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SECTION II: SCHEDULE OF BENEFITS AND COPAYSPLAN TDA A800RADACODEPROCEDURE DESCRIPTIONDIAGNOSTICD0120Periodic Oral Exam (once in a 6 month period)D0120Periodic Oral Exam (Additional*)D0140Problem Focused Oral Exam (during office hours)D0145Oral Evaluation, patient under 3 years’ of ageD0145Oral Evaluation, patient under 3 years’ of age(Additional*)D0150Comprehensive Oral Evaluation (once in a 6 monthperiod)D0150Comprehensive Oral Evaluation (Additional*)D0160Detailed Oral Exam (problem focused)D0170Re-evaluation, limited, problem focused (est. patient)D0210Intraoral x-rays, complete series including bitewing xrays (D0210 or D0330 are covered once in a 3 yearperiod)D0210Intraoral x-rays, complete series (Additional*)D0220Intraoral x-ray – Periapical first filmD0230Intraoral x-ray – Periapical – each additional filmD0270Bitewing – Single filmD0272Bitewings – Two films (once in a 6 month period)D0272Bitewings – Two films (Additional*)D0273Bitewings – Three Films (once in a 6 month period)D0273Bitewings – Three Films (Additional*)D0274Bitewings – Four films (once in a 6 month period)D0274Bitewings – Four films (Additional*)D0277Vertical bitewings, 7 to 8 films (once in a 6 monthperiod)D0277Vertical bitewings, 7 to 8 films (Additional*)D0330Panoramic film – including bitewing x-rays (D0330 orD0210 once in a 3 year period)D0330Panoramic film (Additional*)D0470Diagnostic CastsD9310ConsultationD9430Office Visit – per patient/per visitMEMBERCOPAY 5 15 15 5 20 5 20 15 0 5 55 0 0 0 0 10 0 15 0 20 0 22 5 45 0 0 0PREVENTIVED1110Prophylaxis – Adult (once in a 6 month period)D1110Prophylaxis – Adult (Additional*)D1120Prophylaxis – Child (once in a 6 month period)D1120Prophylaxis – Child (Additional*)D1203Fluoride treatment (limit 1 per year to age 15)D1203Fluoride treatment (Additional* to age 15)D1310Nutrition Counseling – Control/Den DiseaseD1330Preventive Dental Education, home careD1351Sealant permanent molar, to age 17 – once per toothD1510Space Maintainer – Fixed – UnilateralD1515Space Maintainer – Fixed – BilateralD1520Space Maintainer – Removable – UnilateralD1525Space Maintainer – Removable – BilateralD1550Re-cement Space Maintainer 10 40 5 25 0 10 0 0 15 150 160 150 200 15RESTORATIVED2140Amalgam – 1 surface, primaryD2150Amalgam – 2 surfaces, primaryD2160Amalgam – 3 surfaces, primaryD2161Amalgam – 4 or more surfaces, primaryD2140Amalgam – 1 surface, permanentD2150Amalgam – 2 surfaces, permanentD2160Amalgam – 3 surfaces, permanentD2161Amalgam – 4 or more surfaces, permanentD2330Resin – 1 surface, anteriorD2331Resin – 2 surfaces, anteriorD2332Resin – 3 surfaces, anteriorD2335Resin – 4 or more surfaces, anteriorD2391Resin – 1 surface, posteriorD2392Resin – 2 surfaces, posteriorD2393Resin – 3 surfaces, posteriorD2394Resin – 4 or more surfaces, posteriorD2510Inlay metallic – 1 surface 15 25 35 45 15 25 35 45 30 45 55 70 40 60 75 80 250ADACODEPROCEDURE DESCRIPTIONRESTORATIVE (continued)D2520Inlay metallic – 2 surfacesD2530Inlay metallic – 3 surfacesD2542Onlay metallic – 2 surfacesD2543Onlay metallic – 3 or more surfacesD2544Onlay metallic – 4 or more surfacesD2710Crown – Resin – indirectD2720Crown – Resin with High Noble MetalD2721Crown – Resin – Predominantly Base MetalD2722Crown – Resin with Noble MetalD2740Crown – Porcelain/Ceramic SubstrateD2750Crown – Porcelain – High Noble MetalD2751Crown – Porcelain – Predom Base MetalD2752Crown – Porcelain – Fused – Noble MetalD2780Crown – ¾ Cast – High Noble MetalD2781Crown – ¾ Cast – Predom Base MetalD2782Crown – ¾ Cast – Noble MetalD2783Crown – ¾ Cast – Porcelain/CeramicD2790Crown – Full Cast – High Noble MetalD2791Crown – Full Cast – Predom Base MetalD2792Crown – Full Cast – Noble MetalD2910Re-cement inlayD2915Re-cement Cast or Prefabricated Post and CordD2920Re-cement crownD2930Crown – Prefabricated Stainless Steel, primary toothD2932Crown – Prefabricated ResinD2933Crown - Prefabricated Stainless Steel w/Resin WindowD2934Crown - Prefabricated Esthetic Coated Stainless Steel ,primary toothD2940Sedative FillingD2950Core build-up including any pinsD2951Pin retention per tooth, in addition to restorationD2952Cast post and core in addition to crownD2954Prefabricated post/core in addition to crownD2960Labial veneer (resin laminate) – Chair sideD2961Labial veneer (resin laminate) D2962Labial veneer (porcelain laminate) D2970Temporary crown (fractured tooth)D2980Crown repair, by reportENDODONTICS**D3110Pulp Cap – Direct (excluding final restoration)D3120Pulp Cap – Indirect (excluding final restoration)D3220Therapeutic pulpotomy (excluding final restoration)D3221Pulpal debridement, primary and permanent teethD3310Root Canal – Anterior (excluding final restoration)D3320Root Canal – Bicuspid (excluding final restoration)D3330Root Canal – Molar (excluding final restoration)D3410Apicoectomy/Perirad Surgery – AnteriorD3421Apicoectomy/Perirad Surgery – Bicuspid, 1st rootD3425Apicoectomy/Perirad Surgery – Molar, 1st rootD3426Apicoectomy/Perirad Surgery – (each additional root)D3430Retrograde filling, per rootD3450Root amputation, per rootD3920Hemisection – incl. root removal – not incl. root canaltherapyPERIODONTICS**D4210Gingivectomy or gingivoplasty – 4 or more teeth perquadD4211Gingivectomy or gingivoplasty – 1-3 teeth per quadD4240D4241D4260D4261Ging. flap procedure, incl. root planing, 4 or more teethper quadGing. flap procedure, incl. root planing, 1-3 teeth perquadOsseous surg./Flap Entry/Closure, 4 or more teeth perquadOsseous surg./Flap Entry/Closure, 1-3 teeth per quadMEMBERCOPAY 279 327 320 340 380 148 183 183 183 495 495 475 475 475 475 475 475 495 475 475 20 20 20 90 95 110 110 35 70 20 125 85 350 350 Lab 350 Lab 50 100 20 20 55 65 250 350 450 350 400 450 190 95 195 165 265 150 295 155 475 250TDAHPINDVTMPLT03.2014Page 4

ADACODEPROCEDURE DESCRIPTIONPERIODONTICS** (continued)D4320Provisional splinting – intraoralD4321Provisional splinting – extracoronalD4341Periodontal scaling & root planing – 4 or more teethper quadD4342Periodontal scaling & root planing – 1-3 teeth per quadD4355Full mouth debridement to enable evaluation &diagnosisD4381Local del of chemotherapeutic agent (via controlledrelease vehicle) per tooth, by reportD4910Periodontal maintenance following active therapyREMOVABLE PROSTHODONTICSD5110Complete Denture (Maxillary) – (3 adj. w/in 60 days)D5120Complete Denture (Mandibular) – (3 adj. w/in 60 days)D5130Immediate Denture (Maxillary) – (4 adj. w/in 60 days)D5140Immediate Denture (Mandibular) – (4 adj. w/in 60days)D5211Partial Denture (Maxillary) – Resin BaseD5212Partial Denture (Mandibular) – Resin BaseD5213Partial Denture (Maxillary) – Cast Metal Frameworkw/resin denture bases (incl. any conventional clasps,rests and teeth)D5214Partial Denture (Mandibular) – Cast Metal Frameworkw/resin denture bases (incl. any conventional clasps,rests and teeth)D5281Partial Denture – Removable Unilateral – 1 piece metalcastD5410Denture Adjustment (Maxillary) – full or partialD5422Denture Adjustment (Mandibular) – full or partialD5510Repair broken complete denture base D5520Replace missing/broken teeth – complete denture baseD5610Repair resin denture base D5620Repair cast framework, partial denture D5630Repair or replace broken clasp, partial denture D5640Replace broken tooth (per tooth), partial denture D5650Add tooth to existing partial denture D5660Add clasp to existing partial denture D5670Replace all teeth & acrylic cast metal framework U/L– Maxillary D5671Replace all teeth & acrylic cast metal framework U/L– Mandibular D5710Rebase Complete Denture (Maxillary) D5711Rebase Complete Denture (Mandibular ) D5720Rebase Partial Denture (Maxillary) D5721Rebase Partial Denture (Mandibular) D5730Reline Chair side (Maxillary) – fullD5731Reline Chair side (Mandibular) – fullD5740Reline Chair side (Maxillary) – partialD5741Reline Chair side (Mandibular) – partialD5750Reline, lab (Maxillary) – full D5751Reline, lab (Mandibular) – full D5760Reline, lab (Maxillary) – partial D5761Reline, lab (Mandibular) – partial D5850Tissue conditioning (Maxillary)D5851Tissue conditioning (Mandibular)FIXED PROSTHODONTICSD6205Pontic – Indirect Resin Based CompositeD6210Pontic – Cast – High Noble MetalD6211Pontic – Cast – Predom Base MetalD6212Pontic – Cast – Noble MetalD6240Pontic – Porcelain – High Noble MetalD6241Pontic – Porcelain – Predom Base MetalD6242Pontic – Porcelain – Fused to Noble MetalD6245Pontic – Porcelain/CeramicD6250Pontic – Resin w/High Noble MetalD6250Pontic – Resin w/High Noble MetalMEMBERCOPAY 150 125 95 70 75 75 60 675 675 700 700 675 675 700 700 ADACODEPROCEDURE DESCRIPTIONFIXED PROSTHODONTICS (continued)D6251Pontic – Resin w/Predom Base MetalD6252Pontic – Resin w/Noble MetalD6545Crown – Cast Metal/Resin bonded/Fixed prosthesisD6720Crown – Resin w/High Noble MetalD6721Crown – Resin w/Predom Base MetalD6722Crown – Resin w/Noble MetalD6740Crown – Porcelain/CeramicD6750Crown – Porcelain fused to High Noble MetalD6751Crown – Porcelain fused to Predom Base MetalD6752Crown – Porcelain fused to Noble MetalD6780Crown – ¾ Cast – High Noble MetalD6781Crown – ¾ Cast – Predom Base MetalD6782Crown – ¾ Cast – Noble MetalD6783Crown – ¾ Porcelain/CeramicD6790Crown – Full Cast – High Noble MetalD6791Crown – Full Cast – Predom Base MetalD6792Crown – Full Cast – Noble MetalD6920Connector barD6930Re-cement Fixed Partial Denture – per cemented unitD6940Stress breaker – non-rigid connector D6950Precision attachmentD6970Cast post/core/add to br. retainer, per toothD6972Prefab post/core in addition to br. retainer, per toothD6973Core build-up including any pins, per toothD6980Fixed Partial Denture Repair, by reportMEMBERCOPAY 475 475 475 280 280 280 495 495 475 475 495 475 475 475 495 475 475 90 30 145 Lab 235 125 85 70 100 380 30 30 70 Lab 70 Lab 70 Lab 70 Lab 70 Lab 70 Lab 70 Lab 70 Lab 70 Lab 70 Lab 250 Lab 250 Lab 250 Lab 250 Lab 135 135 135 135 145 Lab 145 Lab 145 Lab 145 Lab 25 25 270 495 475 475 495 475 475 495 495 495 ORAL SURGERY **D7111Extraction – coronal remnants – deciduous toothD7140Extraction – erupted tooth or exposed rootD7210Surgical removal of erupted toothD7220Removal of impacted tooth – soft tissueD7230Removal of impacted tooth – partial bonyD7240Removal of impacted tooth – complete bonyD7250Surgical removal – residual tooth rootsD7270Tooth re-implantation & stabilizationD7280Surgical exposure of impacted toothD7286Biopsy of oral tissue – soft D7310Alveoloplasty per quad with extractionD7311Alveoloplasty in conjunction w/extraction, 1 to 3 teeth,per quadD7320Alveoloplasty per quad without extractionD7321Alveoloplasty (edentulous area) not in conjunctionw/extraction, 1 to 3 teeth, per quadD7471Removal of lateral exostosis (Maxillary/Mandibular)D7510Intraoral I & D abscessD7910Suture of recent small wound, up to 5 cmD7960Frenulectomy (frenectomy or frenotomy)D7971Excision of pericoronal gingivalOTHER SERVICESD9110Palliative (emergency) tx of dental pain, minor txD9210Local Anesthesia not in conj. w/operative procedureD9215Local AnesthesiaD9220General Anesthesia (first 30 minutes)D9221General Anesthesia (each additional 15 minutes)D9230Analgesia, inhalation of nitrous oxideD9241I. V. Sedation (first 30 minutes)D9440Office visit (after regularly scheduled hours)D9940Nightguard (occlusal guard) limited to 1 in a 12-24month period D9951Occlusal adjustment – Limited (per visit)D9952Occlusal adjustment – CompleteD9972Bleaching, arch – Take Home TraysD9973Bleaching, tooth - In-Office ProcedureD9999Missed/Cancelled Appointment (without 24 hr notice) 45 60 90 120 160 190 100 220 230 175 Lab 125 85 250 135 500 145 10 230 90 20 0 0 195 75 25 195 40 125 Lab 45 25025% belowthe dentistregular fees25% belowthe dentistregular fees 25TDAHPINDVTMPLT03.2014Page 5

