of Claims 11 Recovery and Subrogation 10 Release of Information 10 Summary of Dental Benefits 2 To File a Claim 9

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SUMMARY OF DENTAL BENEFITS FOR ACTIVE EMPLOYEES AND DEPENDENTS WELD COUNTY

Maximum Benefits

Annual $1000 per Covered Person and/or Family per Calendar Year.

Deductible Not Applicable.

Benefit Coverage Levels

Class I Preventative 100% of Covered Expenses Incurred. Class II Restorative/Endodontic/ 50% of Covered Expenses Incurred. Prothodontic

Reimbursement under this plan will be made only after the covered person has paid the bill in full*. *Dental Installment Agreement:

When making payments on dental bills, a covered person may sign a dental installment agreement with Weld County which allows receipts for payments to be submitted for reimbursement. The reimbursement on the installment plan will be honored for one year from the date of service. Maximum reimbursement will be based on the benefit limits in the year service is performed. Reimbursement will be applied to limits in the year of payment, up to the expiration of this agreement, or expiration of insurance coverage, whichever occurs first.

DENTAL ASSISTANCE PROGRAM

Weld County agrees to provide for employees during continuance of this program, the benefits hereinafter described, in the event any/or their eligible dependent(s) incur dental expenses covered by this program. The program is subject to all the terms, provisions and conditions recited on the following pages. Weld County has caused this program to take effect as of 12:01 a.m., Mountain Time, on January 1, 1991, at Greeley, Colorado.

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DEFINITIONS

Terms as used herein shall be deemed to define terms that may be used in the wording of the Plan Document. These definitions shall not be construed to provide coverage under any benefit unless specifically provided. GENERAL DEFINITIONS

Age Discrimination – Subject to any changes in the Social Security Act, all covered persons age 65 and over are entitled to the same and/or equal benefits that they had prior to age 65. Amendment – is a formal document changing the provisions of the program and approved by the Board of County Commissioners. Amendments apply to all covered persons, including those persons who are covered before the amendment becomes effective, unless otherwise specified. Calendar Year – is the twelve (12) month period beginning on each January 1st and ending on the following December 31st. Common-Law Marriages – In order for an employee of Weld County to be eligible for dependent vision care coverage, the common-law marriage must be recognized by the state in which the employee resides. Contract Administrator – shall mean the person or firm employed by the county who is responsible for the processing of claims and payment of benefits, administration, accounts, reporting and other services contracted by Weld County. Employer – shall refer to Weld County. Medicare – Title XVIII (Health Insurance for the Aged) of the United States Social Security as amended. Program – shall refer to the benefits and provisions as described herein for payment. Program Administrator – Weld County Subrogation – The transfer of one’s liabilities for another’s; in this case the temporary assumption of the claimant’s liabilities by the program prior to repayment by the party of primary liability. This program contains a subrogation clause and the claimant is obligated to obtain any monies available from third parties to reduce the program’s claim losses.

DENTAL DEFINITIONS

Covered Expense – includes only those usual, customary, and reasonable charges made for services and supplies which most physicians would consider to be necessary for treatment of an injury or illness. Dentally Necessary – any service or supply for treatment or diagnosis of dental disease or injury which is ordered by the attending dentist and consistent with the injury or disease of the covered person. Diagnostic Charges – means the actual cost charged for x-ray or laboratory examinations of the covered person or his/her dependent which are made or recommended by a dentist for diagnostic purposes. Expense Incurred – means only the fees and prices regularly and customarily charged for the dental services and supplies generally furnished for cases of comparable nature and severity in the particular geographical

4

area concerned. Any agreement as to fees or charges made between the individual and the physician shall not bind Weld County Government in determining its liability with respect to expense incurred. Expense incurred is deemed to be incurred on the date on which the service or supply is rendered or except that such charge will be deemed incurred:

• With respect to fixed bridgework, crowns, inlays, onlays, or gold restorations, on the first date of preparation of the tooth or teeth involved.

• With respect to full or partial dentures, on the date the impression was taken, and

• With respect to endodontics, on the date the tooth was opened for root canal therapy.

