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GROUP DENTAL PLANWashington CountyDelta Dental Premier PlanEffective Date: July 1, 2009Group No. 100001652(variable: the form number is one of the following: ODSDENTBK 7-1-2009, ODSDENTPPO 7-12009, or ODSDentMCBK 7-1-2009)

WelcomeOregon Dental Service (ODS) was created in 1955 and was the first company in America to provideprepaid dental coverage. Today ODS is Oregon’s largest, covering over 650,000 people from morethan 1,400 groups.ODS is pleased to have been chosen by the Group as its dental plan. This handbook is designed toprovide members with important information about the Plan’s benefits, limitations and procedures.Members may direct questions to one of the numbers listed below or visit ODS’ member self-helpwebsite, myODS, at www.odscompanies.com. myODS is available 24 hours a day, 7 days a weekallowing members to access plan information whenever it’s convenient.ODS601 S.W. Second AvenuePortland, Oregon 97204Dental Customer Service DepartmentPortland503-265-2965Toll Free1-888-217-2365TDD/TTY1-800-433-6313(for the hearing and speech impaired)En Español503-265-2963Llamado Gratis 1-877-299-9063ODS reserves the right to monitor telephone conversations and e-mail communications between itsemployees and its members for legitimate business purposes as determined by ODS. The monitoringis to ensure the quality and accuracy of the service provided by employees of ODS to all members.Note: This handbook may be changed or replaced at any time, by the Group or ODS, without theconsent of any member. All plan provisions are governed by the Group’s policy with ODS. Thishandbook may not contain every plan provision.WelcomeODSDENTBK 7-1-20091

Table of ContentsWELCOME . 1USING THE PLAN. 2DEFINITIONS. 3TOOTH CHART – THE PERMANENT ARCH . 8EXAMPLE OF HOW THE PLAN PAYS . 9BENEFITS AND LIMITATIONS . 10Class I . 10Diagnostic . 10Preventive. 11Class II . 11Restorative. 11Oral Surgery . 12Endodontic . 12Periodontic . 12Class III . 13Restorative. 13Prosthodontic. 13ORAL HEALTH, TOTAL HEALTH PROGRAM. 15EXCLUSIONS . 16ELIGIBILITY AND ENROLLMENT. 19Eligible Employees. 19When Your Insurance Begins. 19When Your Insurance Ends. 19If You Return From Leave Of Absence Without Pay . 20If You Return From Layoff . 20Continuation Of Insurance . 20Dependents. 20When Dependents Insurance Begins . 22When Dependents Insurance Ends . 23Rescission By Insurer. 24Other . 24CLAIMS ADMINISTRATION AND PAYMENT. 25Submission And Payment Of Claims . 25Claim Submission. 25Explanation of Benefits. 25Claim Inquiries. 25Appeals . 25Definitions . 25Time Limit for Submitting Appeals . 26ODSDENTBK 7-1-2009

The Review Process . 26First Level Appeals . 26Second Level Appeal . 27Benefits Available From Other Sources. 27Coordination of Benefits . 27Third-Party Liability. 28COORDINATION OF BENEFITS . 32Definitions . 32How COB Works . 33Order Of Benefit Determination (Which Plan Pays First?) . 34Effect On The Benefits Of This Plan. 35ODS’ Right To Collect And Release Needed Information . 36Facility Of Payment . 36Right Of Recovery . 36MISCELLANEOUS PROVISIONS. 37Request For Information . 37Disclosure Of Benefit Reduction . 37Confidentiality Of Member Information . 37Transfer Of Benefits . 37Recovery Of Benefits Paid By Mistake . 37Contract Provisions. 37Warranties. 38Limitation Of Liability. 38Provider Reimbursements . 38Independent Contractor Disclaimer. 38No Waiver. 38Group Is The Agent. 38Governing Law . 39Where Any Legal Action Must Be Filed. 39Time Limits For Filing A Lawsuit . 39CONTINUATION OF DENTAL COVERAGE . 40Oregon Continuation Coverage For Spouses And Registered DomesticPartners Age 55 And Over. 40Cobra Continuation Coverage . 42Uniformed Services Employment And Reemployment Rights Act. 47ODSDENTBK 7-1-2009

