www.myMERITAIN.com

A Quick Guide to Your Dental Care Benefits and Enrollment

ESG republic - Group #12422

Improve your overall healthwith dental benefits.It’s amazing how important your oral health can be to yourbody’s total balance and wholeness. Did you know thatgood dental care not only helps to prevent periodontal disease, but can also add as many as 6 years onto your life?That’s just one of the reasons why this plan includes dentalcare benefits for you and your enrolled dependents.

Why is dental health important?Regular dental care produces more than a bright smile. Poor oral health is linked to heart disease, stroke, diabetes,premature birth, osteoporosis and Alzheimer’s Disease. By taking advantage of your dental benefits, you can delaythe onset or progression of these health conditions.

Keep your smile white and bright!Follow these tips to keep your pearly whites in top condition:

� See your dentist regularly. Many children and adultsvisit their dentist every six months, however, your dentist may recommend that you attend check-ups more frequently based on your oral health needs.

� Avoid consuming products that stain your teeth (such as coffee, tea or red wine), or use a straw so the liquid bypasses your front teeth.

� Brush or rinse immediately after consuming stain-causing beverages or foods.

� Brush your teeth twice daily and floss once daily.� Use a whitening toothpaste once or twice a week to

remove stains and prevent yellowing.

Remember: Regular dental check-ups can

keep your smiles bright and beautiful!

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Benefit Highlights

Important things to know about eligibility.Dental plans are put together carefully to provide the best benefits possible for participants. This packet describes some of the most important provisions of your dental benefits. It’s another way Meritain Health is working with you to help you get themost from your benefits—so you can live a life that’s balanced and informed, with no “surprises.”

Dental care benefits for your family, too. Your family members can reap the rewards of the plan, too. Dental care benefits are available for every eligible dependent. Be sure your family knows about the opportunitiesopen to them—share this packet and other materials you receive from the plan!

Your eligible dependents.

This dental plan is open to you and your eligible dependents.

An eligible dependent is:� Your spouse (as defined in your plan documents).� Your children, natural or adopted.� Stepchildren living in your home.� A domestic partner that is living in your home (could vary by plan).� Children who have been placed in your home for adoption.� Children for whom you are the legal guardian.

When your dependents are not eligible for benefits under your plan.

Tell your employer if:� You become divorced from a spouse who was covered under this plan.� A dependent is between the ages of 19-23 and is not a full-time student. � A dependent turns 23 years old.

You’ll have to provide proof now to enroll any student over age 19, and again for each semester of school.The proof may be a letter from the registrar’s office, a copy of a receipt, or other proof of tuition paymentthat includes the number of credits or shows full-time student status.

If you have a family member covered by a different dental plan.

� You can enroll yourself and your eligible dependents in this plan.� You can enroll yourself in this plan, but decline benefits for some or all dependent(s). � You can decline benefits for your whole family.

Special enrollment situation.If you lose other group dental benefits that you or your dependents might have, and it’snot your fault (for example, the covered person is laid off or let go from a job) you’ll beable to sign up for this plan. Likewise, if you have an event such as your own marriage,divorce, or the birth or adoption of a child, you will have another brief period to sign upfor this plan. These are considered “Qualifying Events.”

Special enrollment time limit.

If you’re adding a dependent

to your dental plan through a

special enrollment situation

(marriage, birth, adoption, loss

of the dependent’s other

benefits, etc.), let your

employer know within 31 days

of the marriage, birth,

adoption, etc.; however, this

can vary by group.

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Dental care for you and your family:

Balancing dental care costs: What you pay and what the plan pays.

The Dental Plan Benefits Design in this packet shows how much you pay for dental care,and how much the plan pays. It’s a listing of what is and isn’t included in your benefitsplan. For more detailed information, see your Plan Document.

After you pay your annual deductible and any up-front copays, the plan begins to pay a percentage of your provider’s charges, for example 80%. The remaining percentage, for example 20%, is your responsibility—your “out-of-pocket” costs. You’re protected from financial hardship by a maximum out-of-pocket amount each year—the most you’ll have topay before the plan covers costs at 100%. (Copays do not always apply to the out-of-pocketmaximum. This varies by plan).

Save when you visit network providers.This plan offers a Preferred Provider Organization (PPO), a network of dentists and other dental care professionals who have agreed to accept lower amounts than their standardcharges, just for members of this plan. These lower amounts are negotiated and predetermined. That means when you visit a PPO provider, your share of costs is based ona lower charge—so your costs are lower, too. PPO providers are conveniently located inboth urban and rural areas. Remember: If you go outside the network, you may still have benefits, but your share ofcosts will be higher, and the amount you pay will not be based on a lower rate.

File claims quickly and easily.If you visit a provider in your network, you shouldn’t need to submit a claim for servicesor pay at the time of your service with the exception of a copay, if applicable. Yourprovider will submit the claim on your behalf and you will later receive a bill for any out-of-pocket or other balances due.

If you have visited an out-of-network provider, you may need to file a claim form toensure that the service is billed properly. Dental claim forms can be found online atwww.myMERITAIN.com or you can obtain one from your Human Resources Department.Submit the claim by fax or by mail to Meritain Health (information listed on the right).

Meritain Health Member Statements.The Meritain Health Member Statement is a document that replaces your Explanation ofBenefits document, or EOB. The layout is similar to a bank statement, with a design that isstraight-forward and easier to review than an EOB. You’ll receive a member statement foreach month in which you had claim activity. The statement will list all dental claimsprocessed in the preceding month.

Along with dental care claims, member statements track your deductible. This informationis helpful for you to manage your benefits, including your dental care dollars.

If you remain in favor of EOBs, don’t worry. They’re still available online and will continueto be sent only in cases of coverage denials, when they will contain instructions for filingappeals.

Customer support.

Contact us to talk to a

representative, dedicated to

helping you get the most from

your plan:

1.800.925.2272

Helpful tip.

By visiting doctors and

facilities within your PPO

network, who have agreed to

accept discounted rates for

seeing Meritain Health

members, you can realize

savings while on the road to

meeting your annual

deductible.

Claim submission.

Send dental claim forms and

attachments to:

Meritain Health

P.O. Box 27267

Minneapolis, MN 55427

Or fax to:

1.952.541.0193

PPO networks.

To determine a provider’s

participation in your PPO, you

may call your PPO Provider

Participation line:

Aetna Dental:

1.800.343.3140

DenteMax:

1.800.752.1547

PPO USA:

1.877.277.6872

About your dental plan benefits: You will get credit for prior time under another plan. Gold and Platinum Plans pay Endodontics and Periodontics at 90%. 24 hour access to your benefit information at www.myMERITAIN.com. Unmarried dependent children are covered from age 19 until their 23rd birthday, if enrolled as full-time students. No lifetime deductibles. Prosthetic replacement – one time every 5 years.

THIS IS A SUMMARY OF PLAN BENEFITS ONLY – PLEASE REFER TO YOUR PLAN DOCUMENT FOR COMPLETE BENEFIT DETAILS INCLUDING LIMITATIONS AND EXCLUSIONS.

DENTAL PLAN DESIGN Participating and Non Participating Providers paid at the applicable Fee Schedule

Silver Gold Platinum Benefits

Calendar Year Max $1,000 $1,500 $2,000

Deductible $50 $50 $50

Preventative Services No Waiting Period

100%

100%

100%

Deductible Waived

Exams – 2 per calendar year Cleanings – 2 per calendar year Bitewing X-rays – 2 per calendar yr Fluoride – 1 per calendar year to age 16.

Basic Services No Waiting Period

50%

90%

90%

Simple Extractions Fillings Space Maintainers Diagnostic X-rays

Special Services 6 Month Wait

50%

90%

90%

Oral Surgery Endodontics (Root Canal) Periodontics: Nightguards Scaling 1 per quadrant every 6 months

Major Services 12 Month Wait 50% 50% 50%

Bridges Dentures Crowns Sealants to age 16 -$50 cal yr max Implants: Platinum Plan only

Orthodontic Services 12 Month Wait Calendar Year Maximum Lifetime Maximum

Not Covered

50% $350

$1,000

50% $500

$1,500

Straightening of Teeth Dependent Children only to age 19

Dental Plan Benefits Design

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Complete your enrollment, and you’re on your way!

Card front

Card back

Group Name:

ABC Company

Member Name:

John Smith

Group No.

9416

Member ID

123456789

Customer Service: 1-999-999-9999 or visit www.myMERITAIN.com for

inquiries regarding eligibility, claims and plan benefits

Provider Service: 1-999-999-9999 providerservice@meritain.com

Claims Submission:

Mail PPO claims to:

PPO Network

Street Address

City, State, zip

■ You are enrolled in a Preferred Provider Organization (PPO) dental plan. To receive the in-network

level of benefits, your dental care provider must participate in the PPO. Call the provider info number

for participating providers.

■ Your name, identification number, group number and your group name, are used to identify you and

your covered dependents’ benefits.

■ You or your provider can call Meritain Health to verify eligibility of benefits or check on the status of your dental claims.

■ You can call for information on a dentist or other dental care provider who is close to you and serves your specific needs.

■ All dental claims should be submitted to Meritain Health at this address.

Other Claims Submission:

Meritain Health

P.O. Box xxxx

City, State, zip

www.meritain.com

Complete, sign and return your enrollment form to your employer within 31 days ofyour eligibility date, whether you’re enrolling in the dental plan or declining benefits. � If you’re enrolling a dependent child who is beyond the age limit for benefits,

you must tell us whether that dependent child is a full-time student or disabled, and provide supporting documentation.

� Write clearly! If your form is unreadable, your enrollment may be delayed, or incorrect.

� Don’t forget the back side of the enrollment form! Missing or incomplete information will delay your enrollment.

� Remember to sign and date the form, even if you’re declining benefits.

The final step toward better balance and better living.

After you’ve completed enrollment, your employer has approved it and after any waiting period has passed, your benefits will be effective.

Your Meritain Health ID Card will be on its way to you soon. The card showsMeritain Health as your dental plan administrator. Keep it in your wallet and carry itwith you.

Sample ID Card:

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Access convenient online tools and resources.

Visit your personalized member Web site, www.myMERITAIN.com, to find the dental care benefits information you need.

Once enrolled as a Meritain Health dental plan member, you will have access to www.myMERITAIN.com. When you log in,you’ll find everything you need to know about your benefits–from eligibility, to enrollment, to what’s covered. It’s another waywe’re working with you to help you get the most from your benefits–so you can live a life that’s balanced and informed.

Registration is easy!

If you’re already registered to access your online account, simply enter www.myMERITAIN.com into your browser and loginfrom the homepage.

If you’re not yet registered, it’s OK. Registration is an easy 4-step process.

1. Go to www.myMERITAIN.com.

2. Click on ‘Create a new user account’ and follow the instructions.

You will need to fill in:

� Your group ID (you can find this on your ID Card).� Your member ID (you can find this on your ID Card, as well. Enter with no spaces or dashes).� Date of birth.� Name.� Zip code.� E-mail address.

3. The system will display your username, which is your member ID. You will be asked to change your password. Enter and re-enter your new password, which you will need to create.

4. You will automatically be logged into your myMERITAIN account. The next time you login, use the same username and password from Step 3.

Important Contact Information:

Questions about... You may call... At this number:

� Dental benefits Meritain Health Customer Service 1.800.925.2272

� Participating providers Aetna Dental 1.800.343.3140

DenteMax 1.800.752.1547

PPO USA 1.877.277.6872

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ESG republic

COVERED DEPENDENT INFORMATION RELATIONSHIP TO APPLICANT PERSONAL INFORMATION FULL-TIME

STUDENT? DISABLED

DEPENDENT? COVERED UNDER ANOTHER PLAN? OTHER PLAN INFORMATION

SPOUSE

NAME (LAST, FIRST, MI) SEX

YES NO

NAME OF INSURANCE CARRIER

DATE OF BIRTH SOCIAL SECURITY NO. EFFECTIVE DATE OF COVERAGE

CHILD

NAME (LAST, FIRST, MI) SEX

YES NO

YES

NO YES NO

NAME OF INSURANCE CARRIER

DATE OF BIRTH SOCIAL SECURITY NO. EFFECTIVE DATE OF COVERAGE

CHILD

NAME (LAST, FIRST, MI) SEX

YES NO

YES

NO YES NO

NAME OF INSURANCE CARRIER

DATE OF BIRTH SOCIAL SECURITY NO. EFFECTIVE DATE OF COVERAGE

CHILD

NAME (LAST, FIRST, MI) SEX

YES NO

YES

NO YES NO

NAME OF INSURANCE CARRIER

DATE OF BIRTH SOCIAL SECURITY NO. EFFECTIVE DATE OF COVERAGE

= ATTACH DOCUMENTATION OR ELIGIBILITY WILL BE DELAYED COMPLETE REVERSE

BENEFIT ADMINISTRATOR SECTION EFFECTIVE DATE OCCUPATION

FULL-TIME EMPLOY. DATE PART-TIME EMPLOY. DATE

DIVISION # PPO

PRE-TAX CONTRIB. YES NO

ANNUAL SALARY

HOURLY SALARIED

NEW ENROLLMENT CONTINUOUS COVERAGE EFF. DATE

SPECIAL ENROLLMENT SITUATION

LATE/OPEN ENROLLMENT

FULL-TIME PART-TIME

RETIRED

ACTIVE COBRA

TERMINATION

VOLUNTARY

INVOLUNTARY

EMPLOYEE

DEPENDENT

ENROLLMENT CHANGE

NAME

ADDRESS

BENEFICIARY

STATUS CHANGE

RE-ENROLLMENT

OPEN ENROLLMENT

OTHER ____________________________

I testify that the above information is true and correct to the best of my knowledge.