Weld County Prevailing Charge Study – this study shall be the basis for claim reimbursement at “usual, customary and reasonable” levels. Illness – shall mean bodily sickness or disease, psychiatric disorders, and in the case of a new born child, congenital abnormalities that is medically diagnosed and treated by a dentist. Period of Disability – for a covered employee as it applies to an individual, means all periods of disability arising from the same cause, including any and all complications therefrom except that if the individual completely recovers or returns to active employment, any subsequent period of disability from the same cause shall be considered a new disability. For a covered dependent, the term “Period of Disability”, means all periods of disability arising from the same cause including any and all complications therefrom, except that if the dependent recovers for a period of three months and throughout such period is capable of resuming the normal activities of a person in good health and of the same age and sex, any subsequent period of disability from the same cause shall be considered a new period of disability. Total Disability – shall mean that the covered employee is prevented, solely because of a non-occupational injury of non-occupational disease, from engaging in the employee’s regular or customary occupation and is performing no work of any kind for compensation or profit, or if a covered dependent is prevented, solely because of a non-occupational injury or non-occupational disease, from engaging in ALL of the normal activities of a person of like age and sex in good health. Usual, Customary and Reasonable – A. The Usual charge is the most consistent charge by a Physician or provider of service to patients for a

given service.

B. The charge is Customary when it meets the customary criterion as determined by Weld County Government; or

C. It may be Reasonable if, upon review, it merits special consideration based on the nature and extent of

treatment of the particular case.

NOTE: The 90th percentile of the Weld County Prevailing Charge Study will be used as a basis for usual, customary and reasonable as it refers to the actual amount of fees charged.

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PROVIDER DEFINITIONS

Hospital – means only an institution constituted and operated pursuant to law, engaged in providing on an out-patient basis at the patient’s expense, diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment and care of injured and sick individuals, by or under the supervision of a licensed physician.

Physician – is a person acting within the scope of his/her license and holding the degree of Doctor of Dental Surgery (D.D.S.), or Doctor of Medical Dentistry (D.M.D.), who is legally entitled to practice dentistry in all its branches under the laws of Colorado, or under the laws of the State of jurisdiction where the services are rendered. For the purposes of this policy, the term Physician shall also include a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) who is licensed to perform the particular dental service rendered.

PARTICIPATION DEFINITIONS

Active Service – An employee will be considered in active service with the employer on a day which is one of the employer’s scheduled work days if the employee is performing in the customary manner all of the regular employment duties with the employer on that day, either at one of the employer’s business establishments or at some location to which the employer’s business requires travel. An employee will be considered in active service on a day which is not one of the employer’s scheduled work days only if the employee was performing in the customary manner all of the regular employment duties on the preceding scheduled work day.

A dependent will be considered in active service on any day if the dependent is then engaging in all the normal activities of a person in good health of the same age and sex, and is not confined in a medical facility (This does not apply to a newborn).

Contribution – shall mean the amount payable by the employer or the amount payable by the employer/employee jointly for participation in the benefits of the plan.

Covered Dependents – shall be those who are eligible as provided under the county health plan and enrolled by a covered employee. Covered dependents shall be the spouse of the covered employee; and children, provided such children are unmarried, and dependent upon the covered employee for support and maintenance. The term “children” shall include natural children, adopted children, foster children and step children who depend upon the employee for support and maintenance. No employee will be considered as both a dependent and as an employee. If an employee and spouse are both eligible employees, either may have dependent coverage for eligible children, but not both. Covered Employee – is a regular employee of Weld County who is working at least 20 hours per week consistently and has been enrolled in the program. A covered employee must be enrolled in the Weld County health insurance program to participate in the dental program. Covered Person – is a covered employee or covered dependent enrolled in the program. Eligibility and Effective Dates – A covered person shall become effective as follows: a. Covered employees shall become effective on the first of the month following the first full month’s

pay period.

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b. Dependents shall be covered simultaneously with employees covering them as dependents, provided they are not confined in a hospital on the effective date. Coverage for newborn children will begin from birth. However, they need to be formally enrolled and appropriate coverage arranged within thirty-one (31) days from birth for coverage to be effective thereafter.

c. An open-enrollment period will be scheduled each year.

d. In addition, such a covered person will not be effective unless on the date of eligibility, the person is

in active service as described herein, otherwise his/her effective date will be deferred until return to active service.

Termination of Coverage – A covered person’s coverage shall automatically terminate on the earliest of the following dates: a. The date the employee ceases to be a member of the classes of persons eligible for employee

coverage. b. The date the employee enters into full-time military or similar service of any country or subdivision

thereof, except an employee who is a member of a military reserve unit shall not be considered on full-time military duty.

c. The date of termination of the plan.

d. The end of the month when contributions cease.

Pre-existing Condition – New employees or covered persons becoming eligible on or after January 1, 1991, will not be entitled to covered dental expenses that are incurred as the result of an injury or illness for which the covered person has consulted with a dentist or received any dental care or services within the three month period immediately preceding the effective date of coverage, unless incurred after the expiration of a period of ninety (90) days of continuous coverage under the program. Leave of Absence Without Pay Properly enrolled employees of the employer may continue, at their expense, health coverage for themselves and/or their dependents while on an approved Leave of Absence for the period indicated by the employer’s personnel policy. The employee must pay the county portion along with their portion of the premium by the 1st day of each month while on the Leave of Absence.

DENTAL EXPENSE BENEFIT

ACTIVE EMPLOYEES AND COVERED DEPENDENTS

If a covered person incurs eligible dental expenses, the program will pay benefits at the co-payment rate as specified in the Summary of Benefits for such expense which is not covered by any other dental coverage, up to the Maximum Annual Benefit as specified in the Summary of Benefits.

7

Any available automobile insurance coverage will have primary (first) payment responsibility for all expense otherwise covered by this plan. Maximum Annual Benefits The Maximum Benefit as shown in the Summary of Benefits is the maximum amount of benefits available for any covered family during a calendar year, whether or not there has been an interruption in coverage. Conversion Privilege There is no conversion benefit for dental coverage. Covered Dental Expense Covered Dental Expenses shall mean the following dentally necessary charges by a physician for the prevention of dental disease, treating injured or diseased teeth, and the treatment of supporting bone or tissue, not to exceed the maximum specified in the Summary of Benefits: Class I Services:

a. Initial and periodic oral examinations – one (1) calendar year separated by at least five (5) months;

b. Prophylaxis – one (1) per calendar year separated by at least five (5) months;

c. Topical application of fluorides, including prophylaxis – one (1) per calendar year separated

by at least five (5) months;

d. Bitewings, as part of a routine exam – one (1) set per calendar year separated by at least five (5) months;

e. Single films, as part of a routine exam – thirteen (13) minimum;

f. Entire denture series, as part of a routine exam – fourteen (14) or more films (no more than

one (1) series in a twenty-four (24) consecutive month period);

g. Full-mouth x-ray as part of a routine exam;

h. Consultation with another dentist;

Class II Services a. Dental x-rays to diagnose a symptom;

b. Space maintainers

c. Diagnostic tests or laboratory exams excluding any services for orthodontic procedures;

d. Microscopic examination;

8

e. Biopsy and examination of oral tissue;

f. Emergency or palliative services;

g. Extractions, other oral surgery and related general anesthesia not covered by the health plan;

h. Periodontics;

i. Endodontics;

j. Injectable antibiotic drugs when administered by the attending dentist;

k. Crowns, inlays and onlays;

l. Repair of crowns, inlays, onlays, bridgework or dentures;

m. Relining or rebasing dentures;

n. Prosthodontics

o. Restoration – Amalgam, silicate cement, plastic and composite.

DENTAL LIMITATIONS

The Plan does not cover:

a. Dental care not included in the list of defined eligible expense; or

b. Anything not furnished by a physician, except x-rays ordered by a physician, and services by a licensed dental hygienist or dental technician under the physician’s supervision; nor anything not necessary or not customarily provided for dental care; or

c. Services 1) furnished by or for the U.S. Government, or 2) furnished by or for any other government

unless payment is legally required, or 3) to the extent provided under any governmental program or law under which the individual is, or could be, covered; or

d. An appliance, or modification of one, where an impression was made before the patient was

covered; a crown, bridge or gold restoration for which the tooth was prepared before the patient was covered; root canal therapy if the pulp chamber was opened before the patient was covered; or

e. Services due to an injury arising from or in the course of any employment other than Weld County,

or benefits provided under a Worker’s Compensation Act or similar law; or

f. Replacement of lost or stolen appliances; or

g. Appliances or restorations for the purpose of splinting, or to increase vertical dimension or occlusion; or

h. Any portion of a charge for service in excess of the usual, customary, and reasonable charge as

determined by Weld County; or

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i. Charges for services which are not the generally accepted dental practice or service for the condition

being treated; or

j. Services and supplies provided by any person who ordinarily resides in the covered person’s household or who is related to the covered person, such as a spouse, parent, child, brother, or sister, whether such relationship exists by blood or in law; or

k. Charges a covered person would not be required to pay if there were no plan benefits; or

l. Charges for broker appointments or completion of claim forms; or

m. Charges for oral hygiene instructions or dietary planning for the control of dental decay; or

n. Charges for hospitalization due to dental treatment (see the medical plan for additional details); or

o. Expenses for services which were not recommended or prescribed by a physician; or

p. Charges for dental treatment which is experimental in nature or which is not yet approved by the

Council on Dental Therapeutics of the American Dental Association; or

q. Implants and/or transplants of teeth; or

r. Surgical repositioning of jaw; or

s. Any expenses incurred as a result of an act of war, whether declared or undeclared; or

t. Any expense that is covered by another dental plan; or

u. Any expense that is covered under the health insurance that the employee has with Weld County; or

v. Any expense for treatment of orthodontia and related problems; or

w. Any expense for initial installation of bridgework or dentures replacing natural teeth extracted prior to coverage under the program; or

x. Expenses for prosthetic devices and the fitting thereof which were ordered while covered under the

program but installed or delivered after termination of coverage; or

y. Any expenses for duplicate appliances or prosthetic devices.

