Dear New Member: Welcome to Premier Access! We are pleased you selected us as your provider of dental services. Enclosed are the following:

1. Your Premier Access identification card. 2. Information regarding Plan benefits. 3. Information on obtaining services during a dental emergency; and 4. Your combined Certificate of Insurance and Disclosure form.

Premier Access is proud to provide your child(ren) with dental coverage under the Healthy Kids Santa Barbara. Good oral health is essential for overall well-being. We believe that a balanced diet, routine brushing and regular check-ups are necessary ingredients in achieving good oral health. Because oral health plays such an important role, it makes sense to give the best care possible. While there is no set rule, it is generally advisable that children visit the dentist at least annually for a professional cleaning and exam. By starting visits at an early age, you will help your child have strong, healthy teeth while building good dental habits that will last a lifetime. Regular visits can also be beneficial in the early detection and treatment of any dental problems. We encourage you to follow this program and if you have not already done so, please schedule your child’s next appointment. Premier Access wants to help your child(ren) achieve and maintain good dental health today, tomorrow and always. Again, thank you for selecting Premier Access. If you have any questions regarding this dental coverage or the materials in this packet, please call us at 888-584-5830. We look forward to serving you. Sincerely, Laila Baker, DDS, MSD Dental Director _____________________________________________________________________________________________________ Estimado(a) Nuevo(a) Afiliado(a): ¡Bienvenido(a) al Premier Access! Nos complace que nos haya seleccionado como su proveedor de servicios dentales. Se le adjunta lo siguiente:

1. Su tarjeta de identificación del Premier Access; 2. Información con respecto a los beneficios del Plan; 3. Información sobre cómo obtener servicios durante una emergencia dental; y 4. Su Formulario de Prueba de Cobertura y Revelación de Datos.

El Premier Access se enorgullece de proporcionarle(s) a su(s) hijo(s) cobertura dental bajo el Programa Healthy Kids Santa Barbara. Una buena higiene bucal es esencial para su bienestar en general. Creemos que una dieta balanceada, el cepillado rutinario y los exámenes regulares son ingredientes necesarios para lograr una buena higiene bucal. Puesto que la salud dental desempeña un papel tan importante. Mientras que no existe una regla fija, en general es recomendable que los niños consulten a su dentista por lo menos una vez al año para recibir una limpieza profesional y un examen dental. Al llevarlo(a) a las consultas a una temprana edad, usted ayudará a su hijo(a) a tener dientes fuertes y sanos, a la vez le inculca buenos hábitos dentales que durarán toda la vida. Las consultas regulares también son beneficiosas en la detección y tratamiento oportunos de cualquier problema dental. Le recomendamos que siga este programa y si aún no lo ha hecho, por favor, próxima cita de su hijo(a). El Premier Access desea que su(s) hijo(s) logre(n) y conserve(n) una higiene dental-hoy, mañana y siempre. Nuevamente, gracias por seleccionar el Premier Access. Si tiene alguna pregunta con respecto a la cobertura dental o los materiales en este paquete, por favor llámenos al 888-584-5830. Esperando poder servirle. Atentamente, Laila Baker, DDS, MSD Directora Dental

P. O. Box 659010 Sacramento, CA 95865-9010

phone 888-584-5830 fax 916-646-9000 email info@premierlife.com website www.premierppo.com

HKSB 2011/12

HOW TO ACCESS SERVICES UNDER HEALTHY KIDS SANTA BARBARA

How do I select a dentist to be my Primary Care Dentist? If you reside within a 15-mile radius of a Premier PPO dentist (network dentist), you must go to one of the network dentists listed in your Provider Directory. If there are no PPO dentists within a 15-mile radius, you may select your own non-network dentist or We will assist you in locating a dentist. Once you select a dentist in your area, contact the dentist to make an appointment. You need to inform the dental office to contact Premier Access at 888-584-5380 to verify eligibility information and to receive an explanation on how the plan will reimburse the dental office for providing services. If you would like assistance in locating a dentist please contact a Member Services Representative by calling 888-584-5830. What do I do if I need to see a dental specialist? Your Primary Care Dentist will determine the need for specialty referral and will request from Premier Access to locate a specialist for you. All basic and major treatments require prior authorization by Premier Access. Please refer to your Certificate of Insurance for further discussion on covered benefits and prior benefit authorization. How do I know that my dentist will accept Premier Access Coverage? Most dentists know about our program and will not need to be informed on how Premier Access works. If your dentist does not know about our program, or says that the dental office does not accept the plan, insist that they call Premier Access’ Provider Relations Department at 800-640-4466 to be informed about how Premier Access’ program works. Who do I call if I need to change my personal information such as my address, telephone number or the spelling of my name? You must notify the Healthy Kids Program for CenCal Health formerly known as Santa Barbara Regional Health Authority if you need to change any of your personal information. Please call Member Services at 1-877-814-1861 or write to:

Healthy Kids Santa Barbara 110 Castilian Drive

Goleta, CA 93117-3028

Are braces a covered benefit under Healthy Kids Santa Barbara? Braces are not a covered benefit under Healthy Kids Santa Barbara. However, if you meet the eligibility requirement for medically necessary orthodontia coverage under the California Children's Services (CCS) Program, then benefits shall be determined and provided by CCS.

