Dental Application

Dental Plan Enrollment Form

Eective Date: _________________________

1. Check the appropriate box for coverage desired: Basic Plan Core Plan Premium Plan Member Only ¨ $22.53 ¨ $28.33 ¨ $53.59 Member + 1 Child ¨ $43.61 ¨ $54.84 ¨ $106.82 Member + Spouse ¨ $45.44 ¨ $57.13 ¨ $107.50 Member + Child(ren) ¨ $55.56 ¨ $69.84 ¨ $139.41 Member + 1 Family ¨ $77.79 ¨ $97.79 ¨ $198.22 Applications received in the SEANC home office by the 10th of the month will be effective the first of the following month. These rates are eective until 12/31/2020. For more information on becoming a member, call 800-222-2758. visit www.seanc.org. or www.welcometouhc.com/SEANC. After enrolling, visit www.myuhc.com for provider search, benefits and claims information. You must be a member of SEANC to enroll. Send forms to SEANC o–ce: Fax: 1-919-792-3321 Mail: ATTN: Insurance Depar tment 1621 Midtown Place Raleigh, NC 27609

2. Employee Information (please print clearly): Social Security Number: - - SEANC#

Your Name:

First Name Middle Initial Last Name

Birth Date: / /

Address:

Gender: ¨ M ¨ F Marital Status: ¨ Single ¨ Married ¨ Divorced ¨ Widowed ¨ Domestic Partnership

Home Phone: ( ) - Work Phone: ( ) -

Cell Phone: ( ) - Personal email address:

3. List all eligible family members below (if electing dependent coverage): Note: Adult dependent children up to age 26

Spouse Child Child Child Child First Name Last Nam e Birth Date Gender / / ¨ M ¨ F / / ¨ M ¨ F / / ¨ M ¨ F / / ¨ M ¨ F / / ¨ M ¨ F

I agree to continue enrollment in the dental plan for a period of 12 months

¨ ¨ I authorize payroll/pension deduction for this insurance I prefer to have my premiums invoiced ¨ I authorize bank draft

I, the undersigned, hereby authorize my employer to deduct premiums for the SEANC Insurance identi‡ed above from my wages/pension or bank draft on a monthly basis, in such amounts as are currently established pursuant to the SEANC insurance contract with the provider, or in such adjusted amounts as may be established by SEANC and the provider by contract subsequent to the date of this authorization. This authorization shall continue until cancelled by me by written notice to the SEANC Central OŽce.

Crowns/I nlays/Onlays 1 tim e per tooth per consecutiv e 60 m onths Crown replacem ent: 1 tim e per consecutiv e 60 m onths from initial or supplem ental placem ent. 1 tim e per tooth per consecutiv e 60 m onths Crown replacem ent: 1 tim e per consecutiv e 60 m onths from initial or supplem ental placem ent. Im plants Procedures 1 tim e per tooth per consecutiv e 60 m onths 1 tim e per tooth per consecutiv e 60 m onths Relines and Rebases Dentures Relining and Rebasing Dentures: 6 m onths after initial installation and 1 tim e per consecutiv e 12 m onths. Relining and Rebasing Dentures: 6 m onths after initial installation and 1 tim e per consecutiv e 12 m onths. Occlusal Guards Cov ered if prescribed to control habitual g rinding Cov ered if prescribed to control habitual g rinding Orthodonti a H i g h O p tion Pl an Netwo rk Incenti ve O p tion Orthodonti a Co -In sura nce 50% ( IRUGHSHQGHQWFKLOGUHQRQO\XSWRDJH 0% No t Co vered 7KH$QQXDO0D[LPXP%HQHILWLVWKHPD[LPXPDPRXQWWKHSODQZLOO SD\HDFKFDOHQGDU\HDU,WLVDFRPELQHGDQQXDOPD[LPXPIRU Q HWZRUNDQGRXWRIQHWZRUNEHQHILWVHUYLFHV  Please refer to the UnitedHealthcare Dental Plan Certificate of Coverage fo r a detail description of the plan benefits. Note: The Core Plan is not available to residents in AL, LA, MS or TX.

Not Cov ered Stan dard O p tion Pl an 0% No t Co vered

Not Cov ered Not Cov ered Not Cov ered

Si m ple Extractions Cov ered Cov ered Restorations (Routine Filling s) Cov ered Cov ered Therapeutic Pulputom y Cov ered Cov ered Periodontal ma intenance 2 tim es per consecutiv e 12 m onths following activ e or adjunctiv e periodontal therapy 2 tim es per consecutiv e 12 m onths following activ e or adjunctiv e periodontal therapy Palliati ve Treatm ent Cov ered Cov ered Ma j or S erv ice s H i g h O p tion Pl an Netwo rk Incenti ve O p tion Ma j or Co-Insura nce 50% In – 50% Out – 20% Endodontics Cov ered Cov ered Denture Repairs 12 m onths after initial insertion, 1 tim e per 6 m onths 12 m onths after initial insertion, 1 tim e per 6 m onths A djustm ent to Dentures 12 m onths after initial insertion, 1 tim e per 6 m onths 12 m onths after initial insertion, 1 tim e per 6 mo n ths Oral S urg ery Cov ered Cov ered Periodontal Sc alin g and Root Planing One tim e per quadrant per consecutiv e 24 m onths One tim e per quadrant per consecutiv e 24 mo n ths Root Canal Therapy 1 tim e per tooth per lifetim e 1 tim e per tooth per lifetim e Periodontal Su rg ery Once per quadrant or site ev ery consecutiv e 36 m onths Once per quadrant or site ev ery consecutiv e 36 m onths Oral S urg ery – Other/S urg ical Cov ered Cov ered A nesthesia Cov ered as a basic serv ice Cov ered as a basic serv ice Bridg es/Dentures Full Denture/Partial Denture: 1 per consecutiv e 60 m onths. Relining and Rebasing Dentures: 6 m onths after initial installation and 1 tim e per consecutiv e 12 m onths. Full Denture/Partial Denture: 1 per consecutiv e 60 m onths. Relining and Rebasing Dentures: 6 m onths after initial installation and 1 tim e per consecutiv e 12 m onths.

Not Cov ered

Cov ered Cov ered Cov ered 2 tim es per consecutiv e 12 m onths following activ e or adjuncti ve periodon tal therapy Cov ered Stan dard O p tion Pl an 0% No t Co vered Not Cov ered Not Cov ered Not Cov ered Not Cov ered Not Cov ered Not Cov ered No t Cov ered Not Cov ered Not Cov ered

1(: 7KH3UHQDWDO'HQWDO&DUHQRWDYDLODEOHLQ:$DQG2UDO&DQFHU 6FUHHQLQJSURJUDPVDUHFRYHUHG XQGHUDOOSODQV Premium Plan Co re Pl an Bas ic Plan Annual Maximum Benefit $5, 000 In - $1, 500 Out - $1, 250 $1, 250 Orthodonti a Lif etim e Policy Ma xi mu m $5, 000 No t Co v ered No t Co vered Dedu ctible (Indi vidu al) $50 $25 $25 Dedu ctible (F ami l y ) $150 $75 $75 Preven tive an d Dia g nost ic Service s H i g h O p tion Pl an Netwo rk Incenti ve O p tion Stan dard O p tion Pl an Preven tive & Dia g nost ic Co -In sura nce 100% In - 100% Out – 80% 100% Oral ev aluation Exam s (Routine Exam ) 2 tim es per consecutiv e 12 m onths 2 tim es per consecutiv e 12 m onths 2 tim es per consecutiv e 1 2 m onths Dental Prophylaxis (Teeth Cleaning ) 2 tim es per consecutiv e 12 m onths 2 tim es per consecutiv e 12 m onths 2 tim es per consecutiv e 12 m onths Fluoride Treatm ent s 2 tim es per consecutiv e 12 m onths to ag e 16 2 tim es per consecutiv e 12 m onths to ag e 16 2 tim es per consecutiv e 12 m onths to ag e 16 I ntraoral Radiog raphs (Full Mouth X-rays) 1 tim e per 36 m onths (com plete series and Panorex) 1 tim e per 36 m onths (com plete ser ies and Panorex) 1 tim e per 36 m onths (com plete series and Panorex) Bitewing and Extraoral X-ray s A dults and child(ren) Bitewing : 1 series per calendar year Extraoral: 2 film s per calendar year Bitewing : 1 series per calendar year Extraoral: 2 film s per calendar year Bitewing : 1 series per calendar year Extraoral: 2 film s per calendar year Bas ic Service s H i g h O p tion Pl an Netwo rk Incenti ve O p tion Stan dard O p tion Pl an Bas ic Co -In sura nce 80% In – 80% Out - 60% 70% S ealants Once per first or second perm anent m olar ev ery 36 m onths for dependent children to ag e 16. Once per first or second perm anent m olar ev ery 36 m onths for dependent children to ag e 16. Once per first or second perm anent m olar ev ery 36 m onths for dependent children to ag e 16. S pace m aintainers 1 per consecutiv e 60 m onths for dependent children to ag e 16. 1 per consecutiv e 60 m onths for dependent childre n to ag e 16. 1 per consecutiv e 60 m onths for dependent children to ag e 16.

State Employees Association of North Carolina