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Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expertdental care when you are outside of the United States through our Passport Dental program. This program gives you access to aworldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions andhelp you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our PassportDental information sheet.Maximum Payment – 800 per person total per Benefit Year on all services.Out-of-Pocket Maximum Payment for Non-EHB Covered Services – An Out-of-Pocket Maximum is the maximum amount thatyou or your Eligible Dependent will pay for Covered Services throughout a Benefit Year. There is no Out-of-Pocket MaximumPayment for Non-EHB Covered Services. You will be responsible for all Copayments, Deductibles, Balanced Billing Amounts andother out-of-pocket expenses associated with all Non-EHB Covered Services provided to you or your Eligible Dependent throughoutthe Benefit Year.Deductible – 50 Deductible per person total per Benefit Year limited to a maximum Deductible of 150 per family per Benefit Year.The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, and X-rays.Waiting Period – See BCN Services for your specific new hire waiting period.There is a 365-day waiting period for certain services. Endodontic Services, Periodontic Services, Major Restorative Services,Relines and Repairs, and Prosthodontic Services will not be covered until after a person is enrolled in the dental plan for 365consecutive days. Add after waiting period language: These waiting periods will be waived for employees enrolled in the dental planas of December 31, 2003.Eligible People – All full-time employees of BCN Services working 30 hours per week who choose the EHB compliant plan andCOBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees, if applicable. The Subscriber pays the full cost of thisplan.Also eligible at your option are your legal spouse, your dependent children to the end of the calendar year in which they turn 19, andyour dependent unmarried children to the end of the calendar year in which they turn 25 if eligible to be claimed by you as adependent under the U.S. Internal Revenue Code during the current calendar year. You and your eligible dependents must enroll for aminimum of 12 months. If coverage is terminated after 12 months, you may not re-enroll prior to the open enrollment that occurs atleast 12 months from the date of termination. Your dependents may only enroll if you are enrolled (except under COBRA) and mustbe enrolled in the same plan as you. Plan changes are only allowed during open enrollment periods, except that an election may berevoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125.If you and your spouse are both eligible for coverage under this Contract, you may be enrolled together on one application orseparately on individual applications, but not both. Your dependent children may only be enrolled on one application. Delta Dentalwill not coordinate benefits if you and your spouse are both covered under this Contract.Benefits will cease on the last day of the month in which the employee is terminated.QD-201-Delta-2017-STDLOW-MI

Deductibles for EHB Covered Services – The Deductible is 25 per individual per Benefit Year, limited to a maximum Deductible of 75 for all individuals covered by this Certificate per Benefit Year. The Deductible does not apply to exams, cleanings, fluoride, spacemaintainers, emergency palliative treatment, brush biopsy, and sealants.Waiting Period for EHB Covered Services – There are no waiting periods for individuals under the age of 19 seeking EHB CoveredServices.EHB Covered ServicesThe following services are the specific EHB Covered Services covered under this Certificate:Diagnostic and Preventive ServicesExaminations/EvaluationsD0120 – periodic oral evaluationD0140 – limited oral evaluation – problem focusedD0145 – oral evaluation for a patient under three years of ageD0150 – comprehensive oral evaluationD0160 – detailed and extensive oral evaluation (problem focused)D0180 – comprehensive periodontal evaluationD0190 – screening of a patientD9440 – office visit – after regularly scheduled hoursCleanings (Prophylaxes)D1110 – prophylaxis – adultD1120 – prophylaxis – childFluoride TreatmentD1206 – topical fluoride varnishD1208 – topical application of fluoride (prophylaxis not included)Space MaintainersD1510 – space maintainer – fixed – unilateralD1515 – space maintainer – fixed – bilateralD1520 – space maintainer – removable – unilateralD1525 – space maintainer – removable – bilateralD1550 – re-cementation of space maintainerD1555 – removal of fixed spaceBrush BiopsyD0486 – accession of brush biopsy sample, microscopicexamination, preparation and transmission of written reportD7288 – brush biopsy – transepithelial sample collectionEmergency Palliative TreatmentD9110 – palliative (emergency) minor dental treatmentRadiographs (X-rays)/Diagnostic Imaging/Diagnostic CastsD0210 – intraoral-complete series (including bitewings)D0330 – panoramic filmD0220 – intraoral – periapical first filmD0230 – intraoral – periapical each addl filmD0240 – intraoral – occlusal filmD0250 – extraoral – first filmD0260 – extraoral – each addl filmD0270 – bitewing – single filmD0272 – bitewings – two filmsD0273 – bitewings – three filmsD0274 – bitewings – four filmsD0277 – bitewing, vertical – 7 to 8 filmsD0290 – posterior – anterior or lateral skull and facial bone surveyfilmD0999 – unspecified diagnostic procedure, by reportSealantsD1351 – sealant – per tooth – unrestored permanent molarsD1353 – sealant repair – per toothBasic ServicesQD-201-Delta-2017-STDLOW-MIMinor Restorative Services (local anesthesia is considered to bepart of restorative procedures)D2140 – amalgam – one surface, primary or permanentD2150 – amalgam – two surfaces, primary or permanentD2160 – amalgam – three surfaces, primary or permanentD2161 – amalgam – four or more surfaces, primary or permanentD2330 – resin – based composite – one surface, anteriorD2331 – resin – based composite – two surfaces, anteriorD2332 – resin – based composite – three surfaces, anteriorD2335 – resin – based composite – four or more surfaces, anteriorD2390 – resin – based composite crown, anterior Benefits for composite resin restorations on posterior teeth areoptional treatment. Delta Dental will pay only the amount thatit would pay for an amalgam restoration.D2940 – sedative fillingD2951 – pin retention – per tooth, in addition to restorationD2910 – recement inlay, only or partial coverage restorationD2915 – recement cast or prefabricated post and coreD2920 – recement crownD2980 – crown repair, by reportD2981 – inlay repair, by reportD2982 – onlay repair, by reportD2983 – veneer repair, by reportD2999 – unspecified procedure, by reportOral Surgery ServicesD7111 – extraction, coronal remnants – deciduous toothD7140 – extraction, erupted tooth or exposed rootD7210 – surgical removal of erupted toothD7220 – removal of impacted tooth – soft tissueD7230 – removal of impacted tooth – partial bonyD7240 – removal of impacted tooth – completely bonyD7241 – removal of impacted tooth – completely bony, withunusual surgical complicationsD7250 – surgical removal of residual tooth rootsD7270 – tooth reimplantation and/or stabilization of accidentallyevulsed or displaced toothD7280 – surgical access of an unerupted toothD7282 – mobilization of erupted or malpositioned tooth to aideruptionD7283 – placement of device to facilitate eruption of impactedtoothD7286 – biopsy of soft tissue – softD7290 – surgical repositioning of teethD7291 – transseptal fiberotomy/supra crestal fiberotomyD7310 – alveoloplasty, in conjunction with extractions – four ormore teeth, per quadrantD7311 – alveoloplasty, in conjunction with extractions – one tothree teeth or tooth spaces, per quadrantD7320 – alveoloplasty, not in conjunction with extractions – fouror more teeth, per quadrant

D7321 – alveoloplasty, not in conjunction with extractions – oneto three teeth or tooth spaces, per quadrantD7960 – frenulectomy (frenectomy or frenotomy)D7963 – frenuloplastyD7970 – excision of hyperplastic tissue – per archD7972 – surgical reduction of fibrous tuberosityD7999 – unspecified oral surgery procedure, by reportD7510 – incision and drainage of abscess – intraoral soft tissueD7511 – incision and drainage of abscess – intraoral soft tissue –complicatedD7910 – suture of recent small wounds up to 5 cmD7971 – excision of pericoronal gingivaEndodontic ServicesD3220 – therapeutic pulpotomy (excluding final restoration)D3221 – pulpal debridement, primary or permanent teethD3222 – partial pulpotomy for apexogenesis – permanent toothwith incomplete root developmentD3230 – pulpal therapy (resorbable filling) – anterior, primarytooth (excluding final restoration)D3240 – pulpal therapy (resorbable filling) – posterior, primarytooth (excluding final restoration)D3310 – anterior (excluding final restoration)D3320 – bicuspid (excluding final restoration)D3330 – molar (excluding final restoration)D3331 – treatment of root canal obstruction; non–surgical accessD3332 – incomplete endodontic therapy; inoperable, unrestorableor fractured toothD3333 – internal root repair of perforation defectsD3346 – retreatment of previous root canal therapy – anteriorD3347 – retreatment of previous root canal therapy – bicuspidD3348 – retreatment of previous root canal therapy – molarD3351 – apexification/recalcification – initial visit (apical closurecalcific repair or perforations, root resorptions)D3352 – apexification/recalcification – interim visitD3353 – apexification/recalcification – final visitD3410 – apicoectomy/periradicular surgery – anteriorD3421 – apicoectomy/periradicular surgery – bicuspid (first root)D3425 – apicoectomy/periradicular surgery – molar (first root)D3426 – apicoectomy/periradicular surgery – (each addl root)D3430 – retrograde filling – per rootD3450 – root amputation – per rootD3920 – hemisection (including any root removal)D3999 – unspecified endodontic procedure, by reportPeriodontic ServicesD4210 – gingivectomy or gingivoplasty – four or more teethD4211 – gingivectomy or gingivoplasty – one to three teethD4240 – gingival flap procedure, including root planing – four ormore teethD4241 – gingival flap procedure, including root planing – one tothree contiguous teeth or bounded teeth or bounded teeth spacesD4245 – apically positioned flapD4249 – clinical crown lengthening – hard tissueD4320 – provisional splinting – intracoronalD4321 – provisional splinting – extracoronalD4341 – periodontal scaling and root planing, four or more teethD4342 – periodontal scaling and root planing, one to three teethD4355 – full mouth debridementD4910 – periodontal maintenance proceduresD4999 – unspecified periodontal procedure, by reportRelines and RepairsQD-201-Delta-2017-STDLOW-MID5410 – adjust complete denture – maxillaryD5411 – adjust complete denture – mandibularD5421 – adjust partial denture – maxillaryD5422 – adjust partial denture – mandibularD5510 – repair broken complete denture baseD5520 – replace missing or broken teeth – complete dentureD5610 – repair resin denture baseD5620 – repair cast frameworkD5630 – repair or replace broken claspD5640 – replace broken teeth – per toothD5650 – add tooth to existing partial dentureD5660 – add clasp to existing partial dentureD5670 – replace all teeth and acrylic on cast metal framework(maxillary)D5671 – replace all teeth and acrylic on cast metal framework(mandibular)D5710 – rebase complete maxillary dentureD5711 – rebase complete mandibular dentureD5720 – rebase maxillary partial dentureD5721 – rebase mandibular partial dentureD5730 – reline complete maxillary dentureD5731 – reline complete mandibular dentureD5740 – reline maxillary partial dentureD5741 – reline mandibular partial dentureD5750 – reline complete maxillary denture (laboratory)D5751 – reline complete mandibular denture (laboratory)D5760 – reline maxillary partial denture (laboratory)D5761 – reline mandibular partial denture (laboratory)D5850 – tissue conditioning denture (maxillary)D5851 – tissue conditioning denture (mandibular)D5899 – unspecified removable prosthodontic procedureD5999 – unspecified procedure, by reportD6930 – recement fixed partial dentureD6980 – fixed partial denture repair by reportOther Basic ServicesD0460 – pulp vitality testsD0470 – diagnostic modelsD9310 – consultationD9220 – deep sedation/general anesthesia – first 30 minD9221 – deep sedation/general anesthesia – each addl 15 minD9241 – intravenous conscious sedation/analgesia – first 30 minD9242 – intravenous conscious sedation/analgesia – each addl 15minD9248 – non–intravenous conscious sedationD9920 – behavior management, by reportD9930 – treatment of complications (post–surgical)Major ServicesMajor Restorative ServicesD2542 – onlay – metallic – two surfacesD2543 – onlay – metallic – three surfacesD2544 – onlay – metallic – four or more surfacesD2642 – onlay – porcelain/ceramic – two surfacesD2643 – onlay – porcelain/ceramic – three surfacesD2644 – onlay – porcelain/ceramic – four or more surfacesD2662 – onlay – resin–based composite – two surfacesD2663 – onlay – resin–based composite – three surfacesD2664 – onlay – resin–based composite – four or more surfacesD2710 – crown – resin–based composite (indirect)D2712 – crown – 3/4 resin–based composite (indirect)D2720 – crown – resin with high noble metalD2721 – crown – resin with predominantly base metal

D2722 – crown – resin with noble metalD2740 – crown – porcelain/ceramic substrateD2750 – crown – porcelain fused to high noble metalD2751 – crown – porcelain fused to predominantly base metalD2752 – crown – porcelain fused to noble metalD2780 – crown – 3/4 cast high noble metalD2781 – crown – 3/4 cast predominantly base metalD2782 – crown – 3/4 cast noble metalD2783 – crown – 3/4 porcelain/ceramicD2790 – crown – full cast high noble metalD2791 – crown – full cast predominantly base metalD2792 – crown – full cast noble metalD2794 – crown – titanium Benefits for plastic, resin, porcelain fused to metal, porcelainand porcelain/ceramic crowns or onlays on posterior teeth areoptional treatment. Delta Dental will pay only the amount thatit would pay for a full metal crown or metallic onlay. Benefits for inlays, regardless of the material used, areoptional treatment. Delta Dental will pay only the amount thatit would pay for an amalgam or composite resin restoration.D2929 – prefabricated porcelain/ceramic crown – primary toothD2930 – prefabricated stainless steel crown – primary toothD2931 – prefabricated stainless steel crown – permanent toothD2932 – prefabricated resin crownD2933 – prefabricated stainless steel crown with resin windowD2934 – prefabricated esthetic coated stainless steel crown –primary toothD2950 – core buildup, including pinsD2952 – cast post and core in addition to crownD2954 – prefabricated post and core in addition to crownD2955 – post removalD2960 – labial veneer – (resin laminate) chairsideD2961 – labial veneer (resin laminate) – laboratoryD2962 – labial veneer (porcelain laminate) – laboratoryD2970 – temporary crown (fractured tooth)D2971 – additional procedures to construct new crown underexisting partial denture frameworkProsthodontic ServicesD5110 – complete denture – maxillaryD5120 – complete denture – mandibularD5130 – immediate denture – maxillaryD5140 – immediate denture – mandibularD5211 – maxillary partial denture – resin base (including anyconventional clasps, rests and teeth)D5212 – mandibular partial denture – resin base (including anyconventional clasps, rests and teeth)D5213 – maxillary partial denture – cast metal framework – resindenture base (including any conventional clasps, rests and teeth)D5214 – mandibular partial denture – cast metal framework –resin denture base (including any conventional clasps, rests andteeth)D5225 – maxillary partial denture – flexible base (including anyclasps, rests and teeth)QD-201-Delta-2017-STDLOW-MID5226 – mandibular partial denture – flexible base (including anyclasps, rests and teeth)D5281 – removable unilateral partial denture – one piece castmetal (including clasps and teeth) Benefits for overdentures are optional treatment. Delta Dentalwill pay only the amount that it would pay for a conventionaldenture.D5820 – interim partial denture (maxillary)D5821 – interim partial denture (mandibular)D6210 – pontic – cast high noble metalD6211 – pontic – cast predominantly base metalD6212 – pontic – cast noble metalD6214 – pontic – titaniumD6240 – pontic – porcelain fused to high noble metalD6241 – pontic – porcelain fused to predominantly base metalD6242 – pontic – porcelain fused to noble metalD6245 – pontic – porcelain/ceramicD6250 – pontic – resin with high noble metalD6251 – pontic – resin with predominantly base metalD6252 – pontic – resin with noble metalD6545 – retainer – cast metal for resin bonded fixed prosthesisD6602 – inlay – cast high noble metal, two surfacesD6603 – inlay – cast high noble metal, three or more surfacesD6604 – inlay – cast predominantly base metal, two surfacesD6605 – inlay – cast predominantly base, three or more surfacesD6606 – inlay – cast noble metal, two surfacesD6607 – inlay – cast noble metal, three or more surfacesD6624 – inlay – titaniumD6610 – onlay – cast high noble metal, two surfacesD6611 – onlay – cast high noble metal, three or more surfacesD6612 – onlay – cast predominantly base metal, two surfacesD6613 – onlay – cast predominantly base, three or more surfacesD6614 – onlay – cast noble metal, two surfacesD6615 – onlay – cast noble metal, three or more surfacesD6634 – onlay – titaniumD6720 – crown – resin with high noble metalD6721 – crown – resin with predominantly base metalD6722 – crown – resin with noble metalD6750 – crown – porcelain fused to high noble metalD6751 – crown – porcelain fused to predominantly base metalD6752 – crown – porcelain fused to noble metalD6780 – crown – 3/4 cast high noble metalD6781 – crown – 3/4 cast predominantly base metalD6782 – crown – 3/4 cast noble metalD6783 – crown – 3/4 porcelain/ceramicD6790 – crown – full cast high noble metalD6791 – crown – full cast predominantly base metalD6792 – crown – full cast noble metalD6794 – crown – titanium Benefits for all porcelain/ceramic bridges are optionaltreatment. Delta Dental will only pay the amount that it wouldpay for a conventional fixed bridge.D6999 – unspecified fixed prosthodontic procedure, by reportCustomer Service Toll-Free Number: (800) 524-0149www.DeltaDentalMI.comJanuary 1, 2017

QD-201-Delta-2017-STDLOW-MI. Delta Dental PPO - Basic Plan . Summary of Dental Plan Benefits . For Group# 9453-1004E . BCN Services/Voluntary . This Summary of Dental Plan Benefits should be read along with your Certificate.