SECTION II: SCHEDULE OF BENEFITS AND COPAYS (continued)PLAN TDA A800R**ENDODONTIC SPECIALTY CARE:Endodontic Specialist services shall be provided by a PlanEndodontist, where available, at the participating provider’snegotiated TDA fee schedule.IMPLANTSImplants and implant related procedures and services shall beprovided to the Member at 20% below the dentist’s regular fees.**ORAL SURGERY SPECIALTY CARE: Oral Surgeon Specialistservices shall be provided by a Plan Oral Surgeon, where available, atthe participating provider’s negotiated TDA fee schedule.PEDODONTIC SPECIALTY CARE: Pedodontic Specialistservices shall be provided by a Plan Pedodontist, where available, ata 20% discount off the dentist’s regular fees.**PERIODONTIC SPECIALTY CARE: Periodontic Specialistservices shall be provided by a Plan Periodontist, where available, atthe participating provider’s negotiated TDA fee schedule.PROSTHODONTIC SPECIALTY CARE: ProsthodonticSpecialist services shall be provided by a Plan ProsthodonticSpecialist, where available, at a 20% discount off the dentist’s regularfees.TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ)(Non-Surgical Treatment) TMJ procedures and services shall beprovided to the Member at 20% below the dentist’s regular fees.ORTHODONTICSOrthodontic procedures or services not listed, including Invisalign and Ortho Clear braces, shall be provided at the dentist’s regularfees.Orthodontic diagnostic x-rays, study models, or other related servicesare not covered if provided by an out of network radiology facility orany other type of out of network facility.ORTHODONTICS (continued)Extractions for orthodontic purposes are not included as a benefit.ADACODEPROCEDURE DESCRIPTIONMEMBERCOPAYD8999Screening Exam 0D8999Diagnostic work-up, x-rays/models 200D8030Limited Orthodontic Treatment – adolescent dentition 2,800D8040Limited Orthodontic Treatment – adult dentition 3,200D8050Interceptive Orthodontic Treatment – primary dentition 1,135D8060Interceptive Orthodontic Treatment – transitionaldentition 1,140D8080Comprehensive Ortho Treatment – adolescent dentition 3,400D8090Comprehensive Ortho Treatment – adult dentition 3,700D8210Removable appliance therapy 700D8220Fixed appliance therapy 700D8660Pre-orthodontic treatment visit 45D8680Orthodontic retention (removal of appliances,construction & placement of retainers/arch) 150D8691Repair of orthodontic appliance (functional appliances& palatal expanders) 50D8692Replacement of lost or broken retainer 150D8693Rebonding or re-cementing; and/or repair, as required,of fixed retainers 150D8999Final Orthodontic Records 100SPECIAL LIMITATIONSAny procedure or service not listed shall be provided at the Generaldentist’s regular fees* ADDITIONAL SERVICESAdditional services, as indicated and provided for beyond the statedfrequency limitation, may be performed, if necessary, at the statedcopayment.** SPECIALTY CARE SERVICES PERFORMED BY A PLANSPECIALIST (ENDODONTIST, PERIODONTIST, OR ORALSURGEON), WHERE AVAILABLE, ARE NOT PROVIDEDAT THE LISTED COPAY WITHIN THE SCHEDULE OFBENEFITS AND COPAYS. THE MEMBER SHALL INSTEADBE RESPONSIBLE TO PAY THE PLAN SPECIALIST THEPARTICIPATING PROVIDER’S NEGOTIATED TDAHP FEESCHEDULE AMOUNT FOR THE COVERED SERVICE. Plus lab fee on crowns 100.00 Plus lab fee on dentures and partial dentures 125.00 Other Lab Fees will vary depending upon dental laboratory,procedure and materials used.Other Lab Fees will vary depending upon dental laboratory,procedure, and materials usedTDAHPINDVTMPLT03.2014Page 6

IIICOPAYS - The Copay amounts listed in the Schedule of Benefits and Copays, contained herein arepayable by you directly to the Dental Office as treatment is received. You should discuss all futurepayments and costs before new appointments are made. The Dental Office staff will help you plan yourdental treatment and payments.IVSPECIALTY CARE - If your selected dentist identifies a problem that is best treated by a specialist, heor she will refer you to a fully qualified dental specialist, where available, who participates in theTDAHP network.Specialty Care services performed by a Plan Specialist (Endodontist, Periodontist, or Oral Surgeon),where available, are NOT provided at the listed Copay within the Schedule of Benefits and Copays. Themember shall instead be responsible to pay the Plan Specialist the participating provider’s negotiatedTDAHP fee schedule amount for the covered service.VEFFECTIVE DATE OF COVERAGEA. If enrollment information is received prior to the twentieth (20th) day of the month, coveragewill begin on the first day of the following month.B.In the event that a spouse and child(ren) are newly acquired through marriage and are to becovered by the Member’s dental plan, Member must notify TDA within thirty (30) days of themarriage. If said notification is received prior to the twentieth (20th) day of the month,coverage will begin on the first day of the following month. If coverage for said spouse andchild(ren) results in additional premium becoming due, coverage will begin on the first day ofthe month following receipt of revised premium payment agreement.C.In the event that a spouse and child (ren) are newly acquired through marriage and are to becovered by the Member’s dental plan, Member must notify TDA in writing within thirty (30)days of the marriage. If said notification is received prior to the twentieth (20th) day of themonth, coverage shall begin on the first day of the following month. Newborn naturalchildren, adopted children and the addition of children required to be covered under a court oradministrative order are automatically covered from said child’s date of birth, adoption,adoption placement or court/administrative order provided you have Dependent Coverage inforce. However, you must notify TDA of coverage of a natural child, adopted child orcourt/administrative order within sixty (60) days from the date of birth, adoption, adoptionplacement or court/administrative order for coverage to continue if coverage for said childresults in additional premium becoming due. Family Members, who do not enroll during theinitial enrollment period, cannot enroll until the next annual open enrollment period.VIPARTICIPATING PLAN PROVIDERS (DENTISTS)A. Benefits Obtained from Plan Providers - Except for emergency care, benefits are availableonly from your selected Plan Provider.B.List of Plan Providers - You may obtain a current list of Plan Providers by calling TDA at(602) 266-1995 or toll free at 1-888-422-1995. A current list of Plan Providers is alsoavailable at the TDA website, www.TDAdental.com.C.Choosing a Plan Provider -You may choose any Plan Provider from the list of Plan Providersreferred to above. Upon request, the Plan, TDA, will assist you in selecting a Plan Dentist; butmay not recommend any particular dentist. All covered family Members must go to the samePlan Provider. You must choose a Plan Provider at the time you enroll. You must have a Planprovider to receive benefits.TDAHPINDVTMPLT03.2014Page 7

VIPARTICIPATING PLAN PROVIDERS (DENTISTS) (continued)D.E.Changing Plan Providers - You may change Plan Providers. If you notify the Plan, in writing,by the twentieth (20th) day of the month, the change will be effective on the first of thefollowing month. Should your Plan Provider stop participation, the Plan reserves the righttemporarily to transfer you to another Plan Provider until you inform us of your new providerselection.All Plan Providers (Dentists) furnishing services to a Member do so as independentcontractors. TDA shall not be liable for any claim or demand for damages arising out of or inany manner connected with any injuries suffered by a Member while receiving dental services.VIIEMERGENCY CAREA. You should attempt to obtain emergency care from your Plan Provider when you are withinthe area served by your designated Plan Provider. If you are seeking emergency care duringnormal business hours and your selected Plan Provider is not accessible, please contact theTDA for assistance at (602) 266-1995 or 1-888-422-1995.B.If your Plan Provider is not accessible or when the emergency occurs outside the area servedby your Plan Provider, then you should seek emergency dental care from a licensed dentalhealth professional to control bleeding, relieve pain, including local anesthesia, or eliminateacute infection. Medications, which may be prescribed by the dentist, but must be obtainedthrough a pharmacy, are excluded. A written itemized statement for these services must bepresented to TDA, Inc. for reimbursement. If it is necessary to have additional treatment, itmust be done by your designated Plan Provider.C.The maximum allowable reimbursement for a dental emergency is 50.00 less any membercosts, which you would normally be charged for the procedure.VIIISCHEDULING AN APPOINTMENT - After your Plan becomes effective, you can schedule anappointment by contacting your selected participating Provider. Your dentist will offer you anappointment generally within thirty (30) days of your call - or within 24 hours for emergency care. Mostdental appointments are scheduled Monday through Friday during regular working hours. Each PlanProvider is an independent practitioner who establishes his or her own hours. Some have evening and/orweekend hours. Call your Plan Provider to ask about office hours and the availability of emergency dentalservices.IXPLAN IDENTIFICATION CARD - Although an I.D. card will be issued to you, it is not necessary inorder to receive dental care from your Plan Provider. Your name will appear on an eligibility list, whichis sent to your selected dentist each month.XWORKERS' COMPENSATION EXCLUSION - Expenses for which payment is required underapplicable Workers' Compensation statutes are not eligible for payment under this dental Plan.XITHIRD PARTY LIABILITY EXCLUSION – Expenses for services that are the result of an injury forwhich a Third Party is liable, are not eligible for payment under this dental Plan.This Third Party Liability Exclusion does not apply to individuals who are or who have been victims ofdomestic violence. Individuals that provide counseling, shelter, protection or other services to victimsof domestic violence are also exempt from this Third Party Liability Exclusion.TDAHPINDVTMPLT03.2014Page 8

XIITERMINATION –Benefits under this Plan shall cease upon any of the following events:A. On the date of the expiration of the period for which the last payment was made.B.On the date the Plan contract terminates, if not renewed.XIIIDENTAL RECORDS - The dental records of the Member and/or Subscriber concerning servicesperformed herein shall remain the property of the Plan dentist.XIVCUSTOMER SERVICE INQUIRES - Customer Service is available by calling TDA at (602) 2661995 or toll-free at 1-888-422-1995 during normal business hours. All Individual Dental Plan inquires,including grievance procedures, are handled by TDA.XVGRIEVANCE AND APPEAL - A complaint is any oral or written expression of concern ofdissatisfaction regarding a Plan service or procedure, whether dental or non-dental in nature. In theevent you have a complaint, an initial attempt should be made to resolve it by communicating withTDA's Customer Service Department. If a resolution cannot be reached in this manner, the followingFormal Grievance and Appeal process should be used.XVIFORMAL GRIEVANCE AND APPEAL – Levels of Review: TDA members may ask TDA toreview its decisions involving their requests for service or requests to have claims paid. The ArizonaState Legislatures have established four levels of review. Companies that perform utilization reviewactivities after services are provided (TDA is in this category) are not required to provide Level 1 andLevel 2 re

Each participating dental facility listed in the Participating Provider Directory has a Provider Number listed to the left of the dental office. Be sure to use the Provider Number CODE to identify your selection on the dental application. Turn your dental application into your Broker or TDA, Inc. for processing. 4.