What do I do if I need an interpreter for my dental appointment? By contacting a Premier Access Member Services Representative at 888-584-5830, you have access to interpreters who can interpret from English into as many as 140 languages. A Member Services Representative will assist in explaining your benefits, obtaining covered benefits from participating providers, maintaining appropriate interpretative services, or arranging for a Premier Access interpreter to assist you in obtaining benefits at an appropriate participating provider office. What do I do if I have a dental emergency after normal business hours? If you require emergency care, whether inside or outside of Premier Access' service area, you may seek treatment from the nearest available dentist or emergency facility as circumstances dictate. No prior authorization is required. Emergency care is available to you twenty-four (24) hours a day, seven (7) days a week. Emergency care includes services needed to alleviate severe pain, swelling, or bleeding associated with a sudden serious and unexpected illness or injury. During regular dentists office hours, you may obtain emergency care by contacting your dentist. If the dentist does not respond, you need to proceed to the nearest emergency provider or facility that is willing to provide treatment. What do I do if I have any questions, concerns or complaints about Premier Access, my dentist or my covered benefits? If you have any questions, concerns or complaints, please call our Member Services Department at 1-888-584-5830. A Premier Access representative will be happy to answer your questions and address your concerns.

CÓMO TENER ACCESO A SERVICIOS BAJO EL PROGRAMA DE HEALTHY KIDS SANTA BARBARA

¿Cómo selecciono a un(a) dentista como mi Dentista de –Atención Primaria? Si usted reside dentro de una distancia no mayor a 15 mill as de un dentista de nuestra red Premier (PPO) que se encuentra en el directorio de proveedores, usted debe ir a el. Si no hay dentistas de nuestra red Premier (PPO) dentro de una distancia no mayor alas 15 mill as, usted puede elegir su propio dentista aunque no sea de nuestra red (PPO), o nosotros le asistiremos a encontrar uno. Una vez que elija un dentista en su área, llámelo para hacer su cita. Usted necesita decirle alia la recepcionista en el consultorio dental de que su niño(a) tiene seguro dental. Usted necesita pedirles en el consultorio dental que se comuniquen con Premier Access al 888-584-5830 para que verifiquen la información sobre la elegibilidad, y para que se les explique cómo el plan le reembolsará al consultorio dental por proporcionar los servicios. ¿Qué hago si necesito consultar a un(a) especialista dental? Usted tiene que ir primero a su Dentista de Atención Primaria (PCD) para que evalúe su caso. Una vez que su PCD determine que usted necesita la atención de un(a) especialista, su PCD determinará si necesita un envío a consulta de emergencia o uno de rutina para ver a un(a) especialista. Entonces, su PCD enviará la petición a Premier Access. Premier Access transmita de inmediato los envíos a consulta de emergencia, llamando a un(a) especialista para que coordine la concertación de una cita para usted. Todos los tratarnientos básicos y mayores requieren autorización previa de Premier Access. Por favor, consulte su Certificado de Seguro para mayores informes sobre los beneficios cubiertos y la autorización previa de beneficios. ¿Cómo sé si mi dentista aceptará cobertura de Premier Access? La rnayoría de los dentistas están farniliarizados con nuestro programa y no necesitará decírseles cómo funciona Premier Access. Si su dentista no está familiarizado(a) con nuestro programa, o indica que el consultorio dental no acepta el plan, insista en que llame al Departamento de Relaciones con los Proveedores de Premier Access al 800-640-4466 para que se le indique cómo funciona el programa de Premier Access. ¿A quién llamo si necesito cambiar mi información personal, como mi dirección, número de teléfono o el deletreo de mi monbre? Usted tiene que notificar al Programa de Healthy Kids Program for CenCal Healthy formerly known as Santa Barbara Regional Health Authority si usted necesita cambiar cualquier información personal. Por favor, llame al HKSB al número de teléfono gratuito al 1-877-814-1861 o escriba a:

