S M I L E . W E ’ V E G O T Y O U C O V E R E D .

DUAL OPTION

DENTAL PLAN

S104

94

Wilmington College

ilmington College

15069/15070

PPO Program underwritten by Security Life Insurance Company of America

DUAL CHOICE COVERAGEChoose a benefit which permits the selection of any dentist (PPO), or one that provides

better benefits through a panel of participating dentists (DHMO)....More choices....More value.

THE SECURITY LIFE PPO1 PLAN 100/80/50/0

WHAT ARE THE BENEFITS?Your coverage under the PPO Dental Plan includes all of the extensive services in the SUMMARYOF BENEFITS listed inside this brochure and more. Upon completion of your enrollment, you willbe sent a Group Insurance Certificate with a full listing of benefits and services.

You may use any licensed dentist or one of our Participating PPO Plan dentists (visit us atwww.DominionDental.com for a listing of participating PPO providers near you). When you oryour dependent(s) incur expenses for covered dental services, payments will be made in accordancewith the list of benefits and services you receive with your group insurance certificate.

Participating PPO network dentists are qualified practitioners, licensed and regulated by the appropriategovernment agencies. By receiving your dental care from a PPO network dentist you benefit fromour pre-negotiated fee schedules. Using a PPO dentist can significantly reduce your out-of-pocket costs.

ARE THERE ANY WAITING PERIODS?There are no waiting periods for Class I benefits. To be eligible for Class II benefits you must havecompleted 3 (three) months of continuous coverage. To be eligible for Class III benefits, you musthave completed 12 (twelve) months of continuous coverage. Credit will be given toward thesatisfaction of any benefit class waiting period for the length of time an insured was covered undereach benefit classification under the group’s prior dental plan, provided there was no break in coverage.

WHAT ARE THE DEDUCTIBLES?An annual deductible of $50 per person (family maximum of $150) is required on ClassII and Class III in-network services and all out-of-network services.

WHAT IS THE ANNUAL MAXIMUM BENEFIT PAYMENT?Benefits are subject to an annual maximum of $1,000 per insured person.

CLAIMS FILINGYou may use the dentist of your choice. Benefits will be paid directly to you or they may be assigneddirectly to your dentist. Claim forms should be completed by your dentist at the time services arerendered. Your Dentist may use the standard American Dental Association approved dental claim form.

This brochure provides a brief description of the PPO benefits provided under PolicyGH-1112-3656 issued to the Employers Voluntary Benefit Insurance Trust. Consult your groupinsurance certificate for complete plan details.

PPO Plan Claims Incurred Should Be Filed With:Dominion Dental Services USA, Inc.

P.O. Box 1920Bowie, MD 20717-1920

Telephone 1-888-518-5338

The PPO Plan Is Marketed And Administered By:Dominion Dental Services USA, Inc.115 South Union Street, Suite 300

Alexandria, Virginia 22314Telephone 1-888-518-5338

1 The PPO Plan is underwritten by Security Life Insurance Company of America.

(Administered by Dominion Dental Services USA, Inc.)THE DOMINION DHMO1 PLAN 505XSTAKE CARE OF YOUR TEETH WITH DOMINIONDental disease is preventable. DOMINION plans encourage the early detection of dental problemsand routine maintenance. We help you take better care of your teeth and now it can cost you lessto do it!

DOMINION has contracted with carefully selected, established, local dentists to deliver QUALITYdental services to subscribers through our managed care program.

OUR NETWORK OF PARTICIPATING DENTISTS PROVIDES:• Extensive coverage• Quality dental care at predetermined fees• Your choice of convenient private offices• An emphasis on prevention and early detection of dental problems

DHMO BENEFITS INCLUDE:• No charge for routine semiannual cleanings• No charge for oral examinations• No charge for bitewing x-rays• No charge for topical fluoride for children

These procedures account for over 65% of dental services most frequently performed for adults,and almost 90% of the most frequently performed services for children2.

You will receive more extensive care (fillings, crowns, dentures, root canals, periodontal care, oralsurgery, orthodontia, etc.) at fees 55% to 70% lower than usual and customary charges (see SUMMARYOF BENEFITS listed inside this brochure). You only pay the amount listed. Specialty care is provided atthe scheduled copayment whether performed by a participating general dentist or a participating specialist.

QUALITY COMES FIRSTAll DOMINION participating dentists are licensed and regulated by the appropriate governmentagencies. They are qualified, experienced professionals. And, as part of our requirement forparticipation in the DOMINION program, they undergo extensive credentialing and periodic officereviews by our staff of dentists and Professional Services Representatives.

YOUR CHOICE OF PARTICIPATING DENTISTSYou may select any general dentist from our enclosed DHMO Provider Directory. If you needspecific information on these offices, please call our Member Services Department toll-free at1-888-518-5338. You may also access www.DominionDental.com for provider information such asoffice hours, handicap accessibility, etc.

Each family member may select different participating dentists. And, if you ever need to change yourdentist for any reason, just call our Member Services Department.

