Plan Disclosures

Exclusions:

In addition to the exclusions listed in the Benefits Section, RLHICA will not make payment for the following services, items or supplies and all charges for the same will be the responsibility of the Certificate Holder, unless otherwise specified in the Declarations Section:

1. Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services that are received from any government agency, political subdivision, community agency,

foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;

2. Services or appliances started prior to the date the person became eligible under this Policy, excluding orthodontic treatment in progress (if a Covered Service);

3. Charges for failure to keep a scheduled visit with the Dentist;

4. Charges for completion of forms or submission of claims;

5. Services, items or supplies for which no valid dental need can be demonstrated, as determined by RLHICA;

6. Services, items or supplies that are specialized techniques, as determined by RLHICA;

7. Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by RLHICA;

8. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;

9. Services, items or supplies excluded by the policies and procedures of RLHICA;

10. Services, items or supplies which are not rendered in accordance with accepted standards of dental practice, as determined by RLHICA;

11. Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of RLHICA coverage;

12. Services, items or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;

13. Services, items or supplies that are generally covered under a hospital, surgical/medical or prescription drug program;

14. Services, items or supplies that are not within the categories of Benefits that have been selected by the Policyholder and are not covered in this Policy;

15. Prescription drugs, non-prescription drugs, premedications, localized delivery of chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustments, enamel microabrasions, odontoplasty or bleaching;

16. Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by RLHICA;

17. Any appliance, restoration or surgical procedure used to (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; or (d) splint or stabilize teeth for periodontal reasons.

Limitations:

In addition to the limitations listed in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Declarations Section:

1. RLHICA’s obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;

2. When services in progress are interrupted and completed later by another Dentist, RLHICA will review the claim to determine the amount of payment, if any, to each Dentist;

3. Care terminated due to the death of a Certificate Holder or Eligible Dependent will be paid to the limit of RLHICA’s liability for the services completed or in progress;

4. The Maximum Payment will be limited to the amount specified in the Declarations Section of this Policy;

5. If a Deductible amount is specified in the Declarations Section, RLHICA will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies until the Deductible amount is met.

Notice: This website provides a very brief description of some important features of the coverage. It is not the Insurance Group Policy or Certificate. A full explanation of benefits, exclusions and limitations are contained in the Certificate of Insurance under group policy form D-100A-OH V4.

Plan Disclosures

Exclusions:

In addition to the exclusions listed in the Benefits Section, RLHICA will not make payment for the following services, items or supplies and all charges for the same will be the responsibility of the Certificate Holder, unless otherwise specified in the Declarations Section:

1. Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services that are received from any government agency, political subdivision, community agency,

foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;

2. Services or appliances started prior to the date the person became eligible under this Policy, excluding orthodontic treatment in progress (if a Covered Service);

3. Charges for failure to keep a scheduled visit with the Dentist;

4. Charges for completion of forms or submission of claims;

5. Services, items or supplies for which no valid dental need can be demonstrated, as determined by RLHICA;

6. Services, items or supplies that are specialized techniques, as determined by RLHICA;

7. Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by RLHICA;

8. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;

9. Services, items or supplies excluded by the policies and procedures of RLHICA;

10. Services, items or supplies which are not rendered in accordance with accepted standards of dental practice, as determined by RLHICA;

11. Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of RLHICA coverage;

12. Services, items or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;

13. Services, items or supplies that are generally covered under a hospital, surgical/medical or prescription drug program;

14. Services, items or supplies that are not within the categories of Benefits that have been selected by the Policyholder and are not covered in this Policy;

15. Prescription drugs, non-prescription drugs, premedications, localized delivery of chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustments, enamel microabrasions, odontoplasty or bleaching;

16. Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by RLHICA;

17. Any appliance, restoration or surgical procedure used to (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; or (d) splint or stabilize teeth for periodontal reasons.

Limitations:

In addition to the limitations listed in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Declarations Section:

1. RLHICA’s obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;

2. When services in progress are interrupted and completed later by another Dentist, RLHICA will review the claim to determine the amount of payment, if any, to each Dentist;

3. Care terminated due to the death of a Certificate Holder or Eligible Dependent will be paid to the limit of RLHICA’s liability for the services completed or in progress;

4. The Maximum Payment will be limited to the amount specified in the Declarations Section of this Policy;

5. If a Deductible amount is specified in the Declarations Section, RLHICA will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies until the Deductible amount is met.

Notice: This website provides a very brief description of some important features of the coverage. It is not the Insurance Group Policy or Certificate. A full explanation of benefits, exclusions and limitations are contained in the Certificate of Insurance under group policy form D-100A-OH V4.

THIS IS NOT INSURANCE

The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. It contains a 30 day cancellation period, provides discounts only at the offices of contracted health care providers, and each member is obligated to pay the discounted medical charges in full at the point of service. 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. Member shall receive a reimbursement of all periodic membership fees if membership is cancelled within the first 30 days after the effective date. UT, 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 application fee (minus $5.00) will be refunded if cancelled within the first 30 days and upon return of the discount card. Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475, 800-800-7616. Website to obtain participating providers: MyMemberPortal.com. Not available to KS, UT, VT, WA or FL residents.