Healthy Kids Santa Barbara 110 Castilian Drive

Goleta, CA 93117-3028

¿Son los frenos un beneficio cubierto bajo el Programa de Healthy Kids Santa Barbara? Los trenos no son un beneficio cubierto bajo el Programa de Healthy Kids Santa Barbara. Sin embargo, si usted reúne los requisitos de elegibilidad para la cobertura de ortodoncia, necesaria desde el punto de vista médico, bajo el Programa de Servicios para los Niños de California (California Children's Services - CCS), entonces el programa de CCS determinará y proporcionará los beneficios. ¿Qué hago si necesito un(a) intérprete para mi cita dental? Al comunicarse con un Representante de Atención al Miembro de Premier Access al 888-584-5830, usted tiene acceso a los intérpretes que pueden interpretarle del inglés a aproximadamente 140 idiomas. Un Representante de Atención al Miembro le ayudará a explicarle sus beneficios, a obtener los beneficios cubiertos de los proveedores participantes, a mantener los servicios interpretativos adecuados o a hacer los arreglos para que un(a) intérprete de Premier Access le ayude a obtener beneficios en un consultorio de un proveedor participante adecuado. ¿Qué hago si tengo una emergencia dental después de las horas hábiles normales? Si usted requiere atención de emergencia, ya sea dentro o fuera del área de servicio de Premier Access, usted puede obtener tratarniento del dentista que esté disponible o del establecimiento de emergencia más cercano, segúun dicten las circunstancias. No se requiere autorización previa. La atención de emergencia está a su disposición las veinticuatro (24) horas del dia, los siete (7) días de la semana. La atención de emergencia incluye servicios que se necesitan para aliviar el dolor fuerte, la hinchazón o el sangrado asociado con una enfermedad o lesión repentina, grave e inesperada. Durante las horas hábiles regulares del consultorio del/de la dentista, usted puede obtener atención de emergencia comunicándose con su dentista. Si el/la dentista no responde, necesita ir al proveedor o establecimiento de servicios de emergencia más cercano que esté dispuesto a darle tratamiento. ¿Qué hago si tengo alguna pregunta, inquietud o queja sobre Premier, mi dentista o mis beneficios cubiertos? Si usted tiene alguna pregunta, inquietud o queja, por favor llame a nuestro Departamento de Atención al Cliente al 1-888-584-5830. Un representante de Premier Access le contestará con gusto sus preguntas y escuchará sus inquietudes.

NOTICE OF PRIVACY PRACTICES EFFECTIVE APRIL 14, 2003

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice tells you about the ways Premier Access Insurance Company ("Premier Access") may collect, store, use and disclose your protected health information and your rights concerning your protected health information. “Protected Health Information” is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. Federal and state laws require us to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is still in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards. Uses and Disclosures of Your Protected Health Information We may use and disclose your protected health information for different purposes. The examples below are illustrations of the different types of uses and disclosures that we may make without obtaining your authorization.

Payment. We may use and disclose your protected health information in order to pay for your covered health expenses. For example, we may use your protected health information to process claims or be reimbursed by another insurer that may be responsible for payment.

Treatment. We may use and disclose your protected health information to assist your health care providers (dentists) in your diagnosis and treatment.

Health Care Operations. We may use and disclose your protected health information in order to perform our plan activities, such as quality assessment activities, or administrative activities, including data management or customer service. In some cases, we may use or disclose the information for underwriting or determining premiums.

Enrolled Dependents and Family Members. We will mail explanation of benefits forms and other mailings containing protected health information to the address we have on record for the subscriber of the dental plan.

Other Permitted or Required Disclosures

As Required by Law. We must disclose protected health information about you when required to do so by law. Public Health Activities. We may disclose your protected health information to public health agencies for reasons such as

preventing or controlling disease, injury or disability. Victims of Abuse, Neglect or Domestic Violence. We may disclose your protected health information to government

agencies about abuse, neglect or domestic violence. Health Oversight Activities. We may disclose protected health information to government oversight agencies (e.g. state

insurance departments) for activities authorized by law. Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or

administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.

Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.

Coroners or Funeral Directors. We may release protected health information to coroners or funeral directors as necessary to allow them to carry out their duties.

Research. Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.

To Avert a Serious Threat to Health or Safety. We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.

Workers’ Compensation. We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.

Other Uses or Disclosures With an Authorization Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.

Your Rights Regarding your Protected Health Information You may have certain rights regarding protected health information that the Plan maintains about you.

Right To Access Your Protected Health Information. You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include enrollment, billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your protected health information must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.

Right to Amend Your Protected Health Information. If you feel that your protected health information maintained by Premier Access is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request, if for example, you ask us to amend information that was not created by Premier Access or you ask us to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (paper or electronically). For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.

Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.

Right to Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.

Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our Privacy Officer. See the end of this Notice for the contact information.

Health Information Security Premier Access requires its employees to follow its security policies and procedures that limit access to health information about subcribers to those employees who need it to perform their job responsibilities. In addition, Premier Access maintains physical, administrative and technical security measures to safeguard your protected health information. Changes to This Notice We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any other information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. Any time we make a material change to this Notice, we will promptly revise and issue the new Notice with the new effective date. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint with us by contacting the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint. Our Legal Duty We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice. If you have any questions or complaints, please contact: Privacy Officer Phone: (916) 920-2500

Premier Access Fax: (916) 646-9000 P.O. Box 659010 Email: Privacy Officer@Premierlife.com Sacramento, CA 95865-9010-9010

PREMIER ACCESS INSURANCE COMPANY

P.O. Box 659010 Sacramento, CA 95865-9010

Phone: 888-584-5830 Fax: 916-646-9000

Email: info@premierlife.com Website: www.premierppo.com

CERTIFICATE OF INSURANCE NOVEMBER 1, 2011 – OCTOBER 30, 2012

BENEFIT YEAR Issued by: Premier Access Insurance

Company For: Healthy Kids Santa Barbara

Certificate Effective Date:

Please refer to Identification Card

Reza Abbaszadeh, DDS President

TABLE OF CONTENTS

INTRODUCTION ........................................................................................................................................... 1 USING THIS BOOKLET .................................................................................................................................. 1 WELCOME! ABOUT PREMIER ACCESS INSURANCE COMPANY ....................................................................... 1 LANGUAGE ASSISTANCE SERVICES .............................................................................................................. 1 SUBSCRIBER IDENTIFICATION CARD ............................................................................................................. 2

DEFINITIONS ............................................................................................................................................... 2 SUBSCRIBER RIGHTS AND RESPONSIBILITIES .................................................................................... 4 ACCESSING CARE ...................................................................................................................................... 5

PHYSICAL ACCESS ...................................................................................................................................... 5 ACCESS FOR THE HEARING IMPAIRED ........................................................................................................... 5 ACCESS FOR THE VISION IMPAIRED .............................................................................................................. 5 THE AMERICANS WITH DISABILITIES ACT OF 1990 ......................................................................................... 5 DISABILITY ACCESS GRIEVANCES ................................................................................................................ 5

USING THE DENTAL PLAN ........................................................................................................................ 5 FACILITIES LOCATIONS ................................................................................................................................ 6 CHOOSING A PRIMARY CARE DENTAL PROVIDER .......................................................................................... 6 SCHEDULING APPOINTMENTS ...................................................................................................................... 6 CHANGING YOUR PRIMARY CARE DENTAL PROVIDER ................................................................................... 6 CONTINUITY OF CARE FOR NEW SUBSCRIBERS ............................................................................................ 6 CONTINUITY OF CARE FOR TERMINATION OF PROVIDER ................................................................................ 7 PRIOR AUTHORIZATION FOR SERVICES......................................................................................................... 7 REFERRALS TO SPECIALISTS ....................................................................................................................... 7 OBTAINING A SECOND OPINION ................................................................................................................... 8 UTILIZATION REVIEW ................................................................................................................................... 8 GETTING URGENT CARE .............................................................................................................................. 8 GETTING EMERGENCY SERVICES ................................................................................................................. 9 WHAT TO DO IF YOU ARE NOT SURE IF YOU HAVE AN EMERGENCY .............................................................. 9 NON-COVERED SERVICES ........................................................................................................................... 9 FOLLOW-UP CARE ...................................................................................................................................... 9 COPAYMENTS ............................................................................................................................................. 9 SUBSCRIBER LIABILITIES............................................................................................................................ 10

DENTAL PLAN COVERED BENEFITS MATRIX ...................................................................................... 11 BENEFITS................................................................................................................................................... 14

DIAGNOSTIC AND PREVENTIVE BENEFITS ................................................................................................... 14 RESTORATIVE DENTISTRY ......................................................................................................................... 14 ORAL SURGERY ........................................................................................................................................ 15 ENDODONTIC ............................................................................................................................................ 15 PERIODONTICS ......................................................................................................................................... 15 CROWN AND FIXED BRIDGE ....................................................................................................................... 16 REMOVABLE PROSTHETICS ........................................................................................................................ 16 OTHER BENEFITS ...................................................................................................................................... 17 ORTHODONTIC BENEFITS .......................................................................................................................... 17

COORDINATION OF SERVICES ............................................................................................................... 17 CALIFORNIA CHILDREN’S SERVICES (CCS) ................................................................................................ 17

EXCLUDED BENEFITS .............................................................................................................................. 18 GRIEVANCES AND APPEALS PROCESS ............................................................................................... 19

GRIEVANCES ............................................................................................................................................ 19 GENERAL INFORMATION ........................................................................................................................ 19

COORDINATION OF BENEFITS ..................................................................................................................... 19 THIRD PARTY RECOVERY PROCESS AND SUBSCRIBER RESPONSIBILITIES .................................................... 19 NON-DUPLICATION OF BENEFITS WITH WORKERS’ COMPENSATION ............................................................. 20 COORDINATION OF BENEFITS ..................................................................................................................... 20 LIMITATIONS OF OTHER COVERAGE ........................................................................................................... 20 PROVIDER PAYMENT ................................................................................................................................. 20 REIMBURSEMENT PROVISIONS – IF YOU RECEIVE A BILL ............................................................................. 20 NOTIFYING YOU OF CHANGES IN PREMIER ................................................................................................. 21 PRIVACY PRACTICES ................................................................................................................................. 21 ORGAN AND TISSUE DONATION .................................................................................................................. 21

ATTACHMENT A ........................................................................................................................................ 22

1

Introduction Using this Booklet This booklet, called the Certificate of Insurance (“Certificate”), is part of the legal agreement between You (a “Subscriber”) and Us (“Premier Access Insurance Company”). This certificate contains detailed information about Healthy Kids Santa Barbara benefits, how to obtain benefits, and the rights and responsibilities of Healthy Kids Santa Barbara Subscribers. Please read this booklet carefully and keep it on hand for future reference. As a Subscriber, You are bound by all of the terms of this Certificate. The legal agreement between You and Us includes this Certificate and any amendments made to it. This document sets forth all of the terms of the legal agreement between You and Premier Access Insurance Company ("Premier"). Whenever We refer to Your agreement with Us, We mean the document described above plus all valid written modifications. No change or modification to Your agreement with Us will be valid unless it is in writing and signed by an authorized representative of Premier. Throughout this booklet, “you,” “your,” and “subscriber” refers to the child or children enrolled in the Healthy Kids Santa Barbara. “We,” “us,” and “our” always refers to Premier Access Insurance Company. “Your provider” refers to a licensed dentist who is responsible for providing dental services to you.

Welcome! About Premier Access Insurance Company Premier Access Insurance Company (“Premier”) provides comprehensive dental coverage for individuals who participate in the Healthy Kids Santa Barbara. Premier has a large network of providers that have been credentialed by Us. In areas where there are no network providers close to your residence, Premier will allow you to receive care from any provider. Under Premier, you are guaranteed access to a provider, either a network provider or non-network provider in areas where there are no contracted providers. You can change your dentist at any time. You can choose a dentist whose office is the most convenient for you, and who speaks your language. If a Subscriber moves, the Subscriber should contact a Premier’s Member Services Representative to assist the Subscriber in selecting a new Primary Care Dentist if the Subscriber desires a Primary Care Dentist closer to the Subscriber’s new residence. If a Subscriber permanently moves outside Premier’s Service Area, the Subscriber must contact the Healthy Kids Santa Barbara. If a Subscriber moves temporarily outside the Service Area such as to attend school, the Subscriber may remain with Premier and receive care from his or her Primary Care Dentist upon returning to Premier’s Service Area. If a Subscriber moves temporarily, the Subscriber may obtain Emergency Dental Care or Urgent Care from any dentist and Premier will reimburse the Subscriber for the costs, less applicable Copayments. If you have any questions regarding the material you are reading or Premier, please contact our Member Services toll-free number at 1-888-584-5830.

Language Assistance Services Premier Access’ Language Assistance Program provides language assistance services for our members with a non-English preferred language at no charge.

Interpreter and translation services at no charge to the member: Members can call Premier Access’ Member Service Line at 1-888-584-5830 to access these free services (TDD/TTY for the hearing impaired at 1-800-735-2929).

Speak to a representative in your preferred language: Member Service representatives can answer your questions regarding benefits and eligibility and how to use your dental plan.

Find a provider who speaks your language: Member Service representatives can help you find a provider who speaks your language or who has an interpreter available. If you cannot locate a provider to meet your language needs, you can request to have an interpreter available for discussions of dental information at no charge.

Assistance filing a grievance: You have the right to file a grievance by mail or in person with Premier Access or obtain assistance from the Department of Insurance. You may request to speak with a representative in a specific language. The process for filing a grievance is described under the Grievances and Appeals section of this booklet.

