Benefits Plan · Benefits Plan PLAN HIGHLIGHTS: Baer's Furniture ... and flossing are vital to keeping as many teeth as you can. Keeping your teeth means better chewing function and

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Benefits Plan

PLAN HIGHLIGHTS:

Baer's Furniture

Here is your new coverage. Make sure you are aware of the deadline date for your coverage elections.

If you miss the deadline, the coverage may be delayed or you may not be eligible for enrollment this year.

Questions? Concerns?

Helpline (888) 600-1600Call weekdays, 7:00AM to 8:30PM, EST. And refer to

your plan number: 00495380

Learn more about Guardian atwww.guardianlife.com.

We’re ready to get working for youIf you’re like most employees, finding enough time in the day to accomplish your lengthy

to-do list can often be no easy task.

As your Guardian coverage begins, we want you to know that we’re here for you every step

of the way and are committed to providing you with the resources to obtain fast, accurate

answers to your benefits-related questions.

One way in which we do this is through our online member resource, Guardian Anytimesm,

which allows you to manage your benefits when it works best for you — day or night. Plus,

it offers helpful resources to ensure you get access to the quality care you need.

We encourage you to take a couple minutes to check out and register for Guardian

Anytimesm at www.GuardianAnytime.com. We promise it will be time well spent.

Welcome to Guardian!

Welcome

Prepared for Baer's Furniture Guardian Group Plan Number 00495380

Dear Baer's Furniture Employee,

We�re pleased to tell you that Guardian will be our coverageprovider this year. We have chosen Guardian because of itscompetitive rates, excellent service reputation, and extensive plandesigns.

We have worked hard to negotiate group rates that will beaffordable for all employees. All coverage is paid through payrolldeduction.

Baer's Furniture

Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com Enrollment Kit 00495380, 0001, EN

Plan Details This bookletexplains your basic planoptions. Your detailed certi-ficate of benefits will beprovided to you after youenroll.

Go online Learn moreabout your plans atwww.guardianlife.com.

Call the Helpline Questionsanswered at (888) 600-1600.

Ask your plan administratorChange your plan bycontacting your planadministrator.

UNDERSTAND YOUR COVERAGE:

n Review your benefits

n Complete your enrollment form, if applicable

n Sign and return form to your plan administrator

1

Notes:

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Why Dental Insurance?

Good oral hygiene is important, not only for looks, but for general health as well. A routine dental examination can detect symptoms of more than125 diseases, including heart disease, diabetes, anemia, stomach ulcers, osteoporosis and kidney disease. Regular check ups and cleanings cansave you the pain and expense of future problems. Dental insurance will keep these visits affordable and is a cost-effective way to minimize healthcare costs for you and your family. The American Dental Hygienists� Association estimates that for every $1 spent on prevention or oral health care,as much as $8 to $50 is saved on future emergency and restorative procedures. Using your dental insurance for regular dental check ups canimprove your health by helping you:

1) Prevent Oral Cancer: According to The Oral Cancer Foundation, someone dies from oral cancer every hour of every day in the United Statesalone. When you have your dental cleaning, your dentist is also screening you for oral cancer, which is highly curable if diagnosed early.

2) Prevent Gum Disease: Gum disease is an infection in the gum tissues and bone that keep your teeth in place and is one of the leading causesof adult tooth loss. If diagnosed early, it can be treated and reversed. If treatment is not received, a more serious and advanced stage of gumdisease may follow. Regular dental cleanings and check ups, flossing daily and brushing twice a day are key factors in preventing gum disease.

3) Help Maintain Good Physical Health: Recent studies have linked heart attacks and strokes to gum disease, resulting from poor oral hygiene.A dental cleaning every six months helps to keep your teeth and gums healthy and could possibly reduce your risk of heart disease and strokes,as well as many other serious conditions.

4) Keep Your Teeth: Since gum disease is one of the leading causes of tooth loss in adults, regular dental check ups and cleanings, brushingand flossing are vital to keeping as many teeth as you can. Keeping your teeth means better chewing function and ultimately, better health.

5) Prevent the Need for Advanced Treatment: Your dentist and hygienist will be able to detect any early signs of problems with your teeth orgums that can be easily treatable. If these problems go untreated, root canals, gum surgery and removal of teeth could become the onlytreatment options available.

6) Have a Bright and White Smile: Your dental hygienist can remove most tobacco, coffee and tea stains. During your cleaning, your hygienistwill also polish your teeth to a beautiful shine.

7) Protect your children�s health: Tooth decay is the most common chronic childhood disease, five times more common than asthma and resultsin a loss of 51 million school hours each year. Regular check ups can help prevent tooth decay in your children.

Sources: www.about.com, American Academy of Pediatrics


Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com Enrollment Kit 00495380, 0001, EN 3

Dental PlansYOUR GUARDIANPLAN OFFERS:

Coverage of ViziLite Plusearly cancer detectionscreening exams

Maximum rollover If amember submits at leastone claim and stays underthe claims threshold, a partof the unused maximumwill be rolled over for usein future years.

Great selection of dentistsconvenient to you - yours islikely in our network!

Reliable claims payment fourdays on average

Find out if your dentist is inGuardian�s network atwww.GuardianAnytime.com

Let Guardian put its 30-plus yearsof dental benefits experience towork for you and your family.

Option 1: With your DHMO U30M plan, you enjoy negotiated discounts from our network dentists. You pay a fixed copay for each covered service.Out-of-network visits are not covered.Option 2: With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Out-of-network benefits arelimited to our PPO fee schedule.

Your Dental Plan Option 1: DHMO U30M Option 2: PPONetwork Managed DentalGuard DentalGuard Preferred

Your Bi-weekly premium $5.40 $13.88You and spouse $10.81 $29.04

You and child(ren) $12.03 $34.79

You, spouse and child(ren) $17.44 $46.47

Calendar year deductible In-Network Out-Network

Individual No deductible $50 $100Family limit 3 per familyWaived for Preventive Preventive

Charges covered for you (co-insurance) Network only In-Network Out-Network

Preventive Care You pay a copay for each 100% 80%

Basic Care covered procedure. See 80% 70%

Major Care �Plan Details�, for 50% 40%

Orthodontia more information. Not Covered

Annual Maximum Benefit Unlimited $1000 $1000

Maximum Rollover Maximum Rollover is not YesRollover Threshold applicable for this plan type. $500

Rollover Amount $250

Rollover In-network Amount $350

Rollover Account Limit $1000

Lifetime Orthodontia Maximum Not Applicable Not Applicable

Office visit copay $5 None

Dependent Age Limits 26 * 26 *

*Family coverage for spouse and children if the child is dependent upon the employee for support and is: (i) living in theemployee's household; or (ii) a full-time or part-time student.

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CATEGORY PLAN DETAILS Option 1: DHMO U30M Option 2: PPOYou Pay Plan pays (on average)

Network only In-network Out-of-network

Preventive Care Cleaning (prophylaxis) $0 100% 80%

Frequency: 2 times in 12 months^ Once Every 6 MonthsFluoride Treatments $0 100% 80%

Limits: No Age Limits Under Age 19Oral Exams $0 100% 80%

Sealants (per tooth) $0 100% 80%

X-rays $0 100% 80%

Basic Care Anesthesia* Restrictions Apply 80% 70%

Fillings� $0 80% 70%

Perio Surgery $200-380 80% 70%

Periodontal Maintenance $0 80% 70%

Frequency: 2 times in 12 months^ Once Every 6 Months(Standard) (Enhanced)

Root Canal $120-270 80% 70%

Scaling & Root Planing (per quadrant) $0 80% 70%

Simple Extractions $0 80% 70%

Major Care Bridges and Dentures $381-575 50% 40%

Dental Implants Not Covered 50% 40%

Inlays, Onlays, Veneers** $250-370 50% 40%

Repair & Maintenance ofCrowns, Bridges & Dentures $0-160 50% 40%Single Crowns $375 50% 40%

Surgical Extractions $30-200 50% 40%

Orthodontia Orthodontia $2,500-2,800 Not Covered

Limits: Adults & Child(ren)

Cosmetic Care Bleaching $165 Not Covered Not Covered

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO andor Indemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or otherpathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for"Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required byyour in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status ismaintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings andperiodontal maintenance procedures are combined in a 12 month period.*General Anesthesia - restrictions apply. �For PPO and orIndemnity members, Fillings- restrictions may apply to composite fillings. (^Additional cleanings are available for an additionalco-pay).

Please note: The plandetails listed here are someof the most commonservices related to dentalcoverage. The co-insurance percentages forthe PPO plan optionscorrespond to the coveragecategories of Preventive,Basic, Major andOrthodontia listed in thetable above.

Some services may be paidunder a different categorythan listed. The actualco-insurance shownreflects your plan'scoverage.

EXCLUSIONS AND LIMITATIONS

n Important Information about Guardian�s DentalGuard Indemnity and DentalGuard Preferred PPO plans: This policyprovides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose ortreat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (exceptas covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimentaltreatments (unless they are expressly provided for), any treatments to the extent benefits are payable by any otherpayor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillaryto surgical treatment. The plan limits benefits for diagnostic consultations and for preventive, restorative,endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do notconstitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage.Contract # GP-1-DG2000 et al.

n Important information about Guardian�s Managed DentalGuard Pre-Paid (Florida, New York) Plan, Guardian�s ManagedDentalGuard (Colorado) Plan , Managed DentalGuard Inc.�s (Ohio) Plan, Managed Dental Care�s DHMO (California) Plan,Managed DentalGuard, Inc.�s Managed DentalGuard (New Jersey) Plan, Managed DentalGuard, Inc.�s Managed DentalGuardDHMO (Texas) Plan and Managed DentalGuard -LIBERTY Dental Plan of Nevada, Inc. (Nevada): This plan provides pre-paiddental benefits through a network of participating general dentists and specialty care dentists. All covered services must be

provided by the member�s Primary Care Dentist. Specialty care services are covered only when referred by the member�sPrimary Care Dentist and approved in advance by Managed DentalGuard. Only those services listed in the plan are covered.Certain services are subject to annual or other periodic limitations. Where orthodontic benefits are specifically included, theplan provides for one course of comprehensive treatment per lifetime, per member. Unless specifically included, theManaged DentalGuard plan does not provide orthodontic benefits if comprehensive orthodontic treatment or retention is inprogress as of the member�s effective date under the Managed DentalGuard plan. The services, exclusions and limitationslisted here do not constitute a contract and are a summary only. The Managed DentalGuard plan documents are the finalarbiter of coverage. GP-1-MDG1, et al. or GP-1-MDG-FL-1-08, et al. (Florida), GP-1-MDG-NY1, et al. or GP-1-MDG-NY-1-08,et al. (New York), GP-1-MDG-CO-1, et al. (Colorado), GP-1MDC1, et al. or GP-1-MDC-CA-1-08, et al. (California),GP-1-MDG-1-NJ, et al. or GP-1-MDG-NJ-1-08, et al. (New Jersey), GP-1-MDG-TX1, et al. or GP-1-MDG-TX-1-08, et al.(Texas), GP-1-MDG-OH-1, et al. (Ohio), NV110717, et al (Nevada).

n For PPO and or Indemnity Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan.A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he becameinsured by this plan. We won�t pay for a prosthetic device which replaces such teeth unless the device also replaces one ormore natural teeth lost or extracted after the covered person became insured by this plan. R3 � DG2000

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UNDERSTANDING YOUR BENEFITS�DENTAL

Basic care Moderately complex dental services. Most plans consider fillings and extractions to be basic care.

Co-insurance The portion of the covered charge paid by Guardian.

Copay (short for copayment) A fixed fee paid to a dentist at the time a dental service is performed. Some sample copays are shown in this booklet. A complete list isshown in your certificate booklet.

Claims Payment Basis PPO

In-Network: You receive regular contracted savings, paid at a higher co-insurance level; with no balance billing.Out-of-Network: Charges will be paid for only up to the maximum fee level established with our contracted network dentists;any amount that is charged over the fee schedule is the responsibility of the patient.

Deductible The amount of charges you and your family must pay each plan year before the plan pays you any benefits.

Dental office number The unique identification number assigned to a dental provider. Each family member must select a primary care dentist and enter his orher number on the enrollment form.

Family limit Maximum number of deductibles your family must pay in each plan year before this plan starts paying benefits for all covered familymembers for the rest of the plan year.

In-network charges Charges for services provided by dentists who are a member of your plan's network.

Major care More complex dental services. Most plans consider crowns and dentures to be major care.

Out-of-network charges Charges for services provided by dentists who are not members of your plan's network.

Plan year The 12 month period used to apply this plan's deductible and annual maximum. Your plan's plan year is the calendar year.

PPO (Preferred Provider Organization) Plan that lets you visit any dentist, but usually provides better benefits for the services of PPO network dentists. PPO dentists haveagreed to accept discounted fees as payment in full.

Pre-determination Review Guardian will gladly assist you and your dentist by determining what benefits could be payable for services and procedures over $300.Have your dentist fax your treatment plan to Guardian, note that it is a pre-determination review and we will let your dentist know whatbenefits would be payable. This includes orthodontic treatment if your plan includes it. Pre-determination applies to PPO and Indemnityplans only.

Pre-Paid Plan A plan that requires you to visit a network dentist. You pay a fixed copay to the dentist for each service performed. No benefits areavailable for services of dentists who are not in the network.

Preventive care Most routine dental services. Most plans consider checkups and cleanings to be preventive care.

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Managed DentalGuard - Plan Schedule Plan U30M5

CDT

Codes ++Covered Dental Services

Patient

Charges

D0999 Office visit during regular hours, general dentist only * $5

Evaluations

D0120 Periodic oral examination – established patient 0

D0140 Limited oral evaluation – problem focused 0

D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver 0

D0150 Comprehensive oral evaluation – new or established patient 0

D0170 Re-evaluation – limited, problem focused (established patient, not post-operative visit) 0

D0180 Comprehensive periodontal evaluation – new or established patient 0

Radiographs/Diagnostic Imaging (Including Interpretation)

D0210 Intraoral – complete series (including bitewings) 0

D0220 Intraoral – periapical first film 0

D0230 Intraoral – periapical each additional film 0

D0240 Intraoral – occlusal film 0

D0270 Bitewing – single film 0

D0272 Bitewings – two films 0

D0273 Bitewings – three films 0

D0274 Bitewings – four films 0

D0277 Vertical bitewings – 7 to 8 films 0

D0330 Panoramic film 0

Tests and Examinations

D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or

biopsy procedures 50

D0460 Pulp vitality tests 0

D0470 Diagnostic casts 0

Dental Prophylaxis

D1110 Prophylaxis – adult, for the first two services in any 12-month period + # 0

D1120 Prophylaxis – child, for the first two services in any 12-month period + # 0

D1999 Prophylaxis – adult or child, for each additional service in same 12-month period + # 60

Topical Fluoride Treatment (Office Procedure)

D1203 Topical application of fluoride (prophylaxis not included) – child, for the first two services in any 12-month period + = 0

D1204 Topical application of fluoride (prophylaxis not included) – adult, for the first two services in any 12-month period + = 0

D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients, for the first two services in any 12-month period + = 0

D2999 Topical fluoride (adult or child), each additional service in the same 12-month period + = 20

Other Preventive Services

D1310 Nutritional counseling for control of dental disease 0

D1330 Oral hygiene instructions 0

D1351 Sealant – per tooth (molars) ^ 0

D9999 Sealant – per tooth (non-molars) ^ 35

Space Maintenance (Passive Appliances)

D1510 Space maintainer – fixed - unilateral 0

D1515 Space maintainer – fixed - bilateral 0

D1525 Space maintainer – removable - bilateral 0

D1550 Re-cementation of space maintainer 0

D1555 Removal of fixed space maintainer 0

Amalgam Restorations (Including Polishing)

D2140 Amalgam – one surface, primary or permanent 0

D2150 Amalgam – two surfaces, primary or permanent 0

D2160 Amalgam – three surfaces, primary or permanent 0

D2161 Amalgam – four or more surfaces, primary or permanent 0

Resin-Based Composite Restorations - Direct

D2330 Resin-based composite – one surface, anterior 0

D2331 Resin-based composite – two surfaces, anterior 0

D2332 Resin-based composite – three surfaces, anterior 0

D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) 0

D2390 Resin-based composite crown, anterior 75

D2391 Resin-based composite – one surface, posterior 0

D2392 Resin-based composite – two surfaces, posterior 0

D2393 Resin-based composite – three surfaces, posterior 0

D2394 Resin-based composite – four or more surfaces, posterior 0

Inlay/Onlay Restorations ^^

D2510 Inlay – metallic – one surface ** 265

D2520 Inlay – metallic – two surfaces ** 320

D2530 Inlay – metallic – three or more surfaces ** 350

D2542 Onlay – metallic – two surfaces ** 350

D2543 Onlay – metallic – three surfaces ** 360

D2544 Onlay – metallic – four or more surfaces ** 370

D2610 Inlay – porcelain/ceramic – one surface 265

D2620 Inlay – porcelain/ceramic – two surfaces 320

D2630 Inlay – porcelain/ceramic – three or more surfaces 350

D2642 Onlay – porcelain/ceramic – two surfaces 350

D2643 Onlay – porcelain/ceramic – three surfaces 360

D2644 Onlay – porcelain/ceramic – four or more surfaces 370

Page 1 of 5 V.08254

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CDT


Patient

Charges

Crowns – Single Restorations Only ^^

D2740 Crown – porcelain/ceramic substrate $395

D2750 Crown – porcelain fused to high noble metal ** 375

D2751 Crown – porcelain fused to predominantly base metal 375

D2752 Crown – porcelain fused to noble metal 375

D2780 Crown – ¾ cast high noble metal ** 365

D2781 Crown – ¾ cast predominantly base metal 365

D2782 Crown – ¾ cast noble metal 365

D2783 Crown – ¾ porcelain/ceramic 365

D2790 Crown – full cast high noble metal ** 375

D2791 Crown – full cast predominantly base metal 375

D2792 Crown – full cast noble metal 375

D2794 Crown – titanium 375

Other Restorative Services

D2910 Recement inlay, onlay, or partial coverage restoration 0

D2915 Recement cast or prefabricated post and core 0

D2920 Recement crown 0

D2930 Prefabricated stainless steel crown – primary tooth 88

D2931 Prefabricated stainless steel crown – permanent tooth 88

D2932 Prefabricated resin crown 108

D2933 Prefabricated stainless steel crown with resin window 108

D2934 Prefabricated esthetic coated stainless steel crown – primary tooth 115

D2940 Sedative filling 0

D2950 Core buildup, including any pins 100

D2951 Pin retention – per tooth, in addition to restoration 18

D2952 Post and core in addition to crown, indirectly fabricated 155

D2953 Each additional indirectly fabricated post – same tooth 79

D2954 Prefabricated post and core in addition to crown 125

D2957 Each additional prefabricated post – same tooth 51

D2960 Labial veneer (resin laminate) – chairside 250

D2970 Temporary crown (fractured tooth) 86

D2971 Additional procedures to construct new crown under existing partial denture framework 125

Pulp Capping

D3110 Pulp cap – direct (excluding final restoration) 0

D3120 Pulp cap – indirect (excluding final restoration) 0

Pulpotomy

D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament 0

D3221 Pulpal debridement, primary and permanent teeth 0

D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development 0

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) 0

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) 0

Endodontic Therapy (Including Treatment Plan, Clinical Procedures And Follow-up Care)

D3310 Root canal, anterior (excluding final restoration) 120

D3320 Root canal, bicuspid (excluding final restoration) 145

D3330 Root canal, molar (excluding final restoration) 270

D3331 Treatment of root canal obstruction; non-surgical access 0

D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 75

D3333 Internal root repair of perforation defects 116

Endodontic Retreatment

D3346 Retreatment of previous root canal therapy – anterior 375

D3347 Retreatment of previous root canal therapy – bicuspid 425

D3348 Retreatment of previous root canal therapy – molar 525

Apicoectomy/Periradicular Services

D3410 Apicoectomy/periradicular surgery – anterior 240

D3421 Apicoectomy/periradicular surgery – bicuspid (first root) 270

D3425 Apicoectomy/periradicular surgery – molar (first root) 320

D3426 Apicoectomy/periradicular surgery (each additional root) 116

D3430 Retrograde filling – per root 72

D3950 Canal preparation and fitting of preformed dowel or post 20

Surgical Services (Including Usual Postoperative Care)

D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant 200

D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant 60

D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or bounded teeth spaces per quadrant 240

D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or bounded teeth spaces per quadrant 144

D4249 Clinical crown lengthening – hard tissue 280

D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces per quadrant 380

D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces per quadrant 230

D4268 Surgical revision procedure, per tooth 0

D4270 Pedicle soft tissue graft procedure 350

D4271 Free soft tissue graft procedure (including donor site surgery) 363

D4273 Subepithelial connective tissue graft procedures, per tooth 399

Page 2 of 5 V.08254

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CDT


Patient

Charges

Non-Surgical Periodontal Service

D4341 Periodontal scaling and root planing – four or more teeth per quadrant $0

D4342 Periodontal scaling and root planing – one to three teeth per quadrant 0

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 0

Other Periodontal Services

D4910 Periodontal maintenance, for the first two services in any 12-month period + # 0

D4920 Unscheduled dressing change (by someone other than treating dentist) 0

D4999 Periodontal maintenance, each additional service in same 12-month period + # 60

Complete Dentures (Including Routine Post-Delivery Care)

D5110 Complete denture – maxillary 452

D5120 Complete denture – mandibular 452

D5130 Immediate denture – maxillary 492

D5140 Immediate denture – mandibular 492

Partial Dentures (Including Routine Post-Delivery Care)

D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) 381

D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) 443

D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 500

D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 500

D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) 575

D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) 575

Adjustments to Dentures

D5410 Adjust complete denture – maxillary 0

D5411 Adjust complete denture – mandibular 0

D5421 Adjust partial denture – maxillary 0

D5422 Adjust partial denture – mandibular 0

Repairs To Complete Dentures

D5510 Repair broken complete denture base 40

D5520 Replace missing or broken teeth – complete denture (each tooth) 36

Repairs To Partial Dentures

D5610 Repair resin denture base 44

D5620 Repair cast framework 80

D5630 Repair or replace broken clasp 56

D5640 Replace broken teeth – per tooth 36

D5650 Add tooth to existing partial denture 52

D5660 Add clasp to existing partial denture 64

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 196

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 196

Denture Rebase Procedures

D5710 Rebase complete maxillary denture 160

D5711 Rebase complete mandibular denture 160

D5720 Rebase maxillary partial denture 160

D5721 Rebase mandibular partial denture 160

Denture Reline Procedures

D5730 Reline complete maxillary denture (chairside) 88

D5731 Reline complete mandibular denture (chairside) 88

D5740 Reline maxillary partial denture (chairside) 88

D5741 Reline mandibular partial denture (chairside) 88

D5750 Reline complete maxillary denture (laboratory) 120

D5751 Reline complete mandibular denture (laboratory) 120

D5760 Reline maxillary partial denture (laboratory) 120

D5761 Reline mandibular partial denture (laboratory) 120

Interim Prosthesis

D5820 Interim partial denture (maxillary) 175

D5821 Interim partial denture (mandibular) 175

Other Removable Prosthetic Services

D5850 Tissue conditioning, maxillary 36

D5851 Tissue conditioning, mandibular 36

Fixed Partial Denture Pontics ^^

D6210 Pontic – cast high noble metal ** 350

D6211 Pontic – cast predominantly base metal 350

D6212 Pontic – cast noble metal 350

D6214 Pontic – titanium 350

D6240 Pontic – porcelain fused to high noble metal ** 350

D6241 Pontic – porcelain fused to predominantly base metal 350

D6242 Pontic – porcelain fused to noble metal 350

D6245 Pontic – porcelain/ceramic 360

Fixed Partial Denture Retainers – Inlays/Onlays ^^

D6600 Inlay – porcelain/ceramic – two surfaces 320

D6601 Inlay – porcelain/ceramic – three or more surfaces 350

D6602 Inlay – cast high noble metal, two surfaces ** 320

D6603 Inlay – cast high noble metal, three or more surfaces ** 350

D6604 Inlay – cast predominantly base metal, two surfaces 320

Page 3 of 5 V.08254

9


CDT


Patient

Charges

Fixed Partial Denture Retainers – Inlays/Onlays ^^ (continued)

D6605 Inlay – cast predominantly base metal, three or more surfaces $350

D6606 Inlay – cast noble metal, two surfaces 320

D6607 Inlay – cast noble metal, three or more surfaces 350

D6608 Onlay – porcelain/ceramic, two surfaces 350

D6609 Onlay – porcelain/ceramic, three or more surfaces 360

D6610 Onlay – cast high noble metal, two surfaces ** 350

D6611 Onlay – cast high noble metal, three or more surfaces ** 360

D6612 Onlay – cast predominantly base metal, two surfaces 350

D6613 Onlay – cast predominantly base metal, three or more surfaces 360

D6614 Onlay – cast noble metal, two surfaces 350

D6615 Onlay – cast noble metal, three or more surfaces 360

D6624 Inlay – titanium 320

D6634 Onlay – titanium 350

Fixed Partial Denture Retainers – Crowns ^^

D6740 Crown – porcelain/ceramic 395

D6750 Crown – porcelain fused to high noble metal ** 375

D6751 Crown – porcelain fused to predominantly base metal 375

D6752 Crown – porcelain fused to noble metal 375

D6780 Crown – ¾ cast high noble metal ** 365

D6781 Crown – ¾ cast predominantly base metal 365

D6782 Crown – ¾ cast noble metal 365

D6783 Crown – ¾ porcelain/ceramic 365

D6790 Crown – full cast high noble metal ** 375

D6791 Crown – full cast predominantly base metal 375

D6792 Crown – full cast noble metal 375

D6794 Crown – titanium 375

Other Fixed Partial Denture Services

D6930 Recement fixed partial denture 36

D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated 155

D6972 Prefabricated post and core in addition to fixed partial denture retainer 125

D6973 Core build up for retainer, including any pins 100

D6976 Each additional cast post – same tooth 79

D6977 Each additional prefabricated post – same tooth 51

D6999 Multiple crown and bridge unit treatment plan – per unit, six or more units per treatment plan ^^ 125

Extractions

D7111 Extraction, coronal remnants – deciduous tooth 0

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 0

Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, And Routine Postoperative Care)

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 30

D7220 Removal of impacted tooth – soft tissue 114

D7230 Removal of impacted tooth – partially bony 140

D7240 Removal of impacted tooth – completely bony 160

D7241 Removal of impacted tooth – completely bony, with unusual surgical complications 200

D7250 Surgical removal of residual tooth roots (cutting procedure) 35

D7261 Primary closure of a sinus perforation 250

Other Surgical Procedures

D7280 Surgical access of an unerupted tooth 250

D7283 Placement of device to facilitate eruption of impacted tooth 50

D7285 Biopsy of oral tissue – hard (bone, tooth) 60

D7286 Biopsy of oral tissue – soft 50

D7288 Brush biopsy – transepithelial sample collection 65

Alveoloplasty – Surgical Preparation Of Ridge For Dentures

D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant 125

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant 65

D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant 150

D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant 105

Surgical Excision Of Intra-Osseous Lesions

D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm 180

D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm 289

Excision Of Bone Tissue

D7471 Removal of lateral exostosis (maxilla or mandible) 204

D7472 Removal of torus palatinus 283

D7473 Removal of torus mandibularis 283

Surgical Incision

D7510 Incision and drainage of abscess – intraoral soft tissue 25

D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) 30

Other Repair Procedures

D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure 133

D7963 Frenuloplasty 163

Page 4 of 5 V.08254

10


CDT


Patient

Charges

Unclassified Treatment

D9110 Palliative (emergency) treatment of dental pain – minor procedure $0

D9120 Fixed partial denture sectioning 15

D9215 Local anesthesia 0

D9220 Deep sedation/general anesthesia – first 30 minutes +++ 195

D9221 Deep sedation/general anesthesia – each additional 15 minutes +++ 75

D9241 Intravenous conscious sedation/analgesia – first 30 minutes +++ 195

D9242 Intravenous conscious sedation/analgesia – each additional 15 minutes +++ 75

Professional Consultation

D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) 0

Professional Visits

D9430 Office visit for observation (during regularly scheduled hours) – no other services performed 0

D9440 Office visit – after regularly scheduled hours 50

D9450 Case presentation, detailed and extensive treatment planning 0

Miscellaneous Services

D9951 Occlusal adjustment – limited 10

D9971 Odontoplasty – one to two teeth 10

D9972 External bleaching – per arch 165

Broken appointment 25

Current Dental Terminology (CDT) © American Dental Association (ADA)

+

++

*

#

=

^

**

^^

+++

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health

Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed

DentalGuard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc., and Managed

Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Limitations and exclusions

apply. Plan documents are the final arbiter of coverage.

The Guardian Life Insurance Company of America, New York, NY 10004 2008-6567

Routine prophylaxis or periodontal maintenance procedure - a total of four services in any 12-month period. One of the covered periodontal maintenance procedures

may be performed by a participating periodontal Specialist if done within three to six months following completion of approved, active periodontal therapy (periodontal

scaling and root planing or periodontal osseous surgery) by a participating periodontal Specialist. Active periodontal therapy includes periodontal scaling and root planing

or periodontal osseous surgery.

Fluoride Treatment - a total of four services in any 12-month period.

Sealants are limited to permanent teeth up to the 16th birthday.

The Patient Charge for these services is per unit.

Procedure codes D9220, D9221, D9241 and D9242 are limited to a participating oral surgery Specialist. Additionally, these services are only covered in conjunction with

other covered surgical services.

The Patient Charges for codes D1110, D1120, D1203, D1204, D1206 and D4910 are limited to the first two services in any 12-month period. For each additional service

in the same 12-month period, see codes D1999, D2999 and D4999 for the applicable Patient Charge.

Covered Services are subject to exclusions, limitations and Plan provisions as described in Member’s Plan booklet and the Manual (including the Quality Management

retrospective review). Other codes may be used to describe Covered Services.

If high noble metal is used, there will be an additional Patient Charge for the actual cost of the high noble metal.

The Member will be responsible for the Office Visit Fee when the Plan Schedule suffix listed on the ID Card and Eligibility Report is an "M". The Plan will be responsible

for the Office Visit Fee when the Plan Schedule suffix listed on the ID Card and Eligibility Report is a "G". The ID Card and Eligibility Report will indicate if the Office Visit

Fee is $5 or $10.

Page 5 of 5 V.08254

11

12

Managed DentalGuard is underwritten by Managed Dental Care in CA; First Commonwealth in IL, MO, MI and IN; Guardian in FL and NY, and Managed

DentalGuard, Inc. in NJ and TX. Managed Dental Care, First Commonwealth and Managed DentalGuard, Inc. are wholly owned subsidiaries of The

Guardian Life Insurance Company of America.

MANAGED DENTALGUARD ORTHODONTIC BENEFITS

Managed DentalGuard Orthodontic Plan Schedule – Option V

CDT Codes

Covered Services and Patient Charges Patient

Charges Orthodontics In Progress

Orthodontics

D8070 Comprehensive orthodontic treatment of the transitional dentition **

D8080 Comprehensive orthodontic treatment of the adolescent dentition **

D8090 Comprehensive orthodontic treatment of the adult dentition **

Child: $2500 Adult: 2800

*** ***

D8660 Pre-orthodontic treatment visit (includes treatment plan, records, evaluation and consultation) 250 ***

D8670 Periodic orthodontic treatment visit 0 ***

D8680 Orthodontic retention 400 ***

Broken appointment 25 ***

Current Dental Terminology (CDT) © American Dental Association (ADA) v.08192 ** Child orthodontics is limited to dependent children under age 19; adult orthodontics is limited to dependent children age 19 and above

and employee or spouse. A Member’s age is determined on the date of banding. *** Treatment in progress: Orthodontic Treatment – Comprehensive orthodontic treatment is started when the teeth are banded.

Orthodontic treatment procedures which are listed on the Plan Schedule and were started but not completed prior to the Member’s eligibility to receive benefits under this plan may be covered if the Member identifies a Participating Orthodontic Specialty Care Dentist who is willing to complete the treatment at a patient charge equal to 85% of the Participating Orthodontic Specialty Care Dentist’s usual fee. In this situation retention services would also be at 85% of the Participating Orthodontic Specialty Care Dentist’s usual fee. When comprehensive orthodontic treatment is started prior to the Member’s eligibility to receive benefits under this plan, the Patient Charge for orthodontic retention is equal to 85% of the Participating Orthodontic Specialty Care Dentist’s usual fee. Also refer to the Orthodontic Takeover Treatment-in-Progress section.

++ Covered Services are subject to exclusions, limitations and Plan provisions as described in Member’s Plan Booklet and the Manual.

The Plan Covers:

Orthodontic services as listed under Covered Dental Services and Patient Charges, limited to one (1) course of treatment per Member. We must preauthorize treatment, and it must be performed by a Participating Orthodontic Specialist Dentist.

Up to twenty-four (24) months of comprehensive orthodontic treatment.

Treatment plan and records, including initial records and any interim and final records.

Comprehensive orthodontic treatment, including the fixed banding appliances and related visits only.

Retention services following a course of comprehensive orthodontic treatment that was covered under this Plan.

Orthodontic retention, including any and all necessary fixed and removable appliances and related visits.

If a Member has orthodontic treatment associated with orthognathic surgery (a non-covered procedure involving the surgical moving of teeth), the Plan provides the standard orthodontic benefit. The Member will be responsible for additional charges related to the orthognathic surgery and the complexity of the orthodontic treatment. The additional charge will be based on the Participating Orthodontic Specialist Dentist’s usual fee.

This Plan Does Not Cover:

Any procedure listed as an exclusion, in excess of Plan limitations, or as not covered under MDG.

Orthodontic treatment performed by any dentist other than a Participating Orthodontic Specialist Dentist.

Limited orthodontic treatment and interceptive (Phase I) treatment.

Treatment beyond twenty-four (24) months. (The Member will be responsible for an additional charge for each additional month of treatment, based upon the Participating Orthodontic Specialist Dentist’s contracted fee.)

Except as described under treatment in progress – orthodontic treatment, orthodontic services are not covered if comprehensive treatment begins before the Member is eligible for benefits under the Plan. If a Member’s coverage terminates after the fixed banding appliances are inserted, the Participating Orthodontist Specialty Care Dentist may prorate his or her usual fee over the remaining months of treatment.

Orthodontic services after a Member’s coverage terminates.

Any incremental charges for non-standard orthodontic appliances or those made with clear, ceramic, white or other optional material or linqual brackets.

Procedures, appliances or devices to (a) guide minor tooth movement or (b) to correct or control harmful habits.

Re-treatment of orthodontic cases, or changes in orthodontic treatment necessitated by any kind of accident.

Replacement or repair of orthodontic appliances damaged due to the neglect of the Member.

Extractions performed solely to facilitate orthodontic treatment.

Orthognathic surgery (moving of teeth by surgical means) and associated incremental charges.

If a Member transfers to another Participating Orthodontic Specialty Care Dentist after authorized comprehensive orthodontic treatment has started under this Plan, the Member will be responsible for any additional costs associated with the change in Orthodontic Specialty Care Dentist and subsequent treatment.

13

14

Dental Maximum Rollover

Save Your Unused Claims Dollars For When You Need Them Most

Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). If you reach your Plan Annual Maximum in future years, you can use money from your MRA. To qualify for an MRA, you must have a paid claim (not just a visit) and must not have exceeded the paid claims threshold during the benefit year. Your MRA may not exceed the MRA limit. You can view your annual MRA statement detailing your account and those of your dependents on www.GuardianAnytime.com. Please note that actual maximum limitations and thresholds vary by plan. Your plan may vary from the one used below as an example to illustrate how the Maximum Rollover functions.

Plan Annual Maximum* Threshold Maximum Rollover Amount In-Network Only Rollover Amount Maximum Rollover Account Limit

$1000 $500 $250 $350 $1000

Maximum claims reimbursement

Claims amount that determines rollover eligibility

Additional dollars added to Plan Annual Maximum for future years

Additional dollars added to Plan Annual Maximum for future years if only in-

network providers were used during the benefit year

Plan Annual Maximum plus Maximum Rollover cannot exceed

$2,000 in total

* If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines the Maximum Rollover plan.

Here’s how the benefits work:

YEAR ONE: Jane starts with a $1,000 Plan Annual Maximum. She submits $150 in dental claims. Since she did not reach the $500 Threshold, she receives a $250 rollover that will be applied to Year Two.

YEAR TWO: Jane now has an increased Plan Annual Maximum of $1,250. This year, she submits $50 in claims and receives an additional $250 rollover added to her Plan Annual Maximum.

YEAR THREE: Jane now has an increased Plan Annual Maximum of $1,500. This year, she submits $1,200 in claims. All claims are paid due to the amount accumulated in her Maximum Rollover Account.

YEAR FOUR: Jane’s Plan Annual Maximum is $1,300 ($1,000 Plan Annual Maximum + $300 remaining in her Maximum Rollover Account).

For Overview of your Dental Benefits, please see About Your Benefit Section of this Enrollment Booklet. NOTES: You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit.

Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effective date in October, November or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of 2013, the claim activity in 2014 will be used and applied to MRAs for use in 2015.

Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefit year, will not begin until the start of the next full benefit year. Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts when coverage of Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year. (Actual eligibility timeframe may vary. See your Plan Details for the most accurate information.)

Guardian's Dental Insurance is underwritten and issued by The Guardian Life Insurance Company of America or its subsidiaries, New York, NY. Products are not available in all states. Policy limitations and exclusions apply.

Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage. Policy Form #GP-1-DG2000, et al.

��

$1000 $1000 $1000 $1000

! " # $ % ! " # $ % & " # % %

15

16

Guardian AnytimeSM Mobile

Guardian’s network in the palm of your hand.

The best way to save money through your dental and vision benefits is to see a provider in your network. Guardian makes it easy to find a dentist orvision provider near you, online or on the go! Plus, you can access your member ID card to present at your visit.Choose between:

Search on the go!

It’s fast and easy to find a provider from your smart phone through our Guardian Anytime mobile app.It’s easy to download and use! Simply search by location or name.

Visit www.GuardianAnytime.com/mobile.

View/Print your Member ID Card

You no longer need to show your dental or vision provider a paper ID card. Simply access an image ofyour card through Guardian Anytime Mobile and show them at your visit!

You can also Find a Provider at our website www.GuardianAnytime.com. Customize your search, getside-by-side comparisons, or create a quick list of “favorite” providers and more!

17

18

Finding a dentist or vision care provider is easy

Go online – it just takes minutes! The best way to save money through your dental or vision plan is by seeing a provider in your plan’s network. Guardian’s Find a Provider site makes it easy for you to search for a dental or vision provider meets your needs. Guardian’s Find a Provider site is available to you 24 hours a day, 7 days a week.

Here are just a few things you can do online:

• Customize your search by specialty, languages spoken and more

• Get side-by-side comparisons of provider information (ie. office status, distance)

• Create a quick-list of “favorite” providers — for easy reference online

• Get maps and directions to a providers office location

• View your results online or have them faxed or emailed to you

• Save your search criteria for easy access when you revisit the site

• Create a customized provider directory

• Nominate a dentist to be included in a network

Just go to www.GuardianAnytime.com and click on “Find a Provider”. You can also find a provider on the go from your smart phone – simply download our app.

19

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20

Why Vision Insurance?

Eye care is health care. The health of your eyes is an indicator of your overall health, so it's important to have regular eye exams to detectdiseases like glaucoma, diabetes, and blindness. Eye exams are also important for children, since good vision is closely linked to doing wellin school. So, make sure you and your family visit your vision provider regularly. Vision insurance is a wellness benefit that can keep theseimportant visits affordable by helping to defray costs of eye exams, eyewear, and other vision services.

There are many reasons why seeing an eyecare provider can help improve your health and way of life:

1) Early detection: With regular eye exams, your eyecare professional can detect problems early and prescribe proper treatments to delay or preventvision loss.

2) Fight disease: Regular eye exams routinely detect early onset of glaucoma and diabetes, among other medical conditions. Left untreated, thesediseases can have a devastating effect. Early intervention can result in reducing health concerns and financial impact.

3) Protect children�s health and development: Eye exams can play an important role in your child's growth because vision is closely linked tothe learning process. Children who have trouble seeing or interpreting what they see will often have trouble with their schoolwork.

4) Keep your sight: Blindness or low vision affects 3.3 million Americans age 40 and over. Researchers predict that figure will reach 5.5 millionby 2020.

Source: Study conducted by the Eye Disease Prevalence Research Group and sponsored by the National Eye Institute, 2006


Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com Enrollment Kit 00495380, 0001, EN 21

Vision PlansSignificant out-of-pocket savings available with your Full Feature plan by visiting one of Davis Vision's network locations including retail centers such asWal-Mart®, JCPenney®, Sears®, Target®, Sam�s Club®, and Pearle®.

Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com Enrollment Kit 00495380, 0001, EN

Your Vision Plan Davis Designer

Network Davis Vision

Your Bi-weekly premium $ 2.75

You and spouse $ 4.63

You and child(ren) $ 4.72

You, spouse and child(ren) $ 7.47

Copay

Exams Copay $ 15

Materials Copay (waived fornon-formulary elective contactlenses)

$ 25

Service Frequencies

Exams Every calendar year

Lenses (for glasses or contact

lenses)��

Every calendar year

Frames Every two calendar years

Network discounts (cosmeticextras, glasses and contactlenses)

Applies to first purchase & courtesy discountfrom most providers on subsequentpurchases.

Dependent Age Limits 261

��Benefit includes coverage for glasses or contact lenses, not both.

Family coverage for spouse and children if the child is dependent upon theemployee for support and is: (i) living in the employee's household; or (ii) a full-timeor part-time student.


YOUR GUARDIANPLAN OFFERS:

Reduced prices An average 40% to

60% discount off an extensive list of

"cosmetic extras", including tints,

special lenses and scratch-resistant

coatings.

No claims submission for

in-network services and supplies.

Did you know?

"Two-thirds of employees would rather

trade a vacation day for eyecare

benefits." � Bests Review, 2006

22

PLAN DETAILS DAVIS DESIGNER

You pay (after copay if applicable):

In-network Out-of-network

Eye Exams $0 Amount over $50

Single Vision Lenses $0 Amount over $48

Lined Bifocal Lenses $0 Amount over $67

Lined Trifocal Lenses $0 Amount over $86

Lenticular Lenses $0 Amount over $126

Frames 80% of amount over$120*

Amount over $48

Contact Lenses (Elective and conventional) 85% of amount over$120*

Amount over $105

Contact Lenses (Planned replacement and disposable) 85% of amount over$120*

Amount over $105

Contact Lenses (Medically Necessary) $0 Amount over $210

Cosmetic Extras Avg. 40-60% off retailprice

No discounts

Glasses (Additional pair of frames and lenses) Courtesy discount frommost providers

No discounts

Laser Correction Surgery Discount Up to 25% off the usualcharge or 5% offpromotional price

No discounts

This is only a partial list of vision services. Your certificate of benefits will show exactly what is covered and excluded.

With the Davis Vision Designer plans, frames from the Fashion or Designer collections are covered in full in excess of the plan�s materials copay, if applicable. Frames from the Premier collection are covered in full in excessof a $25 copay applied in addition to the plan�s materials copay, if applicable. Frames from a network provider that are not in the collections are covered up to the plan�s retail allowance in excess of the plan�s materialscopay, if applicable.

Contact lenses from Davis Vision's Collection are available at most private practice locations with Full Feature and Materials Only plans. Contacts from the collection are covered in full including fitting and evaluation, inexcess of the plan's materials copay. Elective contacts that are not part of the Collection are covered up to the plan's elective contact lens allowance and the materials copay is waived.

For Davis Vision, complete eyeglasses must be purchased at one time from one provider. For example, if a member purchases only lenses, he or she cannot purchase frames later in the same benefit period. The memberis not eligible for new vision materials until the next benefit period.

Only charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use.

*Due to lower prices available at Wal-mart and Sam's Club locations, discounts do not apply. Members will pay 100% of the amount over their allowance.

23

UNDERSTANDING YOUR BENEFITS�VISION

Bifocal Lenses Lens with two focal lengths, one for distance and one for near. Usually the distance correction is on top and the

correction for near is on the bottom.

Calendar Year A type of Plan Year in which eligibility for services starts at the beginning of the calendar year, regardless of the date

of service the previous year(s).

Contact Lens A thin, bowl shaped lens worn on the surface of the eye to correct refractive error.

Contact Lenses (Conventional) Hard or soft contact lenses that are worn daily, removed, cleaned, disinfected and re-used repeatedly, then replaced

as needed. With proper care and handling, these lenses may last up to approximately one year.

Contact Lenses (Disposable) A soft contact lens that is designed to be replaced after a short period of time, from one day up to two weeks.

Contact Lenses (Elective) Contact Lenses not required for the visual welfare of the patient. This is an optical choice over eyeglasses.

Contact Lenses

(Evaluation & fitting)

Provided in addition to the routine eye exam for ensuring proper fit of contacts and evaluating vision with the

contacts. Includes prescription, fitting, evaluation, modification and/or dispensing of contact lenses.

Contact Lenses (Medically necessary) Medically necessary contacts are prescribed by a doctor as required for certain medical conditions that prevent you

from wearing eyeglasses. Medically necessary contacts must be pre-approved.

Contact Lenses (Planned Replacement) Soft lenses that are replaced on a planned schedule, usually monthly or quarterly.

Cosmetic Extras A lens style, coating, or feature that enhances the appearance or functionality of a lens but is not required to meet

the patient's visual needs. Also referred to as Cosmetic Options or Lens Coatings.

Eye Exams Exam by an eye care practitioner, includes refractive and dilatation testing. Does not include evaluation for contact

lenses.

Multifocal Lens Eyeglass lens incorporating two or more different powers, usually three (trifocal).

In-network charges Negotiated discounted fees charged by network providers.

Out-of-network charges Fees charged by providers who are not part of the network. These fees are often higher than in-network charges.

Network Discounts Discounts on non-covered services and materials that offer added value and savings to members.

PPO (Preferred Provider Organization) Network of vision providers who have agreed to accept discounted fees from our members as payment in full.

Service frequency Indicates when you will be eligible again for an exam or materials. These are based on the last date you received an

exam or materials.

Single Vision Lens Lens with one power, as opposed to bifocals, trifocals, quadrifocals or multifocals.

EXCLUSIONS ANDLIMITATIONS:

Important Information: This policyprovides vision care limited benefitshealth insurance only. It does notprovide basic hospital, basic medicalor major medical insurance as definedby the New York State InsuranceDepartment. Coverage is limited tothose charges that are necessary fora routine vision examination. Co-paysapply. The plan does not pay for:orthoptics or vision training and anyassociated supplemental testing;medical or surgical treatment of theeye; and eye examination or correctiveeyewear required by an employer as acondition of employment; replacementof lenses and frames that are furnishedunder this plan, which are lost or broken(except at normal intervals when ser-vices are otherwise available or a war-ranty exists). The plan limits benefitsfor blended lenses, oversized lenses,photochromic lenses, tinted lenses,progressive multifocal lenses, coated orlaminated lenses, a frame that exceedsplan allowance, cosmetic lenses; U-Vprotected lenses and optional cosmeticprocesses. The services, exclusions andlimitations listed above do not constitutea contract and are a summary only. TheGuardian plan documents are the finalarbiter of coverage. Contract#GP-1-DAVIS-05-VIS et al.

Laser Correction Surgery:

� Up to 25% off for vision laser surgery.

� Laser surgery is not an insured benefit.The surgery is available at a discountedfee. The covered person must pay theentire discounted fee. In addition, thelaser surgery discount may not beavailable in all states.

24

Members Save on Eyewear Enhancements through Davis Network Discounts

Designer Plan Spectacle Lenses Member Cost All ranges of prescriptions (single vision, bifocal, trifocal) Included Choice of glass or plastic lenses Included Oversize lenses Included Fashion or gradient tinting of plastic lenses Included Blended Segment Lenses $20 Coating - Scratch Resistant $20 Coating - Ultraviolet $12 Corning™ Photochromic Glass Lenses $20 Intermediate Vision Lenses $30 Polycarbonate Lenses $30* Progressive Lenses - Standard $50 Progressive Lenses (VarilexTM, etc.) - Premium $90 Coating – Ultra Anti-Reflective $60 Coating - Premium Anti-Reflective $48 Coating - Standard Anti-Reflective $35 Hi-Index Lenses $55 Plastic Photosensitive Lenses $65 Polarized Lenses $75 Eyeglass Breakage Warranty Included

Prices subject to change

For standard eyeglass lenses, you will receive the lower of the Davis vision discounted charge or Walmart or Sam’s Club everyday low price. *Polycarbonate lenses covered-in-full for monocular patients and patients with prescriptions 6.00 diopters or greater.

www.GuardianLife.com or contact member services at 877-393-7363 for more information

25

ADDITIONAL MATERIALS

26

Employee Benefits Hotline (EBH)

Benefit specialists are available to answer questions as you sign up for your Guardian benefits

Toll-free Phone

1-888-600-1600

Monday-Friday

7:00 a.m. – 8:30 p.m. EST

6:00 a.m. – 7:30 p.m. CST

5:00 a.m. – 6:30 p.m. MST

4:00 a.m. – 5:30 p.m. PST

STEP 1: Ask yourself these questions to determine if you should call the Employee Benefits Hotline. If you answer “yes” to any of these questions, prepare to contact the Hotline (go to STEP 2):

• Do I need help completing my enrollment forms?

• Do I have questions about the benefits covered under the plans my employer is offering?

• Do I need to make my first dental/vision appointment immediately following my enrollment? (If so, it’s suggested you contact the Hotline at least 72 hours prior to your visit so you can ensure your provider has your coverage information. Coverage begins on your plan’s effective date.)

STEP 2: Prepare to contact the Hotline • Name of the company you work for

• Your company’s group number (Both can be found on the front of the enrollment materials)

STEP 3: Call 888-600-1600 to get answers! • Press #1 to identify yourself as an employee.

• At the next prompt: o Press #1 if your questions relate to Dental Benefits o Press #0 for all other questions

• Enter your company’s group number

IMPORTANT NOTE: The Employee Benefits Hotline provides pre-enrollment support in over 50 languages! Once you are enrolled in a plan, you will receive additional information and new toll-free phone numbers. If you are looking for a dentist or vision provider who participates in your plan, go to www.Guardian Anytime.com.

27

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1Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com

DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

DATE FORM PUBLISHED: Dec 11, 2014

The Guardian Life Insurance Company of America

Enrollment/Change Form

Page 1 of 4

Guardian Life, P.O. Box 14319,Lexington, KY 40512 Please print clearly and mark carefully.

CEF2012-FL

Employer Name: Baer's Furniture Group Plan Number: 00495380 Benefits Effective:_____________

PLEASE CHECK APPROPRIATE BOX q Initial Enrollment q Re-Enrollment q Add Employee/Dependents q Drop/Refuse Coverage q Information Change

q Increase Amount q Family Status Change

Class: All Eligible Employees Division:_________________ Subtotal Code:____________________ (Please obtain this from your Employer)

About You: Social Security Number

First, MI, Last Name:___ ___ ___ - ___ ___ - ___ ___ ___ ___

Address City State Zip

Gender: q M q F Date of Birth (mm-dd-yy): ____ - ____ - ____ Phone: ( ) -

Email Address: Are you married or do you have a spouse? q Yes q No Date of marriage/union:____-____-_____

Do you have children or other dependents? q Yes q No Placement date of adopted child: ____-____-_____

About Your Job: Hours worked per week: _______ Job Title:

Work Status:

q Active q Retired q Cobra/State Continuation Date of full time hire: ____ - ____ - ____

About Your Family: Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you,

as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception.

Dependency tax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard

dependents such as a grandchild, a niece or a nephew.

Spouse (First, MI, Last Name) Gender

q M q F

Date of Birth (mm-dd-yyyy)

____ - ____ - ____

Child/Dependent 1: q Add q Drop Gender

q M q F


____ - ____ - ____

Status (check all that apply)q Student (post high school) q Disabled

q Non standard dependent

State of Residence:____________________


q M q F


____ - ____ - ____





q M q F


____ - ____ - ____





q M q F


____ - ____ - ____




2


Drop Coverage:q Drop Employee q Drop Dependents

The date of withdrawal cannot be prior to the date this form is completedand signed.

Last Day of Coverage: _____-_____-_____

q Termination of Employment q Retirement

Last Day Worked: _____-_____-_____

q Other Event: _____________

Date of Event: _____-_____-_____

Coverage Being Dropped:

q Dental q Employee q Spouse q Child(ren)

q Vision q Employee q Spouse q Child(ren)

Loss Of Other Coverage:I and/or my dependents were previously covered under another insuranceplan. Loss of coverage was due to:

q Termination of Employment: _____-_____-_____

q Divorce _____-_____-_____

q Death of Spouse _____-_____-_____

q Termination/Expiration of Coverage _____-_____-_____

Coverage Lost q Dental q Vision

I have been offered the above coverage(s) and wish to drop enrollment for the followingreasons:

q Covered under another insurance plan

q Other ____________________________________________________

(additional information may be required)

Dental Coverage: You must be enrolled to cover your dependents. Check only one box.

Your Bi-weekly Premium Employee Only EE & Spouse EE &Dependent/Child(ren)

EE, Spouse &Dependent/Child(ren)

Option 1: DHMO U30M q $5.40 q $10.81 q $12.03 q $17.44

Option 2: PPO q $13.88 q $29.04 q $34.79 q $46.47

� If Pre-Paid is elected, you must have a Primary Care Dentist (PCD). Please designate your PCD(s) by listing dental office location number(s) for each person.Please visit guardianlife.com for a list of providers. If you do not select a PCD, one will be assigned for you.

Employee _________________________ Spouse _________________________ Child(ren) _____________________________

q I do not want this coverage. If you do not want this Dental Coverage, please mark all that apply:

q I am covered under another Dental plan

q My spouse is covered under another Dental plan

q My dependents are covered under another Dental plan

Vision Coverage: You must be enrolled to cover your dependents. Check only one box.

Your Bi-weekly Premium Employee Only EE & Spouse EE &Dependent/Child(ren)

EE, Spouse &Dependent/Child(ren)

Davis Designer q $2.75 q $4.63 q $4.72 q $7.47

q I do not want this coverage. If you do not want this Vision Coverage, please mark all that apply:

q I am covered under another Vision plan

q My spouse is covered under another Vision plan

q My dependents are covered under another Vision plan

Signature

l An employee's decision to elect Vision or not elect Vision must be retained until the next plan's Open Enrollment period. If the employee elects not to enroll in visioncoverage, they are not eligible to enroll until the plan's next Open Enrollment period.

l I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage.

l I understand that the premium amounts shown above are estimations and are for illustrative purposes only.

l Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approval and meeting the applicable eligibilityrequirements as set forth in the applicable benefit booklet.

l If coverage is waived and you later decide to enroll, late entrant penalties may apply. You may also have to provide, at your own expense, proof of each person'sinsurability. Guardian or its designee has the right to reject your request.

l Plan design limitations and exclusions may apply. For complete details of coverage, please refer to your benefit booklet. State limitations may apply.

l Your coverage will not be effective until approved by a Guardian or its designated underwriter.

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Guardian Group Plan Number: 00495380 Please print employee name:


Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com

l I hereby apply for the group benefit(s) that I have chosen above.

l I understand that I must meet eligibility requirements for all coverages that I have chosen above.

l I agree that my employer may deduct premiums from my pay if they are required for the coverage I have chosen above.

l I attest that the information provided above is true and correct to the best of my knowledge.

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or

misleading information is guilty of a felony of the third degree.

The state in which you reside may have a specific state fraud warning. Please refer to the attached Fraud Warning Statements page.

The laws of New York require the following statement appear: If you are not a resident of New York this statement does not apply to you: Any person who knowingly and

with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or

conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be

subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (Does not apply to Life Insurance.)

SIGNATURE OF EMPLOYEE X ___________________________________________ DATE ______________________

Enrollment Kit 00495380, 0001, EN

Fraud Warning Statements

The laws of several states require the following statements to appear on the enrollment form:

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application forinsurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for paymentof a loss is subject to criminal and civil penalties.

California: For your protection California law requires the following to appear on this form: The falsity of any statement in the application shall not bar the right to recoveryunder the policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed bythe insurer.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting todefraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company whoknowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department ofRegulatory Agencies.

Connecticut, Iowa, Kansas, Nebraska, Oregon, and Vermont: Any person who knowingly, and with intent to defraud any insurance company or other person, files anapplication of insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto, may be guilty of a fraudulent insurance act, which may be a crime, and may also be subject to civil penalties.

Delaware, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of aninsurance policy containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penaltiesinclude imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false informationor conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Louisiana and Texas: Any person 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 andconfinements in state prison.

Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose ofdefrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland : Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in anapplication for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Rhode Island: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents falseinformation in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete ormisleading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. § 638:20

4

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit or knowingly presents false information in an application forinsurance is guilty of a crime and may be subject to civil fines and criminal penalties or denial of insurance benefits.

Ohio: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false ordeceptive statement is guilty of insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claimcontaining any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties.

Thank You

q Check the coverage you want

q Include your social security number

(and those of your dependents, if applicable)

q Include dates of birth

q Indicate the best way to reach you

q Include your name on each page of the form

q Sign and date form

If applicable, return your completed form to your plan

administrator.

Please remember to:

Date form submitted:

© 2005 The Guardian Life Insurance Company of America,

7 Hanover Square, New York 10004

Make the most of your Guardian benefits at

www.GuardianAnytime.com

Enrolled members and their dependents can access helpful,

secure information about their Guardian benefit(s) instantly at

www.GuardianAnytime.com

� Review your benefits

� Look up amounts and services covered in your plan

� Check the status of a claim

� Receive e-mail alerts when a response to your

dental* claim is available online

� View and print dental or vision ID cards

� Print forms and plan materials...and much more

To register, go to www.GuardianAnytime.com

*Not available to members with Guardian pre-paid Dental/DHMO plans (including FirstCommonwealth

and Managed DentalGuard plans).

Baer's FurnitureBenefits Plan

0001

Documents

Benefits Plan · Benefits Plan PLAN HIGHLIGHTS: Baer's Furniture ... and flossing are vital to keeping as many teeth as you can. Keeping your teeth means better chewing function and