Dental & VisionPPO Plan

Available in ALL 50 States and Open to ALL Federal & Postal Employees, Retired &

Temporary Employees for our American Federal Employees Group (AFEG)

Pre-Existing Conditions Covered � Easy to Understand Co-Insurance % for Each Procedure � Vision Discount Plan Included

Coverage Includes: Bridges, Dentures, Partials, Repairs, Orthodontia* (with a 12-month waiting period), and more!

Add Coverage For: Parents, Siblings, Over-Age Children, Grandchildren, & More!

Dental Plans from FCL Dental (First Continental Life Insurance Company)

American Marketing Administrators Inc. 23901 Calabasas Road, Ste. 2014 Calabasas, California 91302-3307

818-223-9750 800-300-PLANF: 818-223-8147

www.fedvp.com info@fedvp.com

Enroll Year-Round � choose your own Dentist No One Refused Coverage � No Waiting Period*

(*With Previous Coverage) Bi-Weekly Premiums from

$15 SELF only $27 Self +1 $45 FamilY

FCL PPO Bi-Weekly Premium Self Self +1 Family High Plan $22 $41 $67 Low Plan $15 $27 $45 FCL PPO Monthly Premium High Plan $46 $87 $145 Low Plan $32 $58 $96 FCL PPO Quarterly Premium High Plan $138 $261 $435 Low Plan $96 $174 $288

Premiums include administrative fees. Please add a one-time enrollment fee of $20 to your chosen Plan premium.

Covered Services & Co-Payments Comparison

FCL Dental Plan Premiums

Type Number

Sample Procedure Co-Insurance

Pays High/Low

High Out-of-Pocket

In-Network

Low Out-of-Pocket

In-Network

Type 1 D0120 Oral Exam 100%/100% $0.00 $0.00 D1110 Prophylaxis (2 per year) 100%/100% $0.00 $0.00 D0274 Bitewings (4 films) 100%/100% $0.00 $0.00

Type 2 D2160 Amalgam Fillings (3 surfaces) 80%/50% $26.00 $65.00

Type 3 D2751 Crown: Porcelain fused to High Noble

50%/25% $450.00 $680.00

D3330 Endodontic Therapy (molar) 50%/25% $400.00 $600.00 Type 4 Orthodontic Treatment (up to age

18) 50%/25% $1500.00

Lifetime Maximum 12-month waiting

period

$1000.00 Lifetime

Maximum 12-month waiting period

Diagnostic & Preventative (Exam, Cleaning, X-Rays): • PPO: High 100%; Low 100%

Restorative (Fillings): • PPO: High 80%; Low 50%

Major Dentistry (Root Canals, Crowns): • PPO: High 50%; Low 25%

Orthodontics (12-month waiting period): • PPO: High $1500; Low $1000

Annual Maximum: • PPO: High $2000; Low $1000

*Percentages quoted are approximate and apply to in-networkdentists. A full list of Covered Services and Prices is available upon request.*There is no waiting period for any treatment exceptOrthodontia. With Prior Coverage through Takeover benefits* If you visit a non-participating dentist, the charges will be higher than the covered amount. The co-insurance level willapply to the maximum allowable fee

* There is no waiting period for any treatment except orthodonitia (12 months) if you provide proof of prior coverage (please see“Takeover Benefits”.The annual maxium per person is $2000.00 per person per candendar year on the High Plan and $1000.00 per person per calendar year for the Low Plan. The annual deductible is $50.00 per person and $150.00 per family on Type 2/3 procedures. If you visit a non-participating dentist, charges can be substantially higher than the amount covered. The co-insurance level will apply to the maxium allowable fee.

Don’t Be Overcharged: Always ask for and review a treatment plan in advance of work!

October 2017

ABOUT FCL DENTAL

First Continental Life & Accident Insurance Company (dba FCL Dental) is one of the largest independent, full-service dental benefits providers with approximately 330,000 covered members and counting. Founded in 1998 to deliver innovative and high-quality dental managed care products to employer groups and individuals, FCL Dental has developed a wide range of dental benefit plans, including health maintenance organization (“HMO”), preferred provider organization (“PPO”) and indemnity plan designs, to provide maximum flexibility to its commercial groups, health plan customers and nursing home facilities. The Company’s commercial customers include employer groups, government agencies, municipalities, unions, associations and individuals. Its public sector business provides dental benefits to beneficiaries of public programs such as Medicare, Medicaid and other social programs in partnership with major health plans as either value added benefits or complex mandated benefits. FCL Dental typically enters into contracts with its health plan customers for whom it operates as a subcontracting dental vendor. In addition, the Company also provides dental insurance programs for residents at nursing home facilities to enhance their quality of life through preventive oral care on a regular basis. FCL Dental is headquartered in Sugar Land, Texas.

Frequently Asked Questions about DenteMax Q. What is DenteMax? DenteMax is a national, dental Preferred Provider Organization network. DenteMax’s group of quality dentists have agreed to accept a set, discounted fee schedule when they see DenteMax patients. This means that you can visit any of our PPO dentists and save on your dental costs. Q. Why should I go to a DenteMax dentist? When you choose a DenteMax dentist, you can save on out-of-pocket expenses. DenteMax fees are generally less than a dentist’s usual office fees. In addition, all dentists are credentialed before joining the network. DenteMax checks into a dentist’s current practice information and history to make sure that they meet our high-quality standards. This gives you peace of mind knowing that you are being treated by one of the best. You can visit the DenteMax Web site at dentemax.com to find the most up-to-date list of DenteMax dentists. You can also call us toll-free at 800-752-1547 and a representative can help you locate a network provider in your area. Directories are available as well and are current as of the printed date. Q. Is DenteMax my insurance company? No, DenteMax is not an insurance company. DenteMax is a network of dentists. Our core competency is in the recruitment, credentialing and retention of a high-quality network. You must call your health benefit plan at the number on your ID card for information on your benefit levels and eligibility. DenteMax is solely a dental network and we do not have information on your benefit levels or what services are covered. Q. If my dentist does not participate with DenteMax, how can he/she join? Contact your dentist and advise him/her that you now have dental coverage that uses the DenteMax network. Ask if he/she would be willing to join. If your dentist would like to review our information, he/she can contact us at 800-752-1547. Or you can refer your dentist by phone or via our Web site at dentemax.com. We will contact the dental office directly with information on joining our program.

COAST-TO-COAST VISION CARE

All Dental Plans come with Vision Discounts. Save at thousands of locations, nationwide!

1. Prescription Eye Wear: Save 20-60% Most frames, lenses, and specialty items (including tints, scratch resistant coatings and ultraviolet protection) are conveniently available at participating locations. 2. Replacement of Contact Lenses: Save 10-40% Most major brands of soft contact lenses are obtainable through the mail order service provided by America’s Eyewear, including disposable, tonics, and E bifocals. Gas permeable materials are also available. 3. Ophthalmology Services: Save 10-30% Vision members receive discounts on eye exams at participating locations. 4. Laser Surgery: Save 40-50% Discount off the overall national average for laser eye surgery. 5. Fully-insured Vision Care Plans are available for an additional premium. Visit www.fedvp.com or call 800-300-PLAN for more details. You and your family can now save hundreds of dollars each year. There is no limit on quantities and no restrictions on selections. There is no paperwork or waiting. Prices may change without notice. Use this plan and SAVE MONEY!

To find the vision provider nearest you, call 800-800-EYES or visit www.mymemberportal.com

Regional Chains: American Vision Center, Budget Optical of America, Cohen’s Optical, Dulings Optical, E.B. Brown Opticians, Eye Masters, Eyes First Vision Center, Sears Optical, Site for Sore Eyes, Steins Op Texas, Soptica Thomas Opticians, TSO, Uhlemann Optical, Value-Vision, Vision Works, Vision World, and many more! THIS VISION PLAN IS NOT INSURANCE. This Plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the provider of medical services. The Plan Member is obligated to pay for all healthcare providers who have contracted with the discount plan organization. The Plan is not insurance coverage and does not meet the minimum creditable coverage requirements under MGLc111M and 956CMR5.00 or Patient Protection and Affordable Care Act. This discount card program contains a 30-day cancellation period. The range of discounts for medical or ancillary services provided under the Plan will vary depending on the type of provider and medical or ancillary service received. The discount medical card program makes available, before purchase and upon request, a list of program providers, including the name, city, State, and specialty of each program provider located in the cardholder’s service area. FL, LA, MS, ND, OK, RI, SC, UT, SD, and TX residents: Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after the effective date. AR and TN residents: a refund of all fees will be issued if membership is cancelled within the first 30 days. MD residents: the membership fee and one-time registration fee (minus $5.00 processing fee) will be refunded if cancelled within the first 30 days and upon return of the discount card to: Discount Medical Plan Organization: New Benefits, LTD., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309, 800-800-7616.