Vital Documents: This notice of available language assistance services will be included with all vital documents sent to the member. Standardized vital documents will be translated into Spanish at no charge to enrollees. For vital documents that are not standardized, but which contain enrollee-specific information, Premier Access shall provide the requested translation within 21 days of the receipt of the request for translation. It can be obtained by calling the Member Service Line at 1-888-584-5830 (TDD/TTY for the hearing impaired at 1-800-735-2929).

Standardized vital documents: Welcome packet Benefit and Copay Schedule

2

Exclusion and Limitation Grievance Form Member notification of change in Primary Care Dentist Privacy Notices HIPPA related forms

Provider Office: If you have a preferred language other than English, please inform your provider. Your provider will work with Premier Access to provide language assistance services for you at no charge. You may request face-to-face interpreting service for an appointment by contacting Premier Access’ Member Service Line. Premier Access will provide timely access to Language assistance Services.

Subscriber Identification Card All Subscribers of Premier are given a Subscriber identification card. This card contains important information regarding obtaining services. If you have not received or if you have lost your Subscriber identification card, please call us at 1-888-584-5830 (TDD/TTY for the hearing impaired at 1-800-735-2929) and we will send you a new card. Please show your Plan Subscriber identification card to your provider when you receive dental care. Only the Subscriber is authorized to obtain dental services using his or her Subscriber identification card. If a card is used by or for an individual other than the Subscriber, that individual will be billed for the services he or she receives. Additionally, if you let someone else use your Subscriber identification card, Premier may not be able to keep you in our plan.

Definitions Acute Condition: A medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Appropriately Qualified Dental Care Professional: A licensed dental care provider who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to a particular illness, disease, condition or conditions. Authorization: Approved covered services for certain procedures by Premier Access Insurance Company or your primary care dentist prior to any dental treatment. Benefits (Covered Services): Dental services and supplies that a Subscriber is entitled to receive pursuant to the terms of this Agreement. A service is not a benefit, (even if described as a covered service or benefit in this booklet) if it is not medically necessary, or if it is not provided by a Premier Access Insurance Company Provider with authorization as required. Benefit Year: The twelve (12) month period commencing July 1 of each year at 12:01 a.m. Certificate of Insurance: This document, which explains the benefits, limitations, exclusions, terms and conditions of Your coverage. Complaint: A complaint is also called a grievance or an appeal. Examples of a complaint can be when:

• You can’t get a service, treatment, or medicine you need. • Your plan denies a service and says it is not medically necessary. • You have to wait too long for an appointment. • You received poor care or were treated rudely. • Your plan does not pay you back for emergency or urgent care that you had to pay for. • You get a bill that you believe you should not have to pay.

Copayment: A fee, which a Premier provider may collect directly from a Subscriber for a particular covered benefit at the time the service is rendered. Dental Plan or Plan: Refers to Premier Access Insurance Company. Emergency Care: An emergency is a dental condition, including severe pain, manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

• Placing the Subscriber’s dental health in serious jeopardy, or • Causing serious impairment to the Subscriber’s dental functions, or

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• Causing serious dysfunction of any of the Subscriber’s bodily organs or parts.

Exclusion: Any dental treatment or service for which the program offers no coverage. Experimental or Investigational Service: Any treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies which are not recognized as being in accordance with generally accepted professional dental standards, or if safety and efficacy have not been determined for use in the treatment of a particular dental condition for which the item or service in question is recommended or prescribed. Federal Poverty Income Guideline: The federal poverty income guideline is set each year by the U.S. Department of Health and Human Services (HHS). The guidelines are used to determine eligibility for certain programs such as HFP or Medi-Cal. The poverty guidelines are sometimes referred to as the “federal poverty level” (FPL). Grievance: A written or oral expression of dissatisfaction regarding Premier and/or a provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration or appeal made by a Subscriber or the Subscriber's representative. Where Premier is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance. Healthy Kids Santa Barbara: A program which provides comprehensive health insurance for uninsured low-income children (age 0 to 19) and incomes below 300 percent of the Federal poverty level and do not qualify for any government programs such as Medi-Cal or Healthy Families.

