2020 Delta Dental

Delta Dental Basic Delta Dental Premium Coverage Coverage Plan Identifying Information Plan Year 2020 2020 Active Plan Code(s) 347, 356 348, 357 Retiree Plan Code(s) 347 348 HPH code(s) ACTDEN347, COBDEN347, ACTDEN348, COBDEN348, RETDEN347, ACTDEN356, RETDEN348, ACTDEN357, COBDEN356 COBDEN357

Dental Coverage Plan Facts Member services 800-335-8289 800-335-8289 Prospective members 800-335-8289 800-335-8289 phone number TTY 877-287-9039 877-287-9039 Outside U.S. phone 800-237-6060 800-237-6060 number Member services hours Monday - Thursday: 8:15 a.m. Monday - Thursday: 8:15 a.m. to to 6:00 p.m. ET; Friday: 8:15 6:00 p.m. ET; Friday: 8:15 a.m. a.m. to 4:45 p.m. ET to 4:45 p.m. ET

Web site www.deltadentalva.com www.deltadentalva.com Prospective members web www.deltadentalva.com www.deltadentalva.com site Network name Delta Dental PPO plus Premier Delta Dental PPO plus Premier

Claims Administrator Delta Dental of Virginia Delta Dental of Virginia General Plan description Corporate Plan - Delta Dental Corporate Plan - Delta Dental PPO plus Premier PPO plus Premier

9/17/19 1 Delta Dental Basic Delta Dental Premium Coverage Coverage How the plan pays Members may visit a dentist Members may visit a dentist from benefits from the Delta Dental PPO the Delta Dental PPO network or network or Delta Dental Premier Delta Dental Premier network. network. Participating dentists Participating dentists have have agreed to accept the agreed to accept the network network plan allowance as plan allowance as payment in payment in full. Delta Dental full. Delta Dental bases its bases its payment on the out-of- payment on the out-of-network network par plan allowance for par plan allowance for covered covered benefits provided by out-benefits provided by out-of- of-network dentists and network dentists and members members are responsible for the are responsible for the difference difference between the out-of- between the out-of-network network dentist's charges and dentist's charges and this plan this plan allowance. All members allowance. All members may be may be responsible for their responsible for their deductible, deductible, coinsurance and coinsurance and amounts amounts exceeding the plan exceeding the plan maximums. maximums.

Use of network dentist No No required? Pretreatment estimate Not required but recommended Not required but recommended for services over $250 for services over $250

Alternate Treatment Please refer to the Alternative Please refer to the Alternative Provision Dental Procedures section in the Dental Procedures section in the SPD SPD

Annual deductible: $75 Individual; $150 family $50 Individual; $100 family Individual/Family Deductible waived for Yes Yes preventive/diagnostic care

Annual maximum benefit $1,000; applies to all services $2,000; applies to all services per person except diagnostic/preventive and except diagnostic/preventive and orthodontics orthodontics

Diagnostic and Preventive Care Oral exams No charge; limited to 2 per No charge; limited to 2 per calendar year calendar year

9/17/19 2 Delta Dental Basic Delta Dental Premium Coverage Coverage Cleanings No charge; limited to 4 cleanings No charge; limited to 4 cleanings per calendar year (maximum of per calendar year (maximum of 2 2 regular/prophylaxis cleanings) regular/prophylaxis cleanings) with history of periodontal with history of periodontal treatment treatment

Topical fluoride No charge; limited to 2 per No charge; limited to 2 per applications for children calendar year to age 19 calendar year to age 19

Bitewing X-ray No charge; limited to 1 per No charge; limited to 1 per calendar year and 4 bitewing calendar year and 4 bitewing films in 1 visit films in 1 visit Full-mouth or panelipse X- No charge; limited to 1 every 5- No charge; limited to 1 every 5- ray year period year period Space maintainers for No charge; limited to 1 per No charge; limited to 1 per children lifetime to age 14 lifetime to age 14 Sealants for children No charge; limited to non- No charge; limited to non- carious, non restored 1st and carious, non restored 1st and 2nd permanent molars for 2nd permanent molars for dependents to age 16, 1 dependents to age 16, 1 application per tooth application per tooth

Basic Services Fillings - amalgam 30% coinsurance after 20% coinsurance after deductible deductible is met; retreatment is met; retreatment limited to 1 limited to 1 per surface in a 24- per surface in a 24-month period month period

Fillings - composite 30% coinsurance after 20% coinsurance after deductible deductible is met; retreatment is met; retreatment limited to 1 limited to 1 per surface in a 24- per surface in a 24-month period month period

Oral Surgery - Routine 30% coinsurance after 20% coinsurance after deductible extractions deductible is met is met Endodontics (root canal 30% coinsurance after 20% coinsurance after deductible therapy) deductible is met is met Periodontics, Scaling and 30% coinsurance after 20% coinsurance after deductible Root Planing deductible is met; limited to is met; limited to once every 2-3 once every 2-3 years apply years apply based on services based on services rendered rendered

Gingivoplasty or 30% coinsurance after 20% coinsurance after deductible gingivectomy deductible is met is met Emergency (palliative) 30% coinsurance after 20% coinsurance after deductible treatment for dental pain deductible is met is met Osseous surgery 30% coinsurance after 20% coinsurance after deductible deductible is met is met

9/17/19 3 Delta Dental Basic Delta Dental Premium Coverage Coverage All other oral surgery 30% coinsurance after 20% coinsurance after deductible deductible is met is met Major Services Inlays/onlays 50% coinsurance after 40% coinsurance after deductible deductible is met; limited to 1 is met; limited to 1 per tooth per tooth every 7 years; every 7 years; predetermination predetermination is strongly is strongly recommended recommended

Crowns 50% coinsurance after 40% coinsurance after deductible deductible is met; limited to 1 is met; limited to 1 per tooth per tooth every 7 years; every 7 years; stainless steel stainless steel crowns to age 14 crowns to age 14

Dentures 50% coinsurance after 40% coinsurance after deductible deductible is met; limited to 1 is met; limited to 1 every 7 years every 7 years

Bridges 50% coinsurance after 40% coinsurance after deductible deductible is met; limited to 1 is met; limited to 1 every 7 years every 7 years

Bruxism (Teeth grinding) 50% coinsurance after 40% coinsurance after deductible deductible is met is met TMJ Coverage 50% coinsurance after 40% coinsurance after deductible deductible is met is met General Anesthesia 30% coinsurance after 20% coinsurance after deductible deductible is met is met Dental implants 50% coinsurance after 40% coinsurance after deductible deductible is met; limited to is met; limited to once per tooth once per tooth every 7 years every 7 years

Orthodontics Primary covered Not covered 50% coinsurance; up to the orthodontics services lifetime maximum Age limit for coverage Not covered None Start-up fees Not covered 50% coinsurance for initial banding fee Lifetime maximum Not covered $3,000 per person benefits - orthodontics Administrative Information Plan Records Plan records are kept on a Plan records are kept on a calendar-year basis: January 1 - calendar-year basis: January 1 - December 31 December 31

9/17/19 4 Delta Dental Basic Delta Dental Premium Coverage Coverage Plan Sponsor and Plan Corporation; General Dynamics Corporation; Administrator 11011 Sunset Hills Road; 11011 Sunset Hills Road; Reston, Reston, VA 20190; 703-876- VA 20190; 703-876-3000 3000

Employer Identification 13-1673581 13-1673581 Number (EIN) DOL Plan Name (Number) ~ ATP, GDIT, Mission Systems, ~ ATP, GDIT, Mission Systems, NASSCO: General Dynamics NASSCO: General Dynamics Corporation Subsidiary Health Corporation Subsidiary Health and Welfare Plan (561); ~ CHQ and Welfare Plan (561); ~ CHQ and SRI: Group Insurance and and SRI: Group Insurance and Health Benefits for Salaried Health Benefits for Salaried Personnel (501); ~ BIW: Bath Personnel (501); ~ BIW: Corporation Health Iron Works Corporation Health Care Program (598); ~ EB Care Program (598); ~ EB salaried: Group Insurance and salaried: Group Insurance and Health Benefits for Salaried Health Benefits for Salaried Employees of General Dynamics Employees of General Dynamics Corporation, Electric Boat Corporation, Electric Boat Corporation (529); ~ GAC: Corporation (529); ~ GAC: Gulfstream Aerospace Gulfstream Aerospace Corporation Health and Welfare Corporation Health and Welfare Benefits Plan (592); ~ LS: Benefits Plan (592); ~ LS: General Dynamics Land Systems General Dynamics Land Systems Health and Welfare Plan (615); Health and Welfare Plan (615); ~ ~ General Dynamics Land General Dynamics Land Systems Systems Bargaining Health and Bargaining Health and Welfare Welfare Plan (616); ~ Jet Plan (616); ~ JA: Aviation Consolidated Welfare Consolidated Welfare Plan (652); Plan (652); ~ Group Insurance ~ Group Insurance and Health and Health Benefits for Hourly Benefits for Hourly Employees of Employees of General Dynamics General Dynamics Corporation, Corporation, Electric Boat Electric Boat Corporation (508) Corporation (508)

Plan Type Welfare plan providing dental Welfare plan providing dental benefits benefits Administration Type For BIW IGA and BIW BMDA: For BIW IGA and BIW BMDA: (Contract or Insured) Insured; For all others: Insured; For all others: Contract/Self funded Contract/Self funded

Funding Type (Self- For BIW IGA and BIW BMDA: For BIW IGA and BIW BMDA: Funded or Insured) Insured; For all others: Insured; For all others: Contract/Self funded Contract/Self funded

Insurer Not applicable Not applicable

9/17/19 5 Delta Dental Basic Delta Dental Premium Coverage Coverage Agent for Service of Legal General Dynamics Corporation; General Dynamics Corporation; Process 11011 Sunset Hills Road; 11011 Sunset Hills Road; Reston, Reston, VA 20190; 703-876- VA 20190; 703-876-3000 3000

Claims Fiduciary Delta Dental of Virginia Delta Dental of Virginia Important Addresses Claims Filing Address Delta Dental of Virginia ; 4818 Delta Dental of Virginia ; 4818 Starkey Road ; Roanoke, Virginia Starkey Road ; Roanoke, Virginia 24018 ; 800-335-8289 24018 ; 800-335-8289

Appeals Filing Address Delta Dental of Virginia ; 4818 Delta Dental of Virginia ; 4818 Starkey Road ; Roanoke, Virginia Starkey Road ; Roanoke, Virginia 24018 ; 800-335-8289 24018 ; 800-335-8289

Corporate Address: Claims Delta Dental of Virginia ; 4818 Delta Dental of Virginia ; 4818 Administrator Starkey Road ; Roanoke, Virginia Starkey Road ; Roanoke, Virginia 24018 ; 800-335-8289 24018 ; 800-335-8289

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