DATE

BENEFIT ADMINISTRATOR SIGNATURE

PLEASE PRINT CLEARLY AND COMPLETE ENTIRE FORM, FRONT AND BACK

EMPLOYEE NAME (LAST, FIRST, MI) SOCIAL SECURITY NO.

SEX

M F DATE OF BIRTH (MM/DD/YY) # OF ELIGIBLE

CHILDREN E-MAIL ADDRESS

HOME ADDRESS CITY STATE

HOME TELEPHONE WORK TELEPHONE ZIP CODE COUNTY

DO YOU HAVE OTHER HEALTH COVERAGE?

YES NO

NAME OF OTHER INSURANCE CARRIER EFFECTIVE DATE OF COVERAGE

MARITAL STATUS DATE OF MARRIAGE SPOUSE DATE OF BIRTH SPOUSE EMPLOYED FULL-TIME?

YES NO

PLAN OPTION ELECTION DENTAL PLAN OPTION

SILVER PLAN GOLD PLAN PLATINUM PLAN

I DO NOT ELECT TO ENROLL IN

THE DENTAL PLAN.

LEVEL OF COVERAGE

EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + CHILD EMPLOYEE + CHILDREN FAMILY

EVEN IF YOU ARE DECLINING COVERAGE, YOU MUST SIGN REVERSE

12422

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NEW PLAN ENROLLEES ONLY

Have you been covered by health insurance in the past 63 days? YES NO

If yes, please submit to your employer a copy of the Certificate of Creditable Coverage from your previous employer or insurance company. If a Certificate of Creditable Coverage is not available at the time of application, submit it as soon as it is available; without it, a delay in claims processing may occur. If you need help obtaining a Certificate of Creditable Coverage or other evidence of past coverage, please contact your employer.

PLAN DECLARATION

I understand that the above elections will remain in effect until the last day of the Plan Year for which they are effective and will continue in effect indefinitely beyond that Plan Year unless I make an election change permitted under the Plan. I understand that I may change my elections during the Plan Year only if (i) I experience a “status change”, as defined under the Plan, and if my change in elections is consistent with that “status change”, (ii) I exercise a Special Enrollment Period Right (as described in the Notice of Special Enrollment Periods below), or (iii) I qualify (under applicable law, as determined by the Plan Administrator) to make another election change because of certain changes in cost or coverage of a benefit option, or for certain other reasons. I understand that the cost of a benefit option that I have elected under the Plan may change from one Plan Year to the next and I hereby agree that my payroll deductions will automatically change accordingly unless I submit a new Election Form during the appropriate annual election period to change or terminate that coverage. I also understand that, during a Plan Year, if there is a change in the cost of a benefit option that I have elected, the Employer may automatically increase the payroll deductions, if any, I am required to make per pay period to pay for that benefit option. I understand further that, except to the extent that I am permitted to make a change under the Plan, the payroll deduction elections I have made above will continue in effect notwithstanding any changes in the features or coverage offered under the benefit options I have elected above.

I understand that my employer may modify my benefit elections if appropriate to insure that the Plan complies with the terms of the Plan and the requirements (including tax-qualification requirements) of applicable law and that, subject to the requirements of applicable law or any applicable insurance contract, my employer retains the right to amend or terminate coverage under a benefit option. Also, I understand that the employer may modify my elections for health benefit options if required to do so by a Qualified Medical Child Support Order that requires me to provide health coverage for a dependent.

NOTICE OF SPECIAL ENROLLMENT PERIODS

If you are declining enrollment in the Plan’s health coverage options for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in the Plan’s health coverage features if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you are declining to enroll yourself or an eligible dependent for health coverage because you have (or your dependent has) existing health coverage, your employer may require that you provide a written statement indicating that you are declining coverage because of the existing health coverage. If the employer requires such a statement and notifies you of that requirement, you will receive a separate form to complete and you must complete it to preserve your right to a future special enrollment situation following a loss of that existing coverage.

To request special enrollment or obtain more information, contact your Human Resources representative.

SIGNATURE EMPLOYEE SIGNATURE

DATE