Income Category, A, B, or C: How much you pay for the monthly premium and copayments is determined by your income category. The income categories are determined based on the current Federal Poverty Income Guidelines as follows:

Income Category A = 100%-150% of the Federal Poverty Income Guideline Income Category B = 151%-200% of the Federal Poverty Income Guideline Income Category C = 201%-250% of the Federal Poverty Income Guideline

Interpreting Service: Premier’ contracted vendor which provides phone and face-to-face language interpreting service. Language Assistance Services: Translation of standardized and enrollee-specific vital documents into threshold languages and interpretation services at all points of contact. Limited English Proficient or LEP Member: A member who has an inability or a limited ability to speak, read, write, or understand the English language at a level that permits that individual to interact effectively with health care providers or plan employees. Medically Necessary: Those dental treatments or supplies which are (a) furnished in accordance with professionally recognized standards of practice; (b) determined by the treating physician to be consistent with the dental condition; and (c) furnished at the most appropriate type, supply and level of service which considers the potential risks, benefits and alternatives. Non-Covered Benefit: A dental procedure or service that you choose to have performed even though it is not a covered benefit. Non-Participating Provider: A provider who is not contracted with Premier Access Insurance Company to provide services to Subscribers. Optional Benefit: A dental benefit that you choose to have upgraded. For example, when a filling would correct the tooth but you choose to have a full crown instead. Participating Provider: A dentist or dental facility licensed to provide covered services who or which at the time care is rendered to a Subscriber, has a contract in effect with Premier Access Insurance Company to provide covered services to its Subscribers. Premier: Refers to Premier Access Insurance Company. PPO (“Preferred Provider Organization”): A Provider, such as a dentist, who has entered into an agreement with Us for direct billing of Covered Services at the negotiated rate, and who agrees to accept Our payment in full for such Covered Services. We will pay the PPO Provider directly. Primary Care Dentist: A dentist, who is responsible for providing initial and primary care to Subscribers, maintains the continuity of patient care, initiates referral for specialist care, and coordinates the provision of all benefits to Subscribers in accordance with the Agreement. Program: Refers to Healthy Kids Santa Barbara.

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Provider Directory: The directory of all the providers contracted with Premier Access Insurance Company to provide services to its Subscribers. Serious Chronic Condition: A medical condition due to a disease, illness or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Service Area: The geographic area in the State of California where the Department of Insurance has authorized Premier Access Insurance Company to provide dental services. Subscriber: Individuals who are eligible for coverage under this Certificate. Subscriber Identification Card: The identification card provided to Subscribers by Premier Access Insurance Company that includes the Subscriber number and the telephone for Premier. Threshold language(s): The language(s) identified by Premier. Generally, threshold languages are determined by the size of the dental plan. Timely: In a manner appropriate for the situation in which language assistance is needed. Urgent Care: Dental care needed to prevent serious deterioration of a Subscriber’s health resulting from unforeseen illness or injury for which treatment cannot be delayed. Vital documents: The following documents, when produced by Premier, including when the production or distribution is delegated by the plan to a dental provider or administrative services provider:

Letters containing important information regarding eligibility and participation criteria; Notices pertaining to the denial, reduction, modification, or termination of services and benefits, and the right to file a

grievance or appeal; Notices advising LEP enrollees of the availability of free language assistance and other outreach materials that are provided

to enrollees; Explanation of benefits or similar claim processing information that is sent to an enrollee if the document requires a response

from the enrollee; and The standard disclosure of benefits, limitations and exclusions, and copayments document.

"We," "Our," and "Us" refer to Premier Access Insurance Company. "You", "Your", “Subscriber”, and “Enrollee” refer to the Subscriber.

Subscriber Rights and Responsibilities As a Premier Subscriber, you have the right to: Be treated with respect and dignity. Choose your primary care provider from our Provider Directory. Get appointments within a reasonable amount of time. Participate in candid discussions and decisions about your dental care needs, including appropriate or medically necessary

treatment options for your condition(s), regardless of cost or regardless of whether the treatment is covered by Premier. Have your dental records kept confidential. This means that we will not share your dental care information without your written

approval or unless it is required by law. Voice your concerns about Premier, or about dental services you received, to Premier Access Insurance Company. Receive information about Premier Access Insurance Company, our services, and our providers. Make recommendations about your rights and responsibilities. See your dental records. Get services from providers outside of our network in an emergency. Request an interpreter at no charge to you. Use interpreters who are not your family members or friends. Receive Subscriber materials translated into your language. File a complaint if your linguistic needs are not met.

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Your responsibilities are to: Give your providers and Premier Access Insurance Company correct information. Understand your dental problems(s) and participate in developing treatment goals, as much as possible, with your provider. Always present your Subscriber Identification Card when getting services. Ask questions about any dental condition and make certain that the explanations and instructions are understandable. Make and keep dental appointments. You should inform your provider at least 24 hours in advance when an appointment must be

cancelled. Help Premier Access Insurance Company maintain accurate and current medical records by providing timely information

regarding changes in address, family status, and other health care coverage. Notify Premier Access Insurance Company as soon as possible if a provider bills you inappropriately or if you have a complaint. Treat all Premier Access Insurance Company personnel and providers respectfully and courteously.

