Group Dental Insurance SUMMARY OF BENEFITS

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1 Group Dental Insurance SUMMARY OF BENEFITS For Members of Arkansas State Employee Association Dental Benefits High Option For dental expenses incurred after satisfying the all benefit waiting period(s) and deductibles, the policy pays the following percentage of allowable expenses up to the maximum benefit. Type 1: Preventive Type 2: Basic Type 3: Major Type 4: Orthodontics (Children) - Routine Oral Exams - Bitewing X-rays - Full-mouth or Panoramic X-rays - Other Dental X-rays (including periapical films) - Routine Cleanings - Fluoride Treatments - Sealants - Problem Focused Exams - Labs and Other Tests - Space Maintainers for children - Palliative Treatment (including emergency relief of dental pain) - Injections of antibiotics and other therapeutic medications - Fillings - Simple Extractions - Consultations - Prefabricated Stainless Steel and Resin Crowns - Biopsy and Examination of Oral Tissue (including brush biopsy) - Prosthetic Repair and Recementation Services - Periodontal Maintenance procedures- Surgical Extractions - Oral Surgery - General Anesthesia and I.V. Sedation - Endodontics (including Root Canal Treatment) - Non-surgical Periodontal Therapy - Periodontal Surgery - Bridges - Full and Partial Dentures - Denture Reline and Rebase Services - Crowns, Inlays, Onlays and related services - Implants and related services - Occlusal Adjustment - Orthodontic Treatment- Including Orthodontic Exams, X-rays, Extractions, Study Models and Appliances In-Network Out-of-Network 100% 80% 80% 60% 60% 50% 50% 50% Benefits paid Benefits paid are based upon the following Negotiated Fee 95 th % UCR Deductible Calendar year deductible. Waived for Preventive services. $50 Individual $150 Family $50 Individual $150 Family Maximum Benefit Calendar year maximum for Preventive, Basic and Major services $5,000 $5,000 Ortho Maximum Lifetime Ortho Maximum for children $1,000 $1,000 Weekly Bi-Weekly Semi-Monthly Monthly Member Only $9.02 $18.05 $19.55 $39.10 Member & Spouse $17.98 $35.96 $38.96 $77.92 Member & Child(ren) $17.56 $35.12 $38.05 $76.09 Member & Family $29.17 $58.34 $63.20 $ GLM Rev. 7/13 Dental_Grp_PPO Generated 8/21/2014

2 While you may choose any dentist, using dentists participating in the network should lower your out-of-pocket expenses, vs an out of network dentist. A list of in network dentists may be accessed at You do not need a referral to see a specialist. Dental Benefits Cont'd. Benefit Waiting Period Prior Carrier Credit Lincoln DentalConnect Predetermination of Benefits Type 1: Preventive Services 0 months Type 2: Basic Services 0 months Type 3: Major Services 12 months Type 4: Orthodontia Services 12 months For Members and Dependents who were enrolled on the State Sponsored Dental Plan immediately prior to electing this plan: credit will be given toward the satisfaction of your benefit waiting period. By enrolling in the dental plan you and your enrolled family members will have access to Lincoln DentalConnect, our free on-line dental health information Web site. Allows you to find the amount covered prior to having a dental procedure. We recommend that you use this service when expenses are expected to exceed $300. Enrolling for Coverage Member You are eligible to enroll if you are a Member of A.S.E.A. Dependent Unmarried dependent children may be covered to age 26. Benefit Termination This coverage terminates when you cease to be an A.S.E.A. Member.

3 Exclusions and Other Limitations This highlights policy exclusions and limitations, see the policy for a full list. The plan does not cover services started before coverage begins or after it ends. Benefits are limited to those appropriate and necessary procedures listed in the policy and any additional procedures required by state law. Benefits are not payable for duplication of services. Covered expenses will not exceed the policy s usual and customary allowances. Plan benefits are not payable for a condition for which the claimant is eligible for benefits under worker s compensation or a similar law; are attributed to employment, military service; or are related to self-inflicted injury, involvement in an illegal occupation, felony, or riot. If benefits for orthodontia are included, the plan does not cover any treatment plan started before coverage begins or during the benefit waiting period unless the member was receiving orthodontia benefits from this employer s previous group dental policy. In that case, Lincoln Financial will continue orthodontia benefits until the combined benefit paid by the two policies is equal to this policy s lifetime orthodontia. Plan benefits are not payable if the orthodontic appliance was installed on or after the dependent s 23 rd birthday. Alternative benefits provision: In certain situations there may be more methods of treating a dental condition. Your policy includes an alternative benefits provision that may reduce benefits to the lowest cost, generally effective and necessary form of treatment. For assistance or additional information Contact Lincoln Financial Group at (800) or log on to This policy does not include coverage of pediatric dental services as required under federal law. Coverage of pediatric dental services is available for purchase in the State of Colorado, and can be purchased as a stand-alone plan, or as a covered benefit in another health plan. Please contact your insurance carrier, agent, or Connect for Health Colorado to purchase either a plan that includes pediatric dental coverage, or an Exchange-qualified stand-alone dental plan that includes pediatric dental coverage. NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Should there be a difference between this summary and the policy, the policy will govern Lincoln National Corporation Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Each affiliate is solely responsible for its own financial and contractual obligations. GLM Rev. 7/13 Dental_Grp_PPO

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6 The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE Phone: (800) Fax: (877) ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or GROUP ID: Type ARSEA GROUP POLICY #: 00001D Billing Division or Location: A. Member Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print) Arkansas State Employee Association County Pulaski Employer ZIP State Arkansas Member Last Name First Name Middle Initial Social Security Number Date of Birth Street Address City State Zip Gender: Male Female Marital Status: Married Single Home Phone ( ) address B. Product Selection NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Date Type of Coverage Amount of Coverage Monthly Premium High Option Yes No Employee Only Employee/Spouse Employee/Children Employee/Spouse/Children $39.10 $77.92 $76.09 $ D. Dependent and Other Insurance Information Last Name First Name Middle Initial Gender Date of Birth Spouse: Children: Are you or any of your eligible dependents covered by any other dental plan? YES (If YES, please list) NO Name of Insured Insurance Company Name & Phone and Policy Number Employer NOTE: A PERSON COMMITS INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: