80% 75% 50%** N/A N/A. No Wait No Wait No Wait

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1 Schedule of Benefits Group Name: California State University Fresno, Association Benefit Plan Name: Custom PPO Plan 18/124 PCN **** PPO **** NON-NETWORK Class I / Preventive 100% 100% 100%** Class II / Basic 100% 90% 80%** Class III / Major Benefit Year Deductible Waived for Preventive? Family Deductible Benefit Year Max 80% 75% 50%** $0 $0 $50 N/A N/A Yes N/A N/A 3 per Family $1,500 $1,500 $1,500 Class IV / Orthodontia Ortho Coverage Ortho Lifetime Max 50% Child (<19 ) Only $500 50% Child (<19 ) Only $500 50% Child (<19 ) Only $500 TMJ Rider TMJ Lifetime Max No N/A No N/A No N/A Wait Period for Major -Existing Employees -New Hire Wait Period for Ortho -Existing Employees -New Hire Covered charges are UCR based on the usual charge of the majority of Dentists in the same geographic area. ** **** Premier Access does not guarantee all services can be rendered by a contracted PCN or PPO provider. You may be subject to a deductible and co insurance for an out of network Specialist. Page 1 of 2

2 Schedule of Benefits Group Name: California State University Fresno, Association Benefit Plan Name: Custom PPO Plan 18/124 PCN PPO NON-NETWORK Class I / Preventive Oral Exams, Full Mouth X-Rays/Pano, Bitewings, Other X-Rays, Prophylaxis, Fluoride Oral Exams, Full Mouth X-Rays/Pano, Bitewings, Other X-Rays, Prophylaxis, Fluoride Oral Exams, Full Mouth X-Rays/Pano, Bitewings, Other X-Rays, Prophylaxis, Fluoride Class II / Basic Sealants, Space Maintainers, Restorations, Emergency(Palliative), Endodontics, Periodontics, Oral Surgery Sealants, Space Maintainers, Restorations, Emergency(Palliative), Endodontics, Periodontics, Oral Surgery Sealants, Space Maintainers, Restorations, Emergency(Palliative), Endodontics, Periodontics, Oral Surgery Inlays, Crowns, Bridges, Dentures Inlays, Crowns, Bridges, Dentures Inlays, Crowns, Bridges, Dentures Class III / Major How It Works The Dental Program offered is administrated by Premier Access Insurance Company, a national carrier and widely accepted dental plan. What is important to know about your dental plan is that you may see any dentist. Although, there are PCN (Premier Choice Network) and PPO provider lists available, and the benefits are enhanced if you elect to use either network, you may elect to see the dentist of your choice without penalty. Using the PCN or PPO providers, you maximize your benefits and reduce your out-of-pocket costs. The PPO dentists offer discounted care (about 30%) and the plan normally pays a higher level of benefit when using an in-network provider. Additionally, the PCN/PPO dentist cannot "balance bill" you for amounts greater than the contracted rate. Out-of-State Network and Claims The Premier Access Dental network is available to eligible members outside the State of California, with nearly 80,000 dentists to choose from. A complete provider listing is available on the internet at: It is important that you confirm with your dentist at the time of treatment that they are participating in the Premier Access network. For a dentist near you call Please check your Certificate of Insurance for a description of coverage, limitations and exclusions under the plan. Some services require prior authorization. How to Reach Us Premier Access Claim Dept. P.O. Box Sacramento, CA Member Services Line On the Web Page 2 of 2