Accessing Care Physical Access Premier Access Insurance Company has made every effort to ensure that our offices and the offices and facilities of Premier providers are accessible to the disabled. If you are not able to locate an accessible provider, please call us toll free at 1-888-584-5830 and we will help you find an alternate provider.

Access for the Hearing Impaired The hearing impaired may contact us through our TDD number at 1-800-735-2929, Monday through Friday, from 8:30 AM to 6:00 PM. Between 6:00 PM and 8:30 AM and on weekends, please call the California Relay Service TTY at 1-800-735-2929 to get the help you need.

Access for the Vision Impaired This Certificate and other important Plan materials will be made available in large print, enlarged computer disk formats, and audiotape for the vision impaired. For alternative formats, or for direct help in reading the Certificate and other materials, please call us at 1-888-584-5830.

The Americans with Disabilities Act of 1990 Premier Access Insurance Company complies with the Americans with Disabilities Act of 1990 (ADA). This Act prohibits discrimination based on disability. The Act protects Subscribers with disabilities from discrimination concerning program services. In addition, section 504 of the Rehabilitation Act of 1973 states that no qualified disabled person shall be excluded, based on disability, from participating in any program or activity which receives or benefits from federal financial assistance, nor be denied the benefits of, or otherwise be subjected to discrimination under such a program or activity.

Disability Access Grievances If you believe Premier or its providers have failed to respond to your disability access needs, you may file a grievance with Premier by calling 1-888-584-5830. If your disability access complaint remains unresolved, you may contact the: ADA Coordinator

Managed Risk Medical Insurance Board P.O. Box 2769 Sacramento, CA 95812-2769 (916) 324-4695 The hearing impaired should call the California Relay Service at 711 (TTY).

Using the Dental Plan Remember you can keep your dental expenses down by:

Using only Premier’s participating dentists, Visiting your dentist regularly for checkups, Following your dentist’s advice about regular brushing and flossing, and Seeking treatment before you have a major problem.

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Facilities Locations PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED. Premier’s contracted Providers' dental offices are located close to where You work and live. To find out the exact address of a contracted dental office near you, You may look up his or her address in the Provider Directory or call Premier at 888-584-5830. If there are no PPO dentists in Your area within a 15-mile radius, You may select any available dentist in Your area to receive care.

Choosing a Primary Care Dental Provider If you reside within a 15-mile radius of a Premier PPO dentist (participating provider), you must go to one of these dentists which are listed in your Provider Directory. If there are no PPO dentists within a 15-mile radius, you may select your own non-participating provider, or We will assist you in locating a dentist. Once you select a dentist in your area, contact the dental office to make an appointment. If you would like assistance in locating a dentist, please contact a Member Services Representative by calling 888-584-5830.

Scheduling Appointments Provider offices are open during normal business hours and some offices are open Saturday on a limited basis. If you cannot keep your scheduled appointment, you are required to notify the dental office at least 24 hours in advance. A fee of $5.00 may be charged for failure to cancel an appointment without 24 hours prior notification. Subscribers may call the Provider directly to schedule an appointment or contact Premier and Premier will assist the Subscriber in scheduling a dental appointment. If the Subscriber requires specialty care, the Subscriber's Primary Care Dentist will contact Premier who will arrange for such care.

Primary Care Dentists are required to provide covered services to Subscribers during normal working hours and during such other hours as may be necessary to keep Subscriber’s appointment schedules on a current basis.

Appointments for routine, preventive care and specialist consultation shall not exceed three weeks from the date of the request for an appointment.

Wait time in the Primary Care Dentist’s office shall not exceed 30 minutes.

Changing Your Primary Care Dental Provider If you reside within a 15-mile radius of a Premier PPO dentist (participating provider), you must go to one of these dentists, which are listed in your Provider Directory. If there are no PPO dentists within a 15-mile radius, you may select your own non-participating provider or We will assist you in locating a dentist. Once you select a dentist in your area, contact the dental office to make an appointment. If you would like assistance in locating a dentist, please contact a Member Service Representative by calling 888-584-5830.

Continuity of Care for New Subscribers Under some circumstances, the Plan will provide continuity of care for new subscribers who are receiving dental services from a non-participating dental provider when the Plan determines that continuing treatment with a non-participating provider is medically appropriate. If you are a new subscriber, you may request permission to continue receiving dental services from a non-participating provider if you were receiving this care before enrolling in the Plan and if you have one of the following conditions:

An acute dental condition. Completion of covered services shall be provided for the duration of the acute condition. A serious chronic condition. Completion of covered services shall be provided for a period of time necessary to complete a

course of treatment and to arrange for a safe transfer to another provider, as determined by the Plan in consultation with you and the non-participating provider and consistent with good professