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SCHEDULE OF BENEFITS (CONTINUED) • Plan 1 - All Active Full -time Employees located in a PPO service area BENEFITS FOR CLASS 1 Eligible Class: All Full -Time Employees located in a PPO service area Contributions: Covered Employees are not required to contribute to the cost for Employee Dental Coverage. Covered Employees are required to contribute to the cost for Dependent Dental Coverage. Benefit Waiting Period: Type II Procedures: None Type III Procedures: 6 Months The Benefit Waiting Period(s) shown above for Type III Procedures will not apply to Covered Persons who become covered on the Policy Effective Date; but only if they were covered under the Group Policyholder's prior group dental plan on the day before the Policy Effective Date. Terms of the Prior Carrier Credit Provision apply for persons enrolled on the issue date of the Policy: Yes Late Entrant Limitation (when applicable): Type II Procedures: 12 Months Type III Procedures: 12 Months DENTAL BENEFITS PPO PLAN PPO PLAN In- Network Out -of- Network Services Services OALENDAR YEAR DEDUCTIBLE for these Procedure Types (combined) Types II & III Types II & III INDIVIDUAL $50 $50 FAMILY $150 $150 PERCENT PAYABLE Type I - Diagnostic & Preventive Services 100% 100% Type II - Basic Services 85% 75% Type III - Major Services 55% 45% CALENDAR YEAR MAXIMUM $2,000 $2,000 for these Procedure Types (combined) Types I, II & III Types I, II & III Under the CLAIMS PROCEDURES provision, the paragraph captioned "TO WHOM PAYABLE" is amended to read as follows. TO WHOM PAYABLE. Dental Expense Benefits generally will be paid to the Covered Employee; unless the Covered Employee has assigned such benefits to the Dentist, or an overpayment has been made. However, if services are provided by a Participating Dentist, benefits are automatically assigned to that Dentist, unless the bill has been paid. • GL11 -3 -SB 3 -2 09/01/01