TO FILE A CLAIM

Claim forms can be obtained from Personnel Services. The Employee Statement on the top of the claim form must be completed IN FULL and signed by the employee. After a covered person receives treatment by a dentist as defined herein and pays the bill in full, itemized bills and copy of the paid receipt should be attached to the claim form. The Attending Dentist Statement form should be completed by the appropriate dentist unless all necessary information is included on the dentist’s own form. The completed claim form, the attached bills and the paid receipt should be sent or delivered in a sealed envelope to:

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Weld County Accounting Department 915 10th Street P O Box 758

Greeley, Colorado 80632 Claim forms are available for plan participants from Personnel Services of Weld County or at the employee’s department.

RELEASE OF INFORMATION

For the purposes of determining the applicability of and implementing the terms of the provision of this program or any similar provision of another plan, Weld County may, without consent of or notice to any individual, release to or obtain from any other insurance company or other organization or individual any information, concerning any individual, which Weld County considers to be necessary for those purposes. Any individual claiming benefits under this program will furnish to Weld County the information that may be necessary to implement the above provisions.

PAYMENTS Whenever payments which should have been under this Program in accordance with the provision of this program have been made under any other plans, the program administrator will have the right, exercisable alone and in its sole discretion to pay to any organization making those payments any amounts it determines to be warranted in order to satisfy the intent of the Coordination of Benefits provision. Amounts paid in this manner will be considered to be benefits paid under this program; and to the extent of these payments, the employer will be fully discharged from liability under this program.

CLAIM PAYMENTS MADE IN ERROR

If payment in excess of the correct amount due is made, the program may recover all excess amounts paid. Recovery will be made by reducing or suspending future program payments, or by requiring the covered person to pay back the overpayment in full, or in installments, until the overpayment is recovered.

RECOVERY AND SUBROGATION

Whenever payments have been made by Weld County in excess of the maximum amount of payment necessary to satisfy the intent of the Coordination of Benefit provisions, Weld County will have the right to recover excess payment from any individuals, insurance companies or other organizations. In the event of payment in part or in full by this program of any expense incurred for hospital, surgical, medical, or dental services, and medical supplies for the benefit of a covered person or a covered dependent, this program shall be subrogated to the extent of the amount of such payment to all the rights, powers, privileges and remedies of the covered person or the covered dependent against any person, firm, corporation, organization, plan or other entity regarding the payment of such expense incurred.

LEGAL ACTIONS

No action at law or in equity shall be brought to recover on the program prior to the expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of the program. No such action shall be brought after the expiration of three (3) years after the time written proof of loss is required to be furnished.

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PROOF OF LOSS/TIMELY SUBMISSION OF CLAIMS

Written proof of loss must be furnished to Weld County, in case of claim for loss for which the policy provides any payment, within ninety (90) days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate or reduce any claim it is was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible; and in no event, except in the absence of legal capacity of the claimant, later than one (1) year from the time proof is otherwise required. Under no circumstances will a claim be honored for payment beyond ninety (90) days following the date coverage terminates.

FACILITY OF PAYMENT

If, in the opinion of Weld County, a valid release cannot be rendered for the payment of any benefit payable under this program, Weld County may, at its option, make such payment to the individual or individuals as have, in their opinion, assumed the care and principal support of the covered person and are, therefore, equitably entitled thereto. In the event of the death of the covered person prior to such time as all benefit payments due him/her have been made, Weld County may, at its sole discretion and option, honor benefit assignments, if any, made prior to the death of such covered person. Any payment made by the program in accordance with the above provision shall fully discharge the program to the extent of such payment.

PROCESS IN CASE OF DISPUTED CLAIM

If a covered employee has reason to believe a claim has not been settled properly, or a claim has been improperly denied, the following process applies: Request a review in writing from Personnel Services of Weld County within 60 days of receipt of a denied claim, stating in clear and concise terms the reason for disagreement with the handling of the claim. Upon receipt of the request, the file will be reviewed by the Personnel Director and the consultant servicing the account. Results of the review will be furnished to the covered employee, along with copies of pertinent program documents upon which this declination is based. The decision of the consultant is final. If the covered employee still finds the claim is improperly denied per the program documents, he/she has a legal right to take whatever appropriate action he/she believers is necessary.

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