Application for Membership & Enrollment in the American Federal Employees Group Association (AFEG)* Dental and Vision Care Benefits

Name:

DOB: SS#:

Home Address: Mailing Address (if different from above): Home Phone:

Cell Phone:

Email (never sold or given to others): Employer Name & Address: Work Phone:

Work Fax:

Spouse/Partner Name:

DOB:

Child(ren)/Dependent(s) Name(s):

DOBs:

DENTIST NAME & DDS#:

Plan Selected:

[ ] High [ ] Low

*By signing up for our Traditional PPO Plan and our Maximum Covered Expense Plan, you are joining our successful American Federal Employees Group (AFEG), at no additional fee to you

Premium Amount + $20 Enrollment Fee: $

Payment Options (select one): [ ] Bi-Weekly Federal or Postal Employee Payroll Deduction* [ ] Monthly Credit Card (+4% fee) [ ] Monthly Bank Draft [ ] Direct Billing: [ ] Quarterly [ ] Semi-Annual [ ] Annual This authorization remains in effect until revoked by me in writing. I understand that this enrollment is for a minimum of twelve (12) months. If a future increase in premium requires a premium increase and I don’t elect to do a premium increase I understand that my Plan will change. If coverage is stopped and then I wish to restart I may receive no prior credit and late enrollment reductions in benefits may occur. In several States we are required to advise you on the following: any person who knowingly and with intent to defraud provides false, incomplete or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. As a Member, I hereby apply for the insurance benefits in the Plan’s materials, which I have read, or have had read to me and understand. I represent that the information I have provided is complete and accurate.

I understand that neither American National Dental Services nor American Marketing Administrators (“ANDS/AMA”) represent or warrant the quality or competence of, or guarantee the services performed or results promised by, the dental or vision service provider in the Plan.To the fullest extent permitted by law, I agree to limit liability of ANDS/AMA for any claims or damages I might incur in receiving dental or vision services, and that ANDS/AMA’s liability shall not exceed the total compensation received by ANDS/AMA paid by me for the plan. It is intended that this limitation apply to any and all liability or cause of action however alleged or arising, unless prohibited by law. Applicant for Membership and Coverage Signature: Date: I am interested in receiving information on Vision Care Plans: [ ] Y [ ] N I am interested in receiving information on Disability Insurance, or Individual/Group Medical Insurance: [ ] Y [ ] N

PAYMENT INSTRUCTIONS ENROLLMENT: The regular starting date of eligibility is the 1st of the month. However, if you pay by payroll deduction, your eligiblity will take place 6-8 weeks after receipt of your application and payment. If you would like to expedite your coverage on payroll deduction, please send 2 months premium, plus your $20 enrollment fee.These can be paid in one of the following ways:

1. Check: make checks payable to ANDS and mail to: 29301 Calabasas Road, Ste. 2014, Calabasas, CA 91302-3307 2. Credit Card: fill out your details below and use your Visa or Mastercard (which will incur a 4% charge): 3. Automatic Bank Draft: fill our your details below and provide us with your 9-digit Routing Number and your Account Number

BI-WEEKLY FEDERAL & POSTAL EMPLOYEE PAYROLL DEDUCTION: Your eligibility will begin 6-8 weeks following the receipt of this form and your online account details. To expedite this process, please follow the instructions above. Use the following information to set up payments through MyPay.com or EmployeeExpress.com, or your employer’s payroll solution: FEDERAL EMPLOYEES POSTAL EMPLOYEES

• Wells Fargo #: 121042882 • Account #: 0912028818 • Account Type: Savings

• BOA Routing #: 011900445 • Account #: CGS0225- then your SSN • Account Type Savings

You are hereby requested to establish an account in my name to the designated insurance account. I understand that this account will be used solely for the purpose of receiving monies from my employer for the payment of insurance and will be non-interest bearing to me. This will institute an allotment from my pay to the bank for deposit to my insurance account. I hereby authorize and empower you for and on my behalf to deposit each month, if available, from insurance/savings/checking account. These instructions and authorizations may be cancelled or amended at anytime upon receipt by the bank or assignee of either written notice by me or an executed copy of the US Treasury allotment form as modified by the US Treasuring bearing my signature. Signature: Date: Mail this form and the application form to: AMA, 23901 Calabasas Road, Ste. 2014 Calabasas, California 91302-3307

CREDIT CARD PAYMENT (please note: credit card payments incur a 4% charge): I hereby authorize AMERICAN MARKETING ADMINISTRATORS, INC. to charge my credit card the required preimium and/or fees due for the requested coverage and Plans. This authority is to remain in effect until revoked by me in writing by US Mail. Credit Card Payment: [ ] Mastercard [ ] Visa Please Charge My Card For: [ ] Enrollment Fee [ ] 2 Months Premiums to Start [ ] Monthly Name on Account: Credit Card #: Expiry: Billing Address: Security Code: Signature: Date: Mail this form and the application form to: AMA, 23901 Calabasas Road, Ste. 2014 Calabasas, California 91302-3307

MONTHLY BANK DRAFT: I request and authorize YOU to pay and charge to my account checks drawn on the account by and payable to the order of AMERICAN MARKETING ADMINISTRATORS, INC. (AMA) provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each debit shall be the same as if it were a check drawn by you and signed personally by me. I authorize AMA to initiate debits (&/or corrections to previous debits) from my account with the financial institution indicated for payment of any required preimium &/or fees due for requested coverage & plans. This authority is to remain in effect until revoked by me, in writing, by US Mail & until you actually receive such notice. I agree that you shall be fully protected in honoring such debit. I further agree that if any such debit be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in forfeiture of coverage & fees for dishonored checks. Name of Bank/Financial Institution: Name on Checking Account: Address: Routing ABA# (first 9 #s): Account Number: Type of Account: [ ] Checking [ ] Savings To Pay: [ ] Enrollment Fee [ ] 2 Months [ ] Continuous Monthly Note: you will incur a service charge for any withdrawals not honored. Signature: Date: Mail this form and the application form to: AMA, 23901 Calabasas Road, Ste. 2014 Calabasas, California 91302-3307

DIRECT BILLING: Mail a the application form and a check for the [ ] Quarterly [ ] Semi-Annual [ ] Annual premium amount for your chosen Plan, along with your $20 enrollment fee to: AMA, 23901 Calabasas Road, Ste. 2014 Calabasas, California 91302-3307. We will bill you according to your selected billing period thereafter.

1. relationship with any Member and are unable to do so, the rights of such Member and other members of his/her family under contract may be terminated effective the last day of the month during which termination occurs.

2. 5. In the event that fees or premiums are delinquent, services and benefits under the Plan shall be terminated effective on the last day of the month during which the delinquency occurred.

3. 6. Permitting or committing fraud. In the even to f termination, the Plan shall complete any contracted procedure listed under “Covered Services & Co-Payment Schedule”. The Member is required to pay all fees and premiums.

4. 7. By Member giving thirty (30)-days notice of intention to cancel the Plan by US Mail.

5. 8. After the date on which termination becomes effective the General Dentist will complete any “service in progress.” Benefits shall cease upon (a) the date coverage expires if not renewed; (b) notice a satisfactory dentist/patient relationship cannot be established; or, (c) a dependent attaining age 26 or marriage. Financial Liability of Member: By Statute, in the event the Plan fails to pay the Professional Provider, the Member shall not be liable to the Professional Provider for sums owed by the Plan. If the Plan FAILS TO PAY NON-CONTRACTING PROVIDERS, THE MEMBER MAY BE LIABLE TO THAT NON-CONTRACTING PROVIDER FOR COST OF SERVICES.

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Who May Enroll? All residents in a State where coverage is made available. Eligible dependents include your spouse and unmarried children to age 26. Yes, Add Family Members & Spouses! It is our desire to provide our subscribers with the most flexibility. You may also purchase coverage for over-age children, parents, siblings, domestic partners, or any other individual that you have a financial responsibility for. You may do this by adding the individual “Self” premium for each person needing coverage. How To Enroll: 1. Complete the Application, choose a Dentist, and select a Plan. Attach a note with name and SS# for those in other States, such as children attending school. 2. Please send the premium form (your choice) plus the $20 enrollment fee with application to:

American Marketing Administrators

23901 Calabasas Road, Ste. 2014 Calabasas, CA 91302-3307

3. Mail your application with your check/company check made payable to: American National Dental Services. 4. DO NOT send forms directly to your Payroll or Union offices. This will only delay your eligibility. Grievance Procedure: Please direct all grievances to the Plan. Unresolved grievances will be settled by arbitration. Other Charges and the Member’s Responsibility: The providers are located in many areas. The member must pay the premium applicable to a given area. Co-payments must be paid directly to the assigned provider for all services

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rendered, including those provided at a reduced fee. Services not listed are available on a fee-for-service basis. The fees must be paid directly to the office where services are received. When Will I Become Eligible? The first of the month after your second payroll deduction and/or a full premium and enrollment fee is received. The first week you’re covered, an Information Card (ID) will be sent to you. Your card does not assure coverage. This may only be done through payment of premiums and following the Plan’s requirements. Renewal Provision: You may renew coverage at the prevailing rate for the benefits available at the time your coverage expires. Notice of any rate change will be mailed fifteen (15) days prior to expiration. Individual Continuance of Benefits: You may continue your coverage on a direct basis should your employment be changed or terminated from the Group or Plan by calling 818-223-9750 Termination of Benefits: Benefits will be terminated under the following conditions:

1. 1. On the expiration date. 2. 2. Upon the date of entry into full-time

military service. 3. 3. Upon dependent attaining age 26 or

marriage. 4. 4. The Plan reserves the right if, after

reasonable efforts to establish and maintain satisfactory provider/patient

FAQS & General Plan Information

Principle limitations & exclusions Covered Expenses Will Not Include and No Benefits Will be Payable: 1. For any treatment which is for cosmetic purposes or to correct congenital malformations, except for medically necessary care and treatment of

congenital cleft lip and palate. 2. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these

items, unless required because of an accidental bodily injury sustained while the Insured is covered. Replacement is not covered if the item can be repaired.

3. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of natural teeth during the same period of continuous coverage. But the extraction of a third molar (wisdom tooth) will not qualify the item for payment. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. Coverage does not include the part of the cost that aplies specifically to replacement of teeth extracted prior to the period of coverage.

4. For addition of teeth to an existing prosthetic appliance or fixed bridge unless for replacement of natural teeth extracted during the same period of continuous coverage.

5. For any expense incurred or procedure begun before the Insured’s current period of continuous coverage. 6. For any expense incurred or procedure begun after the Insured’s insurance under this section terminates, except for a prosthetic appliance, fixed

bridge, crown, or inlay or onlay restoration for which both (a) the procedure begins before insurance ends and (b) the item’s final placement is within 90 days after insurance ends.

7. To duplicate appliances or replace lost or stolen appliances. 8. For appliances, restorations or procedures to: a. alter vertical dimension; b. restore or maintain occlusion; c. splint or replace tooth structure lost as

a result of abrasion or attrition; or d. treat jaw fractures or disturbances of the temporomandibular joint. 9. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. 10. For broken appointments or the completion of claim forms. 11. For orthodontia service or for any services associated with orthodontic therapy when this optional coverage is not elected and the premium is not

paid. 12. For sealants which are: a. not applied to a permanent molar; b. applied before age 6 or after attaining age 16; or c. reapplied to a molar within three

years from the date of a previous sealant application. 13. For subgingival curettage or root planing (procedure numbers 4220 and 4341) unless the presence of periodontal disease is confirmed by both x-rays

and pocket depth summaries of each tooth involved. 14. Because of an Insured’s injury arising out of, or in the course of, work for wage or profit. 15. For an Insured’s sickness, injury or condition for which he or she is eligible for benefits under any Workers Compensation Act or similar laws. 16. For services which are not recommended by a dentist, not required for necessary care and treatment, or do not have a reasonably favorable

prognosis. 17. Because of war or any act of war, declared or not, or while on full-time active duty in the armed forces of any country. 18. To an Insured if payment is not legal where the Insured is living when expenses are incurred. 19. For any services related to: equilibration, bite registration or bite analysis. 20. For crowns for the purpose of periodontal splinting. 21. For charges for: any implants; overdentures; precision or semi-precision attachments and associated endodontic treatment; other customized

attachments; or specialized prosthodontic techniques or characterizations. 22. For charges for myofunctional therapy, orthognathic surgery or athletic mouthguards. 23. For procedures for which benefits are payable under the employer’s medical expense benefits plan for employees and their dependents. 24. Services or supplies provided by a family member or a member of the Insured’s household.

Note: This is a general outline of covered benefits and does not include all the benefits, limitations and exclusions of the policy. See your certificate for details. Predetermination of Benefits: As a service to protect the Insured, First Continental Life & Accident Insurance Co. will provide predetermination of benefits for recommended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps Insured's better understand their coverage. The Insured should submit the treatment plan to First Continental Life & Accident Insurance Co. for review and predetermination of benefits before the service begins.

TAKEOVER BENEFITS Takeover means that you are given credit for waiting periods for like coverage's accumulated under your existing plan. No credit is given for deductibles satisfied under your existing plan. 1. In order to provide Takeover Benefits your employer’s current dental plan must have been in effect continuously for at least 12 months prior to the effective date of this plan. 2. All employees insured on the effective date with continuous coverage from the prior group dental contract are eligible for Takeover Benefits. Waiting periods will be reduced by the amount of time insured under the prior plan. 3. A minimum of three (3) enrolled members are needed for an employer to be eligible for Takeover Benefits. 4. Takeover Benefits must be requested and are subject to the approval of First Continental Life & Accident Insurance Co.

Submission of Claims: First Continental Life & Accident Insurance Co. ATTN: Claims Department 101 Parklane Blvd, Suite 301 Sugar Land, TX. 77478

Verification of Claims: 281-313-7170 (local) 1-877-493-6282 (toll free)