3 Customer Service: Dear Premier Access Member, As your dental insurance carrier we are dedicated to get you the information you need promptly. This is why we have developed our website to assist in finding the Provider who is best for you. If you have not already registered as a member, please find instructions at the bottom of the page on how do so. You don t need to be registered to search for providers; however, your search results will be limited to 50 providers. Following is a guide to finding the right Dentist for you. Find a Provider 1. Log onto our website ( 2. Click on Find a Dentist. 3. From here you have the option to perform a Quick Search OR an Advanced Search. 4. To perform a Quick Search it is important that you enter the information marked with an asterisk: a. In the City, State OR Zip field you must enter either a City & State OR a Zip Code. (If you re signed in as a member, your home zip code will automatically populate in this field) b. Next, select a Commercial Plan from the drop down menu. (If you re signed in as a member, the plan you are currently enrolled in will automatically populate in this field). c. Then click SEARCH 5. Once you have clicked the SEARCH button the website will display the provider listing. You have the option to print or the directory. To perform a new search, simply enter another City & State OR Zip Code or click on Advanced Search. 6. To perform an Advanced Search it is important that you enter the information marked with an asterisk: a. In the City, State OR Zip field you must enter either a City & State OR a Zip Code. (If you re signed in as a member, your home zip code and street address will automatically populate in this field). To search by County, simply enter the County in the corresponding field. (If you re signed in as a member, the pre-populated home zip code and street address will disappear as soon as you click on the County field). b. Next, select a Commercial Plan from the drop down menu. (If you re signed in as a member, the plan you are currently enrolled in will automatically populate in this field). Then select the Network otherwise the search will default to PCN & PPO Network. c. Next, select the Specialty otherwise the search will default to All Dentists. If you select Dental HMO as your plan, the Specialty will default to General Practitioner. For DHMO plans you cannot select a Specialist, you need to be referred to Specialist by your Primary Care Dentist (PCD). d. Next, select the Distance otherwise the search will default to 10 miles. e. Then click SEARCH or for an even more Advanced Search, you can enter the dentists name in step 5 and/or indicate additional search criteria in step You can change the order of the provider listing by selecting a sort option from the Sort By drop down menu. 8. Another great feature is the Look Inside addition to our website. Click on Look Inside and you ll see things such as Photos/Videos, Profile, Maps/Directions, Reviews. If you re signed in as a member, you can write a review. Registration Instructions 1. Have a copy of your Premier Access dental card in front of you. 2. Log onto our website ( 3. Click on Register Here. 4. Select User Type as Member. Then you will need to select one of the commercial plans. Either Dental PPO or Dental HMO 5. Enter the information requested: a. The member ID number must be entered exactly as it appears on your card (including the last 00) b. Member s full date of birth (mm/dd/yyyy i.e 12/23/1975) 6. If you ve entered the information and the system does not recognize you, then the information you ve entered does not match what is in our system. If this occurs, please contact Premier Access at the phone number listed above for further assistance. 7. If you enter the information and the next screen asks you for your address, then you have entered the information as it appears in our system and you may continue. Please enter your address. This will be used to your login and password information should you forget it in the future. 8. Now you can choose your own username and password. Please make sure to follow the character instructions to the right of the screen. You also must choose a security question and answer. 9. Accept the terms and conditions and click Next. A message will pop up stating that you have successfully registered online. Now you re ready to administer your dental insurance online. Should you need additional assistance, please do not hesitate to contact us.

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5 Education-PreAuthorize_F.pdf 1 8/22/11 1:39 PM Dental and Vision Be Wise and Pre-Authorize!!!! When you take your automobile in for service, the mechanic/shop is required to provide a written estimate. An estimate details needed repairs and their respective costs. As a result, you understand the scope and cost of the repairs before services are rendered and you are billed. Isn t that an essential piece of information needed to conduct potentially costly business? PRIOR AUTHORIZATION is the dental version of an automobile estimate. Members receiving treatment in excess of $ should ask their provider to submit a pre-authorization to Premier Access. This will prevent any surprises that may result from expensive treatment and empower the member to find a comparable alternative if necessary. Simply ask your provider to provide you with a prior authorization. Receiving a Prior Authorization is your responsibility! Premier Access Insurance Company Corporate Headquarters 8890 Cal Center Drive, Sacramento CA Customer Service:

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7 Dental and Vision EMPLOYEE ENROLLMENT/CHANGE FORM Use this form for a new enrollment or a change to an existing enrollment. Please complete in blue or black ink. Mail to: Premier Access Membership Accounting, P.O. Box , Sacramento, CA or fax to: Group Number: Coverage Type: PPO DHMO Effective Date of Enrollment/Change: Reason for Enrollment Form New Enrollment/New Hire Qualifying Event (Attach supporting documentation) Late Enrollee (Subject to Late Enrollee Waiting Period) Add Dependent (including spouse and registered domestic partner) Qualifying Event: Date of Qualifying Event: Change of Address Terminate Dental Coverage, Subscriber & Dependent(s) Terminate Dental Coverage, Dependent(s) Only Change in Other Dental Insurance (Please see reverse side) Other (Specify: ) Subscriber (Employee) Information Social Security Number: Date of Hire: Last Name: First Name: MI: Street Address: City: State: Zip: Home Phone: ( ) Address: Date of Birth: Sex: M F Married? Yes No Children? Yes No Employer (Company) Name: Job Title: Division/Class: Hours Worked Per Week: Preferred Spoken Language: Ethnicity (optional): Preferred Written Language: Race (optional): Managed Care Only: Please select a Primary Care Dentist (PCD) from the provider directory for yourself and each of your family members. Fill in the Provider ID number and Office ID number in the appropriate areas. If a selection is not made, a PCD will be assigned for you. Primary Care Dentist No. Dependent Information Primary Care Dentist Office No. New Enrollment/New Hire: Complete this section for all dependents you are choosing to enroll. Add Dependent: Complete this section only for the dependents you are adding to your existing enrollment. Terminate Dependent Coverage Only: Complete this section only for dependent(s) you are choosing to terminate. Relation to Subscriber Last Name First Name & MI Date of Birth** Spouse/ or Reg. Domestic Partner Child Child Child Child Child Sex (M/F) Primary Care Dentist Office ID # Primary Care Dentist ID # ** Dependent child eligibility requirements are defined by the Employer Group Policy. Supporting documentation of dependent eligible status must be submitted with this form for dependent children age 19 or over for the enrollment to be processed and claims paid. To the best of my knowledge or belief, I have answered truthfully and completely the information requested on this application, including the information on the back of this application. I understand that Premier Access Insurance Company reserves the right to rescind or terminate coverage if any material misrepresentation is made in this enrollment application. I have read and agree to the notice on the back of this form. MANDATORY BINDING ARBITRATION: Premier Access Insurance Company uses binding arbitration to settle disputes, including to settle claims of dental malpractice. The insured understands and agrees that if a dispute arises in connection with this policy, the parties waive the right to a jury trial and must settle the dispute through binding arbitration. The Premier Certificate of Insurance contains a provision that further addresses this issue Premier Access Insurance Company does not use binding arbitration in connection with any dispute that an insured s life insurance coverage. Employee Signature: Date: FORM :

8 EMPLOYEE ENROLLMENT/CHANGE FORM Other Dental Coverage Do you or your dependents have other dental coverage? Yes No (If yes, complete the information below.) Other Dental Coverage Information Name of Insured: Social Security Number: Insured s Employer: Name of Insurance Carrier: Employer s Street Address: City: State: Zip: Phone: ( ) Are your dependent children enrolled under your spouse s (or registered domestic partner) dental plan? Yes No CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. THEREFORE, PREMIER ACCESS INSURANCE COMPANY WILL NOT REQUIRE THAT AN HIV TEST BE REQUIRED AS A CONDITION OF OBTAINING COVERAGE. IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFETY CODE SECTION , PREMIER ACCESS INSURANCE COMPANY COMPLIES IN ALL RESPECTS WITH THE PROHIBITION AGAINST THE UNAUTHORIZED DISCLOSURES OF AN HIV TEST. I, on my behalf and on behalf of my dependent(s) on this enrollment application, hereby (1) request coverage for the group insurance for which I am or may become eligible; (2) authorize my employer to make the necessary deductions for the contributions, if any, required for the insurance, or agree that the contributions be added to my dues; (3) state that I became a full-time employee on the date stated on the reverse, and do currently work the number of hours per week stated on the reverse, (4) agree to be bound by benefits, copayments, deductibles, exclusions, limitations, and other terms and conditions of the Premier* Certificate of Insurance, (5) agree that if I or my dependents receive dental services after my coverage is terminated or lapses, that I am responsible to reimburse Premier for any unrecovered payments made by Premier for such services, and (6) understand that verification of eligibility by Premier does not guarantee payment of claims and that retroactive eligibility changes supercede verifications of eligibility. DENTAL RELEASE: I, on my behalf and on behalf of my Dependent(s) listed on this Enrollment Application, hereby authorize Premier to release dental information to official government agencies and to other individuals when required under appropriate federal or state law, or pursuant to legal process and to release and obtain dental information to or from other appropriate agencies and providers for the provision of necessary dental services and supplies covered by Premier. If you request, Premier will provide a copy to you of any information it discloses to third parties regarding your dental information. This Dental Release authorization shall remain in effect thirty months from the date the application is signed. This Dental Release authorization solely provides authorization of Premier to release dental information to official government agencies and to other individuals when required under appropriate federal or state law, or pursuant to legal process and to release and obtain dental information to or from other appropriate agencies and providers for the provision of necessary dental services and supplies covered by Premier. The dental information is being collected by Premier solely for the specific purpose of premium underwriting.. RIGHT OF REIMBURSEMENT: I, on my behalf and on behalf of my Dependent(s) listed on this Enrollment Application, hereby agree that in the event any dental services provided to me or my Dependent(s) covered by Premier are the primary financial responsibility of another party, because of other dental coverage, I will fully inform Premier and will execute such assignments, liens or other documents which may be necessary to enable Premier to recover the value of services and supplies provided NOTICE: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison. The Premier Access Vision Plan is administered by MESVision and is underwritten by the Gerber Life Insurance Company of White Plains, NY. * All references to Premier herein refer to Premier Access Insurance Company PRE-ENR

9 Dental and Vision INDIVIDUAL WAIVER STATEMENT (Use this form for employees electing to waive coverage for themselves and/or their dependents.) Waiver Statement: I have been given the opportunity to enroll in the group dental plan my Employer has obtained from Premier* and, after consideration, have decided to waive coverage for: Current Group Number: Myself and all Dependents My Dependents (Spouse and Child(ren)) My Spouse My Dependent Child(ren) Employee Information: Social Security Number: Last Name: First Name: MI: Street Address: City: State: Zip: Home Phone: Address: Employer (Company) Name: Reason for Waiver: I am declining coverage because I am covered under another dental plan not affiliated with my current Employer. This coverage is provided through: My Spouse s Employer Plan (Employer s Name): Military Individual Policy Medicare/Medicaid Other: Insurance Carrier s Name: Coverage is being declined for my Spouse because he/she is covered under another dental plan. Spouse s Name: Insurance Carrier s Name: Coverage is being declined for my Child(ren) because he/she is covered under another dental plan. Child(ren) s Name(s): Insurance Carrier s Name: Coverage is being declined for my Spouse and/or Child(ren). They are not covered under another dental plan. List Name(s): I understand that if I later decide to apply for coverage for myself or any dependents for which I am waiving coverage at this time, Premier may consider me a late enrollee and may impose a Benefit Waiting Period. I also understand that at the time of my subsequent application for coverage, I will have to comply with the applicable group dental Policy requirements for eligibility and enrollment. You will not be considered a late enrollee if one or more of the following applies: 1. You or Your waiving Dependents were covered under another dental plan at the time of waiver, you are no longer covered under the other dental plan for one of the reasons stated below and you request enrollment in Premier within 30 days after termination of coverage or Employer contribution under the other dental plan. a. Termination of employment; b. Change in employment status; c. Termination of the other plan s coverage; d. Cessation of an employer s premium contribution toward an employee s or dependent s coverage; or e. Death of or divorce from the individual through which the waiving individual was covered as a Dependent. 2. A court orders coverage be provided for a spouse or child of an insured Employee and request for enrollment under Premier is made within 30 days of the issuance of the court order. 3. You are employed by an Employer that offers multiple dental plans and You elect a different plan during an open enrollment period. Employee Signature: Date: * All references to Premier herein refer to Premier Access Insurance Company Premier Group Insurance Individual Waiver Statement Form PRE-EE-WAV

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11 Want information instantly? You ve Got It! Logon at You can access your claims information, find a dentist in your neighborhood, check out your benefits, find information on dental care, print an ID card and nominate a dentist you d like us to invite to join our network. All in just a couple of clicks 7 days a week 24 hours a day. Speak to a Customer Service Representative You can reach a Premier Access representative Monday through Friday, 8am to 6pm PST. Friendly and knowledgeable representatives will help you with any benefit questions or assist you if you would like to change dentists. Call after-hours If you have an emergency after business hours, first contact your Primary Care Dentist. You will be given instructions on how to obtain emergency care. If your Primary Care Dentist is not available, you may contact our 24-hour answering service. An operator will obtain information regarding your emergency and relay the information to the On-Call Dentist. The On-Call Dentist will telephone you as soon as possible to address your needs You can also us at customerservice@premierlife.com providing you with the information you need, when you need it.

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13 Medical Dental Vision Access Your Benefits On The Go You are no longer tied to your laptop or computer to access your Premier Access account information. With our new mobile apps you can: Access Benefit information which you can / fax to the dentist s office Find a Dentist near you Pull up your ID card (handy when you re at your dentist s office) Contact Customer Service Access your personal Premier Access account from your iphone, ipad, or Android anytime, anywhere It s safe; it s secure; and it s easy. To access your information from our mobile apps, please use your username and password. Visit to set up your account from your home computer. *Please Note: Mobile app is not available for members under the following programs: Geographical Managed Care, Los Angeles Pre- Paid Health Plan, Healthy Families Program, Healthy Kids Santa Barbara, and UTAH Children s Health Insurance Program.

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15 Medical Dental Vision Preferred Provider Nomination Form I would like to nominate my dentist for inclusion in the Premier Access Preferred Provider network. I understand that the Premier Access retains final authority for approving membership in the provider network. I also understand that Premier Access may use my name when contacting my dentist and inform him / her of my desire for them to join the network. NOTE: This form does not serve as an enrollment form for dental insurance, or to register with the dental office as a patient. Date: Patient s Name: Employer: Telephone: Dentist: Name: Address: Telephone: Specialty: If you have any questions about participating in Premier Access' provider network, please do not hesitate to contact us at: Please submit form to: Premier Access Network Operations P.O. Box Sacramento, CA Or FAX to:

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