Dental Benefits

To receive the advantages of In-Network benefits, visit the Superior Officers Dental web site at Dental PPO Plan (whyuhc.com) to review the Directory of Preferred Providers who participate in the dental plan. The network of participating dentists will treat eligible active members and their eligible dependents with minimal or no out-of-pocket expense for covered services. When services are rendered from participating dentists in the UnitedHealthCare PPO 10 Plan, you will only be responsible for the copayment, if any.

Eligible active members and their eligible dependents may receive services from dentists who do not participate in the UnitedHealthcare PPO 10 Plan. You are free to receive dental care from any licensed dentist not participating in UnitedHealthcare PPO 10 plan network. When services are received from an out-of-network dentist, UnitedHealthcare will pay for all covered services according to the Out-of-Network Schedule of Allowances. For the most current Out-of-Network Schedule of Allowances, you can visit the Superior Officers Council dental landing page at Dental PPO Plan (whyuhc.com) . You will be responsible to your dentist for all charges not covered or not paid in full by the plan.

Out-of-Network Benefits apply when you obtain Dental Care Services from out-of-Network Dental Providers.

Before you are eligible for Coverage of Dental Care Services obtained from out-of-Network Dental Providers, you must meet the requirements for payment of the applicable deductible stated below. Generally you are required to pay more than Network Benefits. Out-of-Network Dental Providers may request that you pay all charges when services are rendered. You must file a claim with us for reimbursement of Allowed Amounts.

We will reimburse an out-of-Network Dental Provider for a Covered Dental Care Service up to an amount equal to the Table of Allowance Schedule provided. The actual charge made by an out-of-Network Dental Provider for a Covered Dental Care Service may exceed the table of allowance. As a result, you may be required to pay an out-of-Network Dental Provider an amount for a Covered Dental Care Service in excess of the allowance. In addition, when you obtain Covered Dental Care Services from an out-of-Network Dental Provider, you must file a claim with us to be reimbursed for Allowed Amounts.

UnitedHealth Care Plans
The open enrollment period for the UnitedHealthcare dental plans starts November 1 and continues through November 30th of each year. Members can fill out this fillable form (CLICK HERE FOR FORM) and either email it to dental.info@nypdsoc.com or mail it to the Superior Officers Council at 40 Peck Slip N.Y. N.Y. 10038

Dis-enrolling If you wish to dis-enroll from the Healthplex PPO/Indemnity Plan, you must complete and submit a Healthplex Subscriber Change Form and follow the enrollment instructions for the plan of your choice.

NOTE: Change forms must be completed and returned by the 12th of the month for your new policy to be effective on the first day of the following month. If a member changes dental plans, he/she is required to do so for a minimum of one year.

The UnitedHealthcare National Preferred Provider (National Options PPO 10):

• SOC’s default premium free plan.
• Consists of over 67,000 nationwide participating dentists to choose from.
• Copayments for many procedures.
• Minimal out of network reimbursement.
• Annual family maximum of $2,000

Pre-Treatment Estimates - Pre-Authorizations If the charge for a Dental Care Service is expected to exceed $500 or if a dental exam reveals the need for fixed bridgework, you may notify us of such treatment before treatment begins and receive a Pre-Treatment Estimate. If you desire a Pre-Treatment Estimate, you or your Dental Provider should send a notice to us, via claim form, within 20 calendar days of the exam. If requested, the Dental Provider must provide us with dental x-rays, study models or other information necessary to evaluate the treatment plan for purposes of benefit determination.

We will determine if the proposed treatment is a Covered Dental Care Service under the Policy and estimate the amount of payment. The estimate of benefits payable will be sent to the Dental Provider and will be subject to all terms, conditions, and provisions of the Policy.

Pre-Treatment Estimate of benefits is not an agreement to pay for expenses. This procedure lets you know in advance approximately what portion of the expenses will be considered for payment. The pre-treatment estimate is valid for 90 calendar days from the date we provide it to the Dental Provider. If you will not receive the services within the 90 calendar days, you or the Dental Provider must request another pre-treatment estimate from us.

Exclusions and Limitations

No coverage is available under this Certificate for the following:

• Aviation. We do not cover services arising out of aviation, other than as a fare-paying passenger ona scheduled or charter flight operated by a scheduled airline.
• Cosmetic Services. We do not Cover cosmetic services or surgery unless otherwise specified,except that cosmetic surgery shall not include reconstructive surgery when such service isincidental to or follows surgery resulting from trauma, infection or diseases of the involved part, andreconstructive surgery because of congenital disease or anomaly of a covered Child which hasresulted in a functional defect. Cosmetic surgery does not include surgery determined to beMedically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgeryand dermatology procedures) is submitted retrospectively and without medical information, anydenial will not be subject to the Utilization Review process in the Utilization Review and ExternalAppeal sections of this Certificate unless medical information is submitted.
• Coverage Outside of the United States, Canada or Mexico. We do not Cover care or treatmentprovided outside of the United States, its possessions, Canada or Mexico. except for EmergencyDental Care.
• Experimental or Investigational Treatment. We do not cover any health care service, procedure,treatment, or device that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under this Policy for non-investigational treatments. See the Utilization Review and External Appeal sections of this Certificate for a further explanation of Your Appeal rights.
• Felony Participation. We do not cover any illness, treatment or medical condition due to Yourparticipation in a felony, riot or insurrection.
• Government Facility. We do not Cover care or treatment provided in a Hospital that is owned oroperated by any federal, state or other governmental entity, except as otherwise required by law.
• Medical Services. We do not cover medical services or dental services that are medical in nature,including any Hospital charges or prescription drug charges.
• Medically Necessary. In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment,test or device is otherwise Covered under the terms of this Policy.
• Medicare or Other Governmental Program. We do not cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid).
• Military Service. We do not cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units.
• No-Fault Automobile Insurance. We do not cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if You do not make a proper or timely claim for the benefits available to You under a mandatory no-fault policy.
• Services Not Listed. We do not cover services that are not listed in this Policy as being covered.
• Services Provided by a Family Member. We do not cover services performed by a member of the covered person's immediate family. "Immediate family" shall mean a child, spouse, mother, father, sister, or brother of You or Your Spouse.
• Services Separately Billed by Hospital Employees. We do not cover services rendered and separately billed by employees of Hospitals, laboratories or other institutions.
• Services with No Charge. We do not cover services for which no charge is normally made.
• War. We do not cover an illness, treatment or medical condition due to war, declared or undeclared.
• Workers' Compensation. We do not cover services if benefits for such services are provided under any state or federal Workers' Compensation, employers' liability or occupational disease law.

Your Provider will submit a completed UnitedHealthcare claim form directly to UnitedHealthcare at:

Claims and pre-treatment/pre-authorization submission addresses

PTE/Prior Authorizations (Except Solstice Benefits) Dental Benefit Providers P.O. Box 30552 Salt Lake City, UT 84130-0552 UnitedHealthcare Dental Claims Unit P.O. Box 30567 Salt Lake City, UT 84130-0567 HealthNet (CA, OR, AZ) P. O. Box 30567 Salt Lake City, UT 84130-0567 Solstice Benefits P.O. Box 19199 Plantation, FL 33318 UMR P.O. 30541 Salt Lake City, UT 84130-0541

Claim Denials and Appeals If Your Claim is Denied If a claim for Benefits is denied in part or in whole, you may call UnitedHealthcare Dental at the number on your ID card before requesting a formal appeal. If UnitedHealthcare Dental cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as described below.

How to Appeal a Denied Claim If a claim for Benefits is denied in part or in whole, you may call the number on your ID card before requesting a formal appeal. If the issue cannot be resolved to your satisfaction over the phone, you have the right to file a formal appeal as described below.

• the patient's name and ID number as shown on the ID card;
• the Dentist's name; ■ the date of dental service;
• the reason you disagree with the denial; and
• any documentation or other written information to support your request.

You or your enrolled Dependent may send a written request for an appeal to:

Dental - Appeals P.O. Box 30569 Salt Lake City, UT 84130-0569

Review of an Appeal

A full and fair review of your appeal will be conducted. The appeal may be reviewed by:

• an appropriate individual(s) who did not make the initial benefit determination; and
• a health care professional with appropriate expertise who was not consulted during the initial benefit determination process.

Once the review is complete, if the denial is upheld, you will receive a written explanation of the reasons and facts relating to the denial.

• Members can select any dentist from a network of providers for their families’ dental needs.
• Consists of over 85,000 nationwide participating dentists to choose from.
• Covers a wide range of procedures with little or no co-pay.
• Implant Coverage is available, with co-pays.
• No out of network reimbursement.
• No annual family maximum

Network and Out-of-Network Benefits

This Schedule of Covered Dental Care Services describes both benefit levels available under the Policy.

Dental Care Services must be provided by a Network Dental Provider in order to be considered Network Benefits. When Covered Dental Care Services are received from a Network Dental Provider, Allowed Amounts are our contracted fee(s) with that provider.

The only exception is if you need Emergency care and you are out of your service area or are unable to contact your Network general Dental Provider. In this situation, Emergency care will be covered as a Network Benefit and you will not be responsible for greater out-of-pocket expenses than if you had attended a Network Dental Provider. You must submit appropriate reports and x-rays.

When Dental Care Services are received from an out-of-Network Dental Provider as a result of an Emergency, the Co-payment will be the Network Co-payment.

Covered Dental Care Services must be provided by or directed by a Network Dental Provider.

Utilization Review

A. Utilization Review.

We review health services to determine whether the services are or were Medically Necessary or experimental or investigational ("Medically Necessary"). This process is called Utilization Review. Utilization Review includes all review activities, whether they take place prior to the service being performed (Preauthorization); when the service is being performed (concurrent); or after the service is performed (retrospective). If You have any questions about the Utilization Review process, please call 1-800-445-9090. The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine.

All determinations that services are not Medically Necessary will be made by: 1) licensed Physicians; or 2)licensed, certified, registered or credentialed health care professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review. We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary. We have developed guidelines and protocols to assist Us in this process. Specific guidelines and protocols are available for Your review upon request. For more information, call 1-800-445-9090 or visit Our website at www.myuhc.com.

B. Preauthorization Reviews.

Non-Urgent Preauthorization Reviews. If We have all the information necessary to make a determination regarding a Preauthorization review, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within three (3) business days of receipt of the request.

If We need additional information, We will request it within three (3) business days. You or Your Provider will then have 45 calendar days to submit the information. If We receive the requested information within 45 days, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within three (3) business days of Our receipt of the information. If all necessary information is not received within 45 days, We will make a determination within 15 calendar days of the end of the 45-day period.

Urgent Preauthorization Reviews.

With respect to urgent Preauthorization requests, if We have all information necessary to make a determination, We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone, within 72 hours of receipt of the request. Written notice will be provided within three (3) business days of receipt of the request. If We need additional information, We will request it within 24 hours. You or Your Provider will then have 48 hours to submit the information. We will make a determination and provide notice to You (or Your designee) and Your Provider by telephone and in writing within 48 hours of the earlier of Our receipt of the information or the end of the 48-hour period.

C. Concurrent Reviews.

Non-Urgent Concurrent Reviews. Utilization Review decisions for services during the course of care (concurrent reviews) will be made, and notice provided to You (or Your designee) and Your Provider, by telephone and in writing, within one (1) business day of receipt of all necessary information. If We need additional information, We will request it within one (1) business day. You or Your Provider will then have 45 calendar days to submit the information. We will make a determination and provide notice to You (or Your designee) and Your Provider, by telephone and in writing, within one (1) business day of Our receipt of the information or, if We do not receive the information, within the earlier of 15 calendar days of receipt of part of the requested information or 15 calendar days of the end of the 45-day period.

Non-Urgent Concurrent Reviews.

For concurrent reviews that involve an extension of urgent care, if the request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment, we will make a determination and provide notice to You (or Your designee) and Your Provider by telephone within 24 hours of receipt of the request. Written notice will be provided within one (1) business day of receipt of the request.

If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment and We have all the information necessary to make a determination, We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of 72 hours or of one (1) business day of receipt of the request. If We need additional information, We will request it within 24 hours. You or Your Provider will then have 48 hours to submit the information. We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or, if We do not receive the information, within 48 hours of the end of the 48-hour period.

D. Retrospective Reviews.

If We have all information necessary to make a determination regarding a retrospective claim, We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request. If We need additional information, We will request it within 30 calendar days. You or Your Provider will then have 45 calendar days to provide the information. We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of all or part of the requested information or the end of the 45-day period.

Once We have all the information to make a decision, Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal.

E. Retrospective Review of Preauthorized Services.

We may only reverse a preauthorized treatment, service or procedure on retrospective review when:

• The relevant medical information presented to Us upon retrospective review is materially different from the information presented during the Preauthorization review;
• The relevant medical information presented to Us upon retrospective review existed at the time of the Preauthorization but was withheld or not made available to Us;
• We were not aware of the existence of such information at the time of the Preauthorization review; and
• Had We been aware of such information, the treatment, service or procedure being requested
  would not have been authorized. The determination is made using the same specific standards, criteria or procedures as used during the Preauthorization review.

F. Reconsideration.

If We did not attempt to consult with Your Provider who recommended the Covered Service before making an adverse determination, the Provider may request reconsideration by the same clinical peer reviewer who made the adverse determination or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable. For preauthorization and concurrent reviews, the reconsideration will take place within one (1) business day of the request for reconsideration. If the adverse determination is upheld, a notice of adverse determination will be given to You and Your Provider, by telephone and in writing.

G. Utilization Review Internal Appeals.

You, Your designee, and, in retrospective review cases, Your Provider, may request an internal Appeal of an adverse determination, either by phone or in writing.

You have up to 180 calendar days after You receive notice of the adverse determination to file an Appeal. We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt. This acknowledgment will if necessary, inform You of any additional information needed before a decision can be made. The Appeal will be decided by a clinical peer reviewer who is not subordinate to the clinical peer reviewer who made the initial adverse determination and who is (1) a Physician or (2) a health care professional in the same or similar specialty as the Provider who typically manages the disease or condition at issue.

H. Standard Appeal.

Preauthorization Appeal. If Your Appeal relates to a Preauthorization request, We will decide the Appeal within 30 calendar days of receipt of the Appeal request. Written notice of the determination will be provided to You (or Your designee), and where appropriate, Your Provider, within two (2) business days after the determination is made, but no later than 30 calendar days after receipt of the Appeal request.

Retrospective Appeal.

If Your Appeal relates to a retrospective claim, We will decide the Appeal within 60 calendar days of receipt of the Appeal request. Written notice of the determination will be provided to You (or Your designee), and where appropriate, Your Provider, within two (2) business days after the determination is made, but no later than 60 calendar days after receipt of the Appeal request.

Expedited Appeal.

An Appeal of a review of continued or extended health care services, additional services rendered in the course of continued treatment, home health care services following discharge from an inpatient Hospital admission, services in which a Provider requests an immediate review, or any other urgent matter will be handled on an expedited basis. An expedited Appeal is not available for retrospective reviews. For an expedited Appeal, Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal. Your Provider and a clinical peer reviewer may exchange information by telephone or fax. An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two (2) business days of receipt of the information necessary to conduct the Appeal.

If You are not satisfied with the resolution of Your expedited Appeal, You may file a standard internal appeal or an external appeal.

Our failure to render a determination of Your Appeal within 60 calendar days of receipt of the necessary information for a standard Appeal or within two (2) business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination.

I. Full and Fair Review of an Appeal.

We will provide You, free of charge, with any new or additional evidence considered, relied upon, or generated by Us or any new or additional rationale in connection with Your Appeal. The evidence or rationale will be provided as soon as possible and sufficiently in advance of the date on which the notice of final adverse determination is required to be provided to give You a reasonable opportunity to respond prior to that date.

J. Appeal Assistance.

If You need Assistance filing an Appeal, You may contact the state independent Consumer Assistance Program at:

Community Health Advocates 633 Third Ave., 10th Floor New York, NY 10017 Or call toll free: 1-888-614-5400, or email cha@cssny.org Website: www.communityhealthadvocates.org

Exclusions and Limitations

No coverage is available under this Certificate for the following:

A. Aviation. We do not cover services arising out of aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline.

B. Cosmetic Services. We do not Cover cosmetic services or surgery unless otherwise specified,except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeal sections of this Certificate unless medical information is submitted.

C. Coverage Outside of the United States, Canada or Mexico. We do not Cover care or treatment provided outside of the United States, its possessions, Canada or Mexico. except for Emergency Dental Care.

D. Experimental or Investigational Treatment. We do not cover any health care service, procedure,treatment, or device that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under this Policy for non-investigational treatments. See the Utilization Review and External Appeal sections of this Certificate for a further explanation of Your Appeal rights.

E. Felony Participation. We do not cover any illness, treatment or medical condition due to Your participation in a felony, riot or insurrection.

F. Government Facility. We do not Cover care or treatment provided in a Hospital that is owned oroperated by any federal, state or other governmental entity, except as otherwise required by law.

G. Medical Services. We do not cover medical services or dental services that are medical in nature,including any Hospital charges or prescription drug charges.

H. Medically Necessary. In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment,test or device is otherwise Covered under the terms of this Policy.

I. Medicare or Other Governmental Program. We do not cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid).

J. Military Service. We do not cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units.

K. No-Fault Automobile Insurance. We do not cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if You do not make a proper or timely claim for the benefits available to Youunder a mandatory no-fault policy.

L. Services Not Listed. We do not cover services that are not listed in this Policy as being covered.

M. Services Provided by a Family Member. We do not cover services performed by a member of the covered person's immediate family. "Immediate family" shall mean a child, spouse, mother, father, sister, or brother of You or Your Spouse.

N. Services Separately Billed by Hospital Employees. We do not cover services rendered and separately billed by employees of Hospitals, laboratories or other institutions.

O. Services with No Charge. We do not cover services for which no charge is normally made.

P. War. We do not cover an illness, treatment or medical condition due to war, declared or undeclared.

Q. Workers' Compensation. We do not cover services if benefits for such services are provided under any state or federal Workers' Compensation, employers' liability or occupational disease law.

The member can choose a conveniently located private dental office from a listing of participating providers. For a listing of participating providers please visit the UnitedHealthcare SOC landing page www.whyuhc.com/nypdsoc/Dental-DHMO-Plan.

UnitedHealth Care Plans
The open enrollment period for the UnitedHealthcare dental plans starts November 1 and continues through November 30th of each year. Members can fill out this fillable form (CLICK HERE FOR FORM) and either email it to dental.info@nypdsoc.com or mail it to the Superior Officers Council at 40 Peck Slip N.Y. N.Y. 10038

Careington/Healthplex Plans
Members who are enrolled in the Careington/Healthplex plan signed on for a two-year commitment, members will be able to enroll in another plan on a rolling basis when their two-year commitment is satisfied.

Your Provider will submit a completed UnitedHealthcare claim form directly to UnitedHealthcare at:

Claims and pre-treatment/pre-authorization submission addresses.