Using the PlanODS’ dental plans are easy to use and cost effective. If members choose a participating dentist fromthe ODS Premier Dental Directory (which is available on ODS’ website at www.odscompanies.comunder “Provider Search”), all of the paperwork takes place between ODS and the dentist's office.More than 90% of all licensed dentists in Oregon are ODS participating dentists. For travelers andemployees outside Oregon, ODS’ national affiliation with Delta Dental Plans Association providesoffices and/or contacts in every state. Also, dental claims incurred any place in the world may beprocessed in Oregon.Members needing dental care may use any dental provider. However, there are differences inreimbursement by ODS for participating dentists and non-participating dental providers.An example is provided on page 9. While a member may choose the services of any dentist, ODS doesnot guarantee the availability of any particular dentist.At an initial appointment, members should tell the dental provider that they have dental benefitsthrough ODS. Members will need to provide their subscriber identification number and ODS Groupnumber to the dentist. These numbers are located on the I.D. card.For expensive treatment plans, ODS provides a predetermination service. The dentist may submit apredetermination request to get an estimate of what the Plan would pay. The predetermination willbe processed according to the Plan’s current contract and returned to the dental provider. Themember and his or her dental provider should review the information before beginning treatment.For questions about the Plan, members should contact ODS’ Dental Customer Service Department.This handbook describes the benefits of the Plan. It is the responsibility of the members to reviewthis handbook carefully and to be aware of the Plan’s limitations and exclusions.MEMBER RESOURCESODS Website (access myODS by clicking “a Member” and logging in)www.odscompanies.comDental Customer Service DepartmentPortland 503-265-2965; Toll-free 1-888-217-2365; TDD/TTY 1-800-433-6313; En Español 503-2652963; Llamado gratis 1-877-299-9063Using the PlanODSDENTBK 7-1-20092

DefinitionsThe following are definitions of some important terms used in this handbook.Abutment is a connection device that attaches a restoration to the root form implant.Accepted Fee means the filed fee approved by ODS for a specific dental procedure performed by aparticipating dentist submitting that fee and performing that dental service. If the database doesnot contain a fee for a particular procedure in a particular area, the claim is referred to ODS’ DentalConsultant who determines a comparable code to the one billed. ODS will use the maximum planallowance for the comparable code to price the claim.Affidavit of Domestic Partnership means a signed document that attests the subscriber and oneother eligible individual meet the criteria in the definition of unregistered domestic partner.Alveolar Structures are the upper and lower jaw bones.Alveoloplasty is the surgical shaping of the bone of the upper or the lower jaw. It is performed mostcommonly in conjunction with the removal of a tooth or multiple teeth to have the gums healsmoothly for the placement of partial denture or denture.Amalgam is a silver-colored material used in restoring teeth.Anterior refers to teeth located at the front of the mouth. (tooth chart on page 8)Benefit Year means a calendar year or portion thereof. Related definition in Claim DeterminationPeriod.Benefits means those dental services which are available under the terms of the Plan.Bicuspid is a premolar tooth, between the front and back teeth. (tooth chart on page 8)Bridge is also called a fixed partial denture. A bridge replaces one or more missing teeth using apontic (false tooth or teeth) permanently attached to the adjacent teeth. Retainer crowns (crownsplaced on adjacent teeth) are considered part of the bridge.Broken A tooth is considered broken when a piece or pieces of the tooth have been completelyseparated from the rest of the tooth. A tooth with cracks is not considered broken.Cast Restoration includes crowns, inlays, onlays, and any other restoration to fit a specificmember’s tooth that is made at a laboratory and cemented into the tooth.Claim Determination Period means a calendar year (January 1 through December 31) or portionthereof.Composite is a tooth-colored material used in restoring teeth.Copay or Copayment means the percentages of covered expenses to be paid by a member.DefinitionsODSDENTBK 7-1-20093

Debridement is the removal of excess plaque. A periodontal ‘pre-cleaning’ procedure done whenthere is too much plaque for the dentist to perform an exam.Deductible is the amount of covered expenses that are paid by a member before benefits arepayable by the Plan.Dental Provider means a duly licensed dentist, certified denturist or registered hygienist, legallyentitled to practice dentistry at the time and in the place services are performed; to the extent thathe or she is operating within the scope of his or her license, certificate, or registration as requiredunder law within the state of practice.Dentally Necessary means: Services that are established as necessary for the treatment or prevention of a dental injuryor disease otherwise covered under the Plan;Services that are appropriate with regard to standards of good dental practice in the servicearea;Services that have a good prognosis; and/orServices that are the least costly of the alternative supplies or levels of service that can besafely provided. For example, coverage would not be allowed for a crown when a filling wouldbe adequate to restore the tooth appropriately.Note:The fact that a dentist may recommend or approve a service or supply does not, of itself,make the charge a covered expense.Denture Repair is a procedure done to fix a complete, immediate, or partial denture. This includesadding a tooth to a partial denture, replacing a broken tooth in a denture, or fixing brokenframework and/or base.Domestic Partner refers to a registered domestic partner and an unregistered domestic partner.Eligible Dependent means any person who is eligible for coverage under the terms of the Planbecause of a relationship to a subscriber.Eligible Employee means any employee who meets the conditions of eligibility outlined in thePlan.Enrollment Date means the date a subscriber’s or dependent’s coverage becomes effective underthe terms of the Plan.Group Eligibility Waiting Period means the period of employment with the Group that aprospective member must complete before coverage begins.Group Health Plan means any plan, fund or program established and maintained by the Group forthe purpose of providing healthcare for its employees or their dependents through insurance,reimbursement or otherwise. This dental benefit plan is a group health plan.DefinitionsODSDENTBK 7-1-20094