OUT-OF-AREA EMERGENCY CAREYou are covered for palliative emergency dental treatment arising from accidental injury or illnesswhile temporarily more than 50 miles from home.

1 Dominion Dental Services, Inc. is licensed as a Dental Plan Organization in Delaware.2 Dominion Dental Services, Inc. - based on annual review of utilization data.

Benefit Your Features Coverage

Summary Your of Benefits Coverage1

Summary Your of Benefits Coverage

Benefit Your Features Coverage

DHMO Plan 505xs2 PPO Plan 100/80/50/01

1 Underwritten by Security Life Insurance Company of America and administered byDominion Dental Services USA, Inc.

2 New applicants must first complete 3 months of continuous coverage.3 New applicants must first complete 12 months of continuous coverage.4 Deductibles and Annual Maximums are per insured person. Deductibles apply

to Class II and Class III in-network services and all out-of-network services.Policy GH-1112-3656Form S10497

Preventive/Diagnostic Services 100%• Initial oral examination of mouth and teeth• Bite-wing and periapical x-rays• Fluoride treatments for children• Semiannual teeth cleaningsBasic Services 55-70%Restorative• Fillings

Amalgam (Silver)Composite (White)

• Panoramic x-raysOral Surgery• Simple extractionsMajor Services3 55%Prosthetics• Crowns and fixed bridgework• Dentures• Relining of dentures once every two (2) yearsPeriodontics• Root planing and therapyEndodontics• Root canal therapyOral Surgery• Extraction of impacted teethOrthodontics 45%• Child• Adult

Office Visit $10 CopaymentDeductibles NoneMaximum Annual Limit NoneWaiting Periods NoneClaims Forms NoneReceive Care From DHMO Dentist

Office Visit $0Deductibles4 $50($150)Maximum Annual Limit4 $1,000Waiting Periods YesClaims Forms YesReceive Care From Any Dentist or PPO Plan Dentist

1 Approximate percentage of coverage based on the ADP Context Fee Schedule’s 80th percentile.A specific fee schedule applies and will be mailed with the Membership Card.

2 Provided by Dominion Dental Services, Inc.3 Specialty care is provided at the scheduled copayment whether performed by a participating general

dentist or a participating specialist.

Class I: 100% / 100%• Initial oral examination of mouth and teeth• Bite-wing x-rays• Fluoride treatments for children• Semiannual teeth cleaningClass II2: 80% / 50%Restorative• Fillings

Amalgam (Silver)Composite (White)

• Diagnostic x-rays (full or panoramic)Oral Surgery• Simple extractionsClass III3: 50% / 50%Prosthetics• Crowns and inlays• Bridges and dentures• Relining of dentures once every two (2) yearsPeriodontics• Root planing and therapyEndodontics• Root canal therapyOral Surgery• Extraction of impacted teethClass IV: Orthodontics 0% / 0%• Child• Adult

in-network / out-of-network

PLAN LIMITATIONS1) Replacement of a bridge, crown or denture within 5 years after the date it wasoriginally installed. 2) Replacement of filling within 2 years after original date ofplacement. 3) Teeth cleaning (Prophylaxis) at intervals of less than six months.4) Crown and bridge fees apply to treatment involving five or fewer units whenpresented in a single treatment plan. Additional crown or bridge units, beginningwith the sixth unit, are available at the provider’s Usual, Customary, andReasonable (UCR) fee, minus 25%. 5) Full mouth x-rays orpanoramic film – one set every three years. 6) Retreatment ofroot canal within 2 years of the original treatment.7) Pedodontic care is covered up to age 5 with areferral from a Participating General Dentist.* All fees exclude the cost of noble and precious metals.An additional fee will be charged if these materials are used.

YOUR INSURANCE ENDS - PPO Insurance for you and your dependents will end on the earliest of:1. the last day you cease to be eligible;2. the last day your dependent ceases to be a dependent, as defined;3. last day of the month for which a premium has been paid, subject to the Grace Period; or4. date the Policy ends.

District of Columbia - WARNING: It is a crime to provide false or misleading information to an insurer for thepurpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, aninsurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or otherperson files an application for insurance or statement of claim containing any materially false information, orconceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulentinsurance act, which is a crime and subjects such person to criminal to and civil penalties.Virginia - It is a crime to knowingly provide false, incomplete or misleading information to an insurance companyfor the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

HOW DO I RECEIVE CARE?After your effective date, simply call the dental office you selected, make an appointment, and presentyour Membership Card upon arrival. You will receive treatment at the dental office listed on yourMembership Card, except when an emergency arises or when otherwise directed by your Plan Dentist.

WHAT IF I CHANGE JOBS?If you leave your place of employment, you have the option of keeping your coverage using analternate method of payment.

WHO IS ELIGIBLE?You and your dependents are eligible. Dependents include your spouse, unmarried childrenunder age 20, and unmarried children who are full-time students (up to age 23).

HOW DO I ENROLL IN THE DHMO PLAN?• Select a dentist from the DHMO Provider Directory enclosed.• Fill out the enclosed enrollment card. List all dependents you want covered. Be sure to check

the DHMO selection box.• Return the completed application to your Benefits Administrator.• A Membership Card and Certificate of Coverage will be mailed to you on or before your first

day of eligibility.

WHAT IS MY COST?The DOMINION dental plan is available to you through your employer for the monthly payrolldeductions of:

Subscriber Subscriber Subscriber Subscriber Only & Spouse & Family & Child/ren

$19.13 $35.45 $50.44 $40.69

PLAN EXCLUSIONS & LIMITATIONS

PLAN EXCLUSIONS1) Services for injuries or conditions which are covered under worker’s compensation and employer’s liability laws.Services which are provided without cost to Subscribers by any federal, state, municipal, county, or other subdivision’sprogram (with the exception of Medicaid). 2) Services which, in the opinion of the attending dentist, are not necessaryfor the patient’s dental health. 3) Cosmetic, elective or aesthetic dentistry. 4) Oral surgery requiring the setting offractures or dislocations. 5) Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic,mandibular prognathism or development malformations where, in the sole discretion of the Participating Dentist, suchservices should not be performed in a dental office. 6) Dispensing of drugs. 7) Hospitalization for any dental procedure.8) Treatment required for conditions resulting from major disaster, epidemic or war, including declared or undeclaredwar or acts of war. 9) Replacement due to loss or theft of prosthetic appliance. 10) General anesthesia and sedation.11) Services that cannot be performed because of the general health of the patient. 12) Implantation and relatedrestorative procedures. 13) Unlisted procedures are not covered. 14) Services obtained outside of the dental officein which enrolled and which are not pre-authorized by such office or Dominion Dental Services, Inc. (with theexception of out-of-area emergency dental services). 15) Services related to the treatment of TMD (TemporalMandibular Disorder). 16) Services related to procedures which are of such a degree of complexity as to not benormally performed by a Participating General Dentist. Above copayments do not apply when performed by a PlanSpecialist (with the exception of Orthodontics). Plan Specialist, if available, will reduce fees 25% from Usual, Customary,and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reductionfrom their UCR that will vary between specialists. 17) Elective surgery including, but not limited toextraction of nonpathologic, asymptomatic impacted teeth.

HOW DO I ENROLL IN THE PPO PLAN?• Fill out the enclosed enrollment card. List all dependents you want covered. Be sure to select

the PPO selection box. You do not need to choose a provider.• Return the completed application to your Benefits Administrator.• A Membership Card and Certificate of Coverage will be mailed to you on or before your first

day of eligibility.• If you have any questions regarding your date of eligibility, please contact your Benefits Department.

WHAT IS MY COST?The DOMINION dental plan is available to you through your employer for the monthly payrolldeductions of:

Subscriber Subscriber Subscriber SubscriberOnly & Spouse & Family & Child/ren

$38.91 $76.28 $117.06 $82.34

PPO EXCLUSIONS & LIMITATIONSEXPENSES NOT COVERED UNDER THE PPO PLAN: No benefits will be paid for expenses incurred:1) for overdentures and associated procedures. 2) for charges in excess of those considered reasonable andcustomary. 3) for cosmetic procedures. 4) for the replacement of dentures, bridges, inlays, onlays or crownsthat can be repaired or restored to normal function. 5) for implants; replacement of lost or stolen appliances;replacement of retainers; athletic mouthguards; precision or semi-precision attachments; denture duplication;sealants; analgesic; or splinting. 6) for oral hygiene instructions; plaque control; completion of a claim form;acid etch; broken appointments; prescription or take-home fluoride; or diagnostic photographs. 7) forservices not completed by the end of the month in which coverage ends, unless continuation of coverage hasbeen requested and accepted by us. 8) for procedures that are begun, but not completed. 9) for services andtreatment provided without charge or for which there would be no charge in the absence of insurance.10) for services in connection with war or any act of war, whether declared or undeclared, or conditioncontracted or accident occurring while on full-time active duty in the armed forces of any country orcombination of countries. 11) for a condition covered under any Worker’s Compensation Act or similar law.12) that are applied toward satisfaction of a deductible, if any. 13) that are generally considered by the dentalprofession as experimental or investigational. 14) for the treatment of cleft palate and anodontia. 15) forservices or supplies payable under any medical expense plan. 16) for orthodontia, unless included by rider. 17)prior to the date the Insured is covered under the Policy. 18) for the diagnosis or treatment ofTemporomandibular Joint Dysfunction. 19) for hospital services. 20) for any unmarried child age 25 years ofage and over unless he is dependent upon you for support, while a full-time student. A full-time student is onewho is enrolled for 12 semester hours for credit in an accredited junior college, college or university. Anyexception for a full-time student will end at age 25. 21) during any waiting period we require, when youvoluntarily end your insurance and re-enroll at a later date. Your waiting period is 2 years and begins on thedate your coverage first ended.