UnitedHealthcare - Dental Rate Card

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1 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 Zone 1 Zip Codes: 8, 81 Zone 2 Zip Codes: 82, 83, 84 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 Zone 3 Zip Codes: 85, 86 1P931 No 1%/8% 8%/6% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P915 No 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 P9944 1% 8% 5% 5% 1, 5/15 8th/Options PPO 3 P7977 No 1% 8% 5% 5% 1,5 5/15 85th/Options PPO 3 LIN2 No Voluntary 1% % % % Unlimited / MAC/Options PPO 15 1P935 Voluntary 1% 8% 5% 8% 1, 5/15 MAC/Options PPO 2 12 Zone 1 1 Specific Procedures within Endodontic, ontic, and Oral Surgery benefits may EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family pay at varying coinsurance levels. For detailed benefit information, please contact $24.82 $49.63 $49.42 $77.52 $2.45 $4.9 $4.72 $63.88 your sales representative to obtain a benefits summary for your plan(s). 1P931 $32.7 $65.4 $66.1 $13.26 $26.95 $53.89 $54.47 $85.9 1P915 $36.46 $72.92 $73.7 $ $3.5 $6.9 $6.74 $94.88 P9944 $41.29 $82.59 $83.61 $13.54 $34.3 $68.6 $68.89 $17.57 P7977 $47.98 $95.95 $97.13 $ $39.53 $79.7 $8.4 $ LIN2 $9.53 $18.53 $24.3 $34.96 $7.85 $15.27 $19.8 $ P935 $34.92 $69.84 $69.67 $19.22 $28.77 $57.56 $57.41 $9.1 Zone 2 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family $24.66 $49.34 $49.12 $77.5 $2.33 $4.66 $4.48 $ P931 $32.35 $64.71 $65.4 $12.16 $26.66 $53.33 $53.89 $ P915 $35.22 $7.45 $71.2 $ $29.3 $58.5 $58.67 $91.65 P9944 $43.38 $86.74 $87.81 $137.1 $35.74 $71.48 $72.36 $ P7977 $5.44 $1.9 $12.13 $ $41.57 $83.14 $84.17 $ LIN2 $1.19 $19.85 $25.76 $37.49 $8.4 $16.36 $21.22 $3.89 1P935 $33.73 $67.47 $67.29 $15.51 $27.8 $55.6 $55.46 $86.95 Zone 3 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family $27.81 $55.6 $55.36 $86.84 $22.92 $45.82 $45.63 $ P931 $37.5 $74.11 $74.9 $117. $3.53 $61.7 $61.72 $ P915 $4.37 $8.75 $81.61 $ $33.27 $66.54 $67.25 $15.5 P9944 $48.56 $97.14 $98.33 $ $4.3 $8.5 $81.3 $ P7977 $55.9 $111.8 $ $ $46.6 $92.14 $93.26 $ LIN2 $11.67 $22.74 $29.51 $42.96 $9.62 $18.74 $24.32 $35.4 1P935 $39.6 $78.11 $77.92 $ $32.19 $64.37 $64.21 $ of 8

2 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 Zone 4 Zip Codes: 78 Zone 5 Zip Codes: 71, 72, 79 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 Zone 6 Zip Codes: 7, 73, 74, 75, 76 1P931 No 1%/8% 8%/6% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P915 No 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 P9944 1% 8% 5% 5% 1, 5/15 8th/Options PPO 3 P7977 No 1% 8% 5% 5% 1,5 5/15 85th/Options PPO 3 LIN2 No Voluntary 1% % % % Unlimited / MAC/Options PPO 15 1P935 Voluntary 1% 8% 5% 8% 1, 5/15 MAC/Options PPO 2 12 Zone 4 1 Specific Procedures within Endodontic, ontic, and Oral Surgery benefits may EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family pay at varying coinsurance levels. For detailed benefit information, please contact $34.34 $68.66 $68.36 $17.24 $28.29 $56.58 $56.34 $88.37 your sales representative to obtain a benefits summary for your plan(s). 1P931 $44.8 $89.6 $9.56 $ $36.92 $73.83 $74.62 $ P915 $49.46 $98.92 $99.98 $ $4.76 $81.51 $82.39 $ P9944 $57.8 $115.6 $117.1 $ $47.63 $95.26 $96.43 $15.57 P7977 $65.11 $13.23 $ $25.83 $53.66 $17.31 $18.63 $ LIN2 $15.21 $29.75 $38.64 $56.31 $12.53 $24.51 $31.84 $46.4 1P935 $48.87 $97.73 $97.49 $ $4.27 $8.54 $8.33 $ Zone 5 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family $28. $56. $55.76 $87.47 $23.7 $46.16 $45.95 $72.8 1P931 $35.94 $71.89 $72.66 $113.5 $29.62 $59.24 $59.87 $ P915 $39.57 $79.14 $79.99 $ $32.61 $65.22 $65.91 $12.96 P9944 $57.57 $ $ $ $47.44 $94.87 $96.3 $ P7977 $66.14 $ $133.9 $29.8 $54.51 $19.1 $11.34 $ LIN2 $17.6 $33.4 $43.39 $63.24 $14.6 $27.52 $35.76 $ P935 $38.4 $76.81 $76.61 $12.11 $31.65 $63.3 $63.13 $98.98 Zone 6 EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family $33.1 $66.21 $65.92 $13.4 $27.28 $54.55 $54.32 $ P931 $42.89 $85.78 $86.7 $ $35.35 $7.7 $71.45 $ P915 $47.26 $94.52 $95.53 $ $38.94 $77.89 $78.72 $ P9944 $61.48 $ $ $ $5.67 $11.33 $12.58 $16.16 P7977 $7.4 $14.79 $ $ $58.1 $116.3 $ $ LIN2 $15.86 $31. $4.25 $58.65 $13.7 $25.54 $33.17 $ P935 $46.1 $92.2 $91.79 $ $37.92 $75.83 $75.64 $ of 8

3 For Groups 2-9 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 1P931 No 1%/8% 8%/6% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P915 No 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 P9944 1% 8% 5% 5% 1, 5/15 8th/Options PPO 3 P7977 No 1% 8% 5% 5% 1,5 5/15 85th/Options PPO 3 LIN2 No Voluntary 1% % % % Unlimited / MAC/Options PPO 15 1P935 Voluntary 1% 8% 5% 8% 1, 5/15 MAC/Options PPO 2 12 Zone 7 Zip Codes: 77, 87, 88, 89 Zone 7 1 Specific Procedures within Endodontic, ontic, and Oral Surgery benefits may EE Only EE & SP EE & Ch(ren) Family EE Only EE & SP EE & Ch(ren) Family pay at varying coinsurance levels. For detailed benefit information, please contact $35.3 $7.7 $69.76 $19.42 $28.87 $57.74 $57.49 $9.17 your sales representative to obtain a benefits summary for your plan(s). 1P931 $45.88 $91.75 $92.74 $ $37.8 $75.61 $76.43 $ P915 $5.71 $11.41 $12.49 $16.1 $41.78 $83.57 $84.46 $ P9944 $61.45 $ $ $ $5.63 $11.27 $12.5 $16.5 P7977 $7.96 $ $ $ $58.48 $ $ $ LIN2 $16.98 $33.23 $43.17 $62.92 $14. $27.39 $35.58 $ P935 $48.92 $97.83 $97.58 $ $4.31 $8.61 $8.41 $ of 8

4 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 Zone 1 Zip Codes: 8, 81 Zone 2 Zip Codes: 82, 83, 84 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 Zone 3 Zip Codes: 85, 86 1P931 No 1%/8% 8%/6% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P915 No 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 Zone 4 Zip Codes: 78 P9944 1% 8% 5% 5% 1, 5/15 8th/Options PPO 3 P7977 No 1% 8% 5% 5% 1,5 5/15 85th/Options PPO 3 1P14 Voluntary 1% 8% 5% 8% 1,5 5/ th/Options PPO 3 Zone Lives Lives 25-5 Lives 1 Specific Procedures within $19.35 $38.7 $38.53 $6.44 $17.38 $34.76 $34.61 $54.29 $17.28 $34.56 $34.41 $53.98 Endodontic, ontic, and 1P931 $25.49 $5.99 $51.54 $8.5 $22.91 $45.8 $46.3 $72.32 $22.77 $45.53 $46.3 $71.9 Oral Surgery benefits may pay at 1P915 $28.43 $56.86 $57.46 $89.76 $25.54 $51.7 $51.62 $8.63 $25.39 $5.77 $51.32 $8.16 varying coinsurance levels. For P9944 $32.2 $64.39 $65.18 $11.78 $28.92 $57.85 $58.55 $91.42 $28.76 $57.5 $58.21 $9.89 detailed benefit information, P7977 $37.4 $74.81 $75.73 $ $33.6 $67.2 $68.2 $16.21 $33.41 $66.81 $67.63 $15.59 please contact your sales 1P14 $45.64 $91.28 $12.33 $ $4.99 $82. $91.91 $139.7 $4.76 $81.52 $91.38 $ representative to obtain a benefits summary for your plan(s). Zone Lives Lives 25-5 Lives $19.23 $38.46 $38.3 $6.7 $17.28 $34.55 $34.4 $53.96 $17.18 $34.35 $34.21 $ P931 $25.22 $5.45 $5.99 $79.65 $22.65 $45.32 $45.8 $71.54 $22.52 $45.5 $45.53 $ P915 $27.46 $54.92 $55.51 $86.71 $24.67 $49.34 $49.86 $77.89 $24.53 $49.5 $49.57 $77.44 P9944 $33.81 $67.63 $68.46 $16.89 $3.37 $6.75 $61.49 $96.2 $3.2 $6.39 $61.14 $95.46 P7977 $39.33 $78.66 $79.63 $ $35.33 $7.66 $71.53 $ $35.13 $7.25 $71.11 $ P14 $47.93 $95.87 $16.9 $162.7 $43.6 $86.12 $96.2 $ $42.81 $85.62 $95.46 $ Zone Lives Lives 25-5 Lives $21.68 $43.36 $43.16 $67.7 $19.47 $38.94 $38.77 $6.81 $19.35 $38.72 $38.55 $6.46 1P931 $28.89 $57.78 $58.39 $91.22 $25.95 $51.9 $52.45 $81.94 $25.8 $51.6 $52.15 $ P915 $31.48 $62.95 $63.63 $99.39 $28.27 $56.55 $57.15 $89.28 $28.11 $56.22 $56.82 $88.76 P9944 $37.87 $75.73 $76.66 $119.7 $34.1 $68.3 $68.86 $17.52 $33.81 $67.63 $68.46 $16.89 P7977 $43.58 $87.17 $88.24 $ $39.15 $78.3 $79.26 $ $38.92 $77.84 $78.8 $ P14 $53.14 $16.29 $ $18.76 $47.74 $95.47 $16.76 $ $47.46 $94.92 $16.14 $ Zone Lives Lives 25-5 Lives $26.77 $53.53 $53.3 $83.61 $24.4 $48.9 $47.88 $75.1 $23.9 $47.81 $47.6 $ P931 $34.93 $69.86 $7.61 $11.29 $31.38 $62.75 $63.43 $99.7 $31.19 $62.38 $63.5 $98.5 1P915 $38.56 $77.12 $77.95 $ $34.64 $69.28 $7.2 $19.37 $34.44 $68.87 $69.61 $18.74 P9944 $45.6 $9.13 $91.23 $ $4.47 $8.96 $81.95 $ $4.24 $8.48 $81.48 $ P7977 $5.77 $11.53 $12.77 $16.47 $45.6 $91.21 $92.32 $ $45.34 $9.68 $91.78 $ P14 $61.92 $ $ $29.76 $55.62 $ $ $ $55.3 $11.6 $123. $ of 8

5 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 Zone 5 Zip Codes: 71, 72, 79 Zone 6 Zip Codes: 7, 73, 74, 75, 76 1% 5% 5% 1 5% 1,5 5/15 MAC/Options PPO 2 Zone 7 Zip Codes: 77, 87, 88, 89 1P931 No 1%/8% 8%/6% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P915 No 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 P9944 1% 8% 5% 5% 1, 5/15 8th/Options PPO 3 P7977 No 1% 8% 5% 5% 1,5 5/15 85th/Options PPO 3 1P14 Voluntary 1% 8% 5% 8% 1,5 5/ th/Options PPO 3 Zone Lives Lives 25-5 Lives 1 Specific Procedures within $21.84 $43.66 $43.48 $68.2 $19.61 $39.23 $39.5 $61.26 $19.5 $38.99 $38.83 $6.91 Endodontic, ontic, and 1P931 $28.2 $56.5 $56.65 $88.49 $25.18 $5.34 $5.88 $79.49 $25.3 $5.5 $5.59 $79.2 Oral Surgery benefits may pay at 1P915 $3.85 $61.7 $62.36 $97.42 $27.71 $55.43 $56.2 $87.5 $27.55 $55.1 $55.69 $87. varying coinsurance levels. For P9944 $44.88 $89.76 $9.86 $ $4.32 $8.63 $81.62 $ $4.8 $8.16 $81.14 $ detailed benefit information, P7977 $51.57 $13.14 $14.4 $163.1 $46.32 $92.64 $93.78 $ $46.5 $92.11 $93.23 $ please contact your sales 1P14 $62.78 $ $14.47 $213.6 $56.4 $ $ $ $56.7 $ $ $19.76 representative to obtain a benefits summary for your plan(s). Zone Lives Lives 25-5 Lives $25.81 $51.62 $51.39 $8.61 $23.18 $46.37 $46.17 $72.41 $23.5 $46.1 $45.9 $ P931 $33.44 $66.89 $67.6 $15.6 $3.4 $6.8 $6.72 $94.85 $29.86 $59.73 $6.38 $94.3 1P915 $36.85 $73.69 $74.48 $ $33.1 $66.19 $66.9 $14.5 $32.9 $65.81 $66.51 $13.9 P9944 $47.93 $95.87 $97.5 $ $43.6 $86.12 $87.18 $ $42.81 $85.62 $86.67 $ P7977 $54.89 $19.77 $ $173.5 $49.3 $98.6 $99.81 $ $49.1 $98.3 $99.23 $ P14 $66.84 $ $ $ $6.4 $12.8 $ $23.3 $59.7 $ $ $22.12 Zone Lives Lives 25-5 Lives $27.31 $54.63 $54.4 $85.32 $25.13 $5.25 $5.3 $78.47 $24.98 $49.96 $49.74 $78.2 1P931 $35.77 $71.54 $72.31 $ $32.9 $65.81 $66.51 $13.89 $32.71 $65.43 $66.12 $ P915 $39.53 $79.6 $79.91 $ $36.36 $72.73 $73.5 $ $36.15 $72.31 $73.8 $ P9944 $47.9 $95.81 $96.98 $ $44.6 $88.13 $89.21 $139.3 $43.81 $87.62 $88.69 $ P7977 $55.33 $11.64 $112. $ $5.89 $11.78 $13.3 $16.86 $5.59 $11.18 $12.43 $ P14 $67.42 $ $15.5 $ $62.1 $124.2 $138.2 $21.16 $61.65 $ $ $ of 8

6 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 Zone 1 Zip Codes: 8, 81 Zone 2 Zip Codes: 82, 83, 84 LIN2 No Voluntary 1% % % 1 % Unlimited / MAC/Options PPO 15 Zone 3 Zip Codes: 85, 86 PIN53 Voluntary 1% 5% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P935 Voluntary 1% 8% 5% 8% 1, 5/15 MAC/Options PPO 2 12 Zone 4 Zip Codes: 78 1P985 No Voluntary 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P944 Voluntary 1% 8% 5% 8% 1,5 5/15 MAC/Options PPO 2 Zone Lives Lives 25-5 Lives 1 Specific Procedures within LIN2 $7.43 $14.45 $18.74 $27.26 $6.67 $12.98 $16.83 $24.49 $6.63 $12.9 $16.73 $24.34 Endodontic, ontic, and PIN53 $2.7 $41.41 $41.23 $64.67 $18.6 $37.2 $37.3 $58.9 $18.49 $36.98 $36.82 $57.75 Oral Surgery benefits may pay at 1P935 $27.23 $54.45 $54.31 $85.16 $24.46 $48.92 $48.79 $76.49 $24.32 $48.63 $48.51 $76.5 varying coinsurance levels. For 1P985 $28.85 $57.71 $58.41 $91.21 $25.92 $51.84 $52.47 $81.93 $25.77 $51.53 $52.16 $81.45 detailed benefit information, 1P944 $33.5 $66.1 $65.94 $13.38 $29.69 $59.38 $59.23 $92.86 $29.52 $59.4 $58.89 $92.32 please contact your sales representative to obtain a benefits summary for your plan(s). Zone Lives Lives 25-5 Lives LIN2 $7.94 $15.48 $2.8 $29.23 $7.14 $13.9 $18.4 $26.26 $7.9 $13.82 $17.93 $26.1 PIN53 $2.58 $41.16 $4.98 $64.27 $18.49 $36.97 $36.81 $57.73 $18.38 $36.75 $36.6 $57.4 1P935 $26.3 $52.6 $52.47 $82.26 $23.62 $47.25 $47.13 $73.89 $23.49 $46.97 $46.85 $ P985 $27.87 $55.74 $56.42 $88.11 $25.4 $5.7 $5.69 $79.14 $24.89 $49.78 $5.4 $ P944 $31.93 $63.86 $63.7 $99.86 $28.68 $57.36 $57.21 $89.71 $28.51 $57.3 $56.89 $89.19 Zone Lives Lives 25-5 Lives LIN2 $9.1 $17.73 $23.1 $33.49 $8.18 $15.93 $2.67 $3.9 $8.13 $15.83 $2.55 $29.91 PIN53 $23.19 $46.39 $46.18 $72.45 $2.83 $41.66 $41.49 $65.7 $2.71 $41.42 $41.25 $64.7 1P935 $3.45 $6.9 $6.75 $95.24 $27.35 $54.7 $54.56 $85.55 $27.19 $54.39 $54.25 $85.5 1P985 $31.95 $63.89 $64.68 $1.99 $28.7 $57.39 $58.1 $9.71 $28.53 $57.6 $57.76 $9.19 1P944 $36.6 $73.2 $73.1 $ $32.88 $65.75 $65.58 $12.82 $32.68 $65.37 $65.2 $12.23 Zone Lives Lives 25-5 Lives LIN2 $11.86 $23.19 $3.13 $43.9 $1.65 $2.83 $27.6 $39.43 $1.59 $2.71 $26.9 $39.2 PIN53 $28.64 $57.28 $57.4 $89.46 $25.72 $51.46 $51.23 $8.36 $25.58 $51.16 $5.94 $79.9 1P935 $38.1 $76.2 $76.1 $ $34.22 $68.45 $68.27 $17.3 $34.3 $68.5 $67.88 $ P985 $39.13 $78.28 $79.24 $ $35.15 $7.31 $71.17 $ $34.95 $69.9 $7.76 $ P944 $44.84 $89.67 $89.45 $14.23 $4.27 $8.55 $8.34 $ $4.4 $8.8 $79.88 $ of 8

7 For Groups 1-5 Eligible Lives with Effective Dates Preferred Portfolio 4/1/218-6/3/218 LIN2 No Voluntary 1% % % 1 % Unlimited / MAC/Options PPO 15 PIN53 Voluntary 1% 5% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P935 Voluntary 1% 8% 5% 8% 1, 5/15 MAC/Options PPO P985 No Voluntary 1% 8% 5% 5% 1,5 5/15 MAC/Options PPO 2 1P944 Voluntary 1% 8% 5% 8% 1,5 5/15 MAC/Options PPO 2 Zone 5 Zip Codes: 71, 72, 79 Zone 6 Zip Codes: 7, 73, 74, 75, 76 Zone 7 Zip Codes: 77, 87, 88, 89 Zone Lives Lives 25-5 Lives 1 Specific Procedures within LIN2 $13.3 $26.4 $33.83 $49.31 $11.95 $23.39 $3.39 $44.29 $6.72 $13.12 $17.4 $24.82 Endodontic, ontic, and PIN53 $23.36 $46.72 $46.52 $72.97 $2.98 $41.97 $41.78 $65.55 $2.86 $41.73 $41.54 $65.17 Oral Surgery benefits may pay at 1P935 $29.94 $59.88 $59.73 $93.64 $26.9 $53.79 $53.65 $84.12 $26.74 $53.48 $53.34 $83.63 varying coinsurance levels. For 1P985 $31.31 $62.62 $63.39 $98.98 $28.12 $56.25 $56.94 $88.91 $27.97 $55.92 $56.61 $88.39 detailed benefit information, 1P944 $35.87 $71.74 $71.55 $ $32.22 $64.44 $64.27 $1.77 $32.3 $64.7 $63.9 $1.19 please contact your sales representative to obtain a benefits summary for your plan(s). Zone Lives Lives 25-5 Lives LIN2 $12.36 $24.17 $31.38 $45.72 $11.1 $21.71 $28.19 $41.7 $11.4 $21.58 $28.3 $4.83 PIN53 $27.61 $55.23 $54.99 $86.26 $24.8 $49.62 $49.39 $77.48 $24.66 $49.33 $49.11 $77.3 1P935 $35.87 $71.75 $71.56 $112.2 $32.22 $64.45 $64.28 $1.78 $32.4 $64.7 $63.91 $1.2 1P985 $37.4 $74.78 $75.7 $118.2 $33.59 $67.17 $68. $16.18 $33.4 $66.78 $67.6 $ P944 $42.84 $85.67 $85.46 $ $38.48 $76.96 $76.76 $12.34 $38.25 $76.51 $76.32 $ Zone Lives Lives 25-5 Lives LIN2 $13.24 $25.91 $33.66 $49.5 $12.18 $23.83 $3.96 $45.12 $12.11 $23.7 $3.78 $44.86 PIN53 $29.23 $58.45 $58.2 $91.29 $26.89 $53.76 $53.53 $83.97 $26.73 $53.46 $53.22 $ P935 $38.14 $76.27 $76.7 $ $35.8 $7.16 $69.98 $19.71 $34.88 $69.75 $69.57 $19.8 1P985 $4.12 $8.24 $81.23 $ $36.9 $73.81 $74.72 $ $36.69 $73.39 $74.28 $ P944 $45.96 $91.92 $91.69 $ $42.28 $84.56 $84.34 $ $42.4 $84.6 $83.85 $ of 8

8 For Groups 2-5 Eligible Lives with Effective Dates Product and Underwriting Information 4/1/218-6/3/218 Rates are guaranteed for 12 months. Rates generated by UnitedHealthcare's rating systems may differ from this illustration. Orthodontia benefit paid at 5% and available to groups of 1 or more eligible employees, with a minimum of 8 enrollees. MAC: The non-network percentage of benefits is based on the allowable amount applicable for the same service that would have been rendered by a network provider (MAC = Maximum Allowable Charge). UCR: The non-network percentage of benefits is based on the schedule of usual and customary fees in the geographic area in which the expense are incurred. (UCR = Usual Customary and Reasonable). Assumed contract situs in. Rates assume a complete Carrier Replacement and standard Exclusions and Limitations. Rates listed above assume the plan design quoted. Rates may change, if plan design changes. Rates assume no change in legislation or regulation that affects the benefits payable, eligibility or contract. For PPO plans, the network and non-network annual maximum are combined. Deductibles and maximums are assumed on a calendar year basis unless otherwise noted. Dependent children are covered up to age 26. Dual option is available on groups of 1 or more eligible emlpoyees as long as the combination is a logical high/low offering. Employer Funded s: Employer must contribute at least 5% of the employee rate. A minimum participation of at least 75% (51%, including valid waivers) is required. Voluntary plans for 2-9 size groups require a waiting period for major services. However, this waiting period may be waived with proof of prior coverage for major services. Voluntary plans without ortho are available down to 2 employees. UnitedHealthcare applies SIC factors to rate calculations for our 2 to 5 small group segment. This will aid in providing your client with the most favorable and competitive dental rate based on their industry classification. Quotes provided from United eservices will have the appropriate factors automatically embedded in them. The information below will help you determine if a SIC factor applies to your client. SIC codes not listed below are base rates (industry factor 1.) and require no additional adjustments from the base rates on the preceding pages. Industry Category SIC Code Industry Factor Agriculture Production & Services 1-291; 7-783; Mining, Construction, Manufacturing ; ; ; Additional Manufacturing 2-299; ; ; 36-39; Jewelry & Silverware Manufacturing Transportation, Communication, Electric, Gas, & Sanitary Services Building Materials, Hardware, Garden Supply, and Mobile Home Dealers Automotive Dealers and Gasoline Service Stations Eating and Drinking Places Depository & Non-depository Institutions Other Finance, Insurance, & Real Estate Beauty Shops, Advertising, Jewelry Repair, & Health Services ; ; ; 8-811; Legal & Educational Services ; Membership Organizations Public Administration & Other Public Administration & Other - Nonclassifiable Establishments All other (except as noted below)* * For Dental Offices (SIC 82, 821), please contact your UnitedHealthcare Sales representative Your UnitedHealthcare Sales Representative will supply you with a very simple Microsoft Excel-based tool to apply the SIC factor (if applicable) to your group's final rates. The output from this tool should be included with a copy of the rate card used when submitting your group's enrollment materials for installation. Please contact your UnitedHealthcare Sales representative for more information Fully Insured quotes: The Dental and/or Vision premium includes expenses related to state & federal taxes, fees, and assessments. It may also include additional new taxes, fees and assessments from the Affordable Care Act. The rates and benefits provided are for general information and discussion purposes only and are not valid unless approved by UnitedHealthcare. This rate quote is not an offer or guarantee of coverage. The group should not, under any circumstances, cancel its existing coverage unless and until coverage is offered by UnitedHealthcare and final rates have been accepted by and initial premium paid by the group. Final rates are determined by UnitedHealthcare's underwriting guidelines and final enrollment. The insurance Policy, not general rates and descriptions on this rate sheet, will form the contract between the insured and UnitedHealthcare, and the Certificate of Coverage issued to the subscriber will provide the legal description of coverage. Specialty benefits and programs may not be available in all states or for all group sizes. Components subject to change. UnitedHealthcare Dental coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, or its affiliates. Administrative services provided by Dental Benefit Providers, Inc., Dental Benefit Administrative Services (CA only), United HealthCare Services, Inc. or their affiliates. s sold in Texas use policy form number DPOL.6.TX (11/15/26) and associated COC form number DCOC.CER.6. UHCNJ Feb United HealthCare Services, Inc. 8 of 8