United HealthOne Dental Insurance

All Plans: Preventive Services Preventive services are covered without a deductible, coinsurance, or waiting periods. Dental Primary and Dental Primary Preferred have a $25 copay for preventive services.

• Oral evaluations – limited to 2 per calendar year.
• Routine cleanings – limited to 2 per calendar year.
• Fluoride treatments – limited to covered persons under the age of 16 years, limited to 2 times per calendar year.
• X-rays (bitewing) – limited to 1 series per calendar year.
• X-rays (full mouth panoramic) – limited to 1 per 36 months.
• Space maintainers – limited to covered persons under the age of 16 years, once per 60 months. Benefit includes all adjustments within 6 months of installation.
• Sealants – limited to covered persons under the age of 16 years and once per first and second permanent molar every 36 months.All Plans: Basic ServicesBasic services are covered subject to the deductible, coinsurance, or waiting periods. Basic services have a 6-month waiting period.

• Fillings (amalgam and composite).
• Simple nonsurgical extractions – limited to 1 per tooth, per lifetime.
• General anesthesia – in conjunction with oral surgery or the removal of 7 or more teeth.
• Local anesthesia.
• Palliative treatment – only if no other services other than exam and radiographs were done on the same tooth during the visit.

Primary Preferred, Premier Choice, and Premier Elite plans only: Major Services (as limited in the policy) Major services are covered subject to the deductible, coinsurance, and waiting periods. Not available with all plans. Major services have a 12-month waiting period. • Root canals – limit 1 time per tooth, per lifetime. • Gum disease treatment. • Crowns – limit 1 per tooth, per 60 months. • Surgical extractions. • Full dentures – limited to 1 per 60 months. • Bridges – limited to 1 time per tooth, per 60 months. • Repairs to crowns, dentures and bridges. • Oral surgery. • Inlays/onlays – limit 1 per tooth, per 60 months.

Change or Misstatement of Residence (Address) You must notify us within 60 days of changing your residence. Your premium based on your new residence will begin on the first due date after the change. If you misstate your residence on the application or fail to notify us of a change of residence, we will apply the correct premium on the first due date you resided at that residence. If the change results in: lower premium, we will refund any excess; higher premium, you will owe us.

Network providers have agreed to discounted pricing for covered expenses with no additional billing to you other than the copayment, coinsurance, and deductible amounts. You may obtain further information about: 1) the status of providers by calling the toll-free telephone number on your identification card (or at myuhc.com); and 2) information on out-of-pocket expenses by calling the claims number listed on your identification card. Premium You will be given at least a 31-day notice of any change in your premium. We will make no change in your premium solely because of claims made by a covered person under the policy. Reimbursement If dental services are caused by the acts or omissions of a third party we have the right to be reimbursed to the extent of benefits we paid for dental services, as outlined in the policy. Renewability The policy term begins as of the effective date of the policy. You may keep the policy in force by paying us the required premium as it comes due. Your policy auto-renews as long as the premium is paid. However, we may cancel the policy if there is fraud or a material misrepresentation made by or with the knowledge of a covered person in filing a claim for benefits. Termination The policy will terminate: • If you fail to pay the premiums when due, subject to the Grace Period defined in the policy; • On the date you request; • If we decline to renew all policies issued on this form with the same type and level of benefits in your state of residence; or • On the date of your death, if your spouse is not covered under this plan.

Dependents Eligible dependents are your lawful husband or wife and eligible children. Eligible children must be unmarried (and under 26 years of age at time of application. Effective Date

For an application sent by electronic means, the effective date will be the later of: (i) the requested effective date; or (ii) the day after receipt by Golden Rule Insurance Company (GRIC). For a mailed application, the effective date will be the later of: (i) the requested effective date; or (ii) the day after the postmark date affixed by the U.S. Postal Service. If mailed and not postmarked by the U.S. Postal Service or if the postmark is not legible, the effective date will be the later of: (i) the requested effective date; or (ii) the date received by GRIC. Health Insurance for Dental Expenses If a covered person has other dental or health insurance that pays for expenses covered by the policy, we will not make payment until we determine what benefits are first paid by the other policy. Our payment will be reduced by the amount paid by the other plans. Non-Network vs. Network Providers Warning: You will pay more using non-network providers for non-emergency services. Non-network providers may bill you for any amount up to the billed charge after the plan has paid its portion. The basis of your benefit payment will be determined according to your policy’s non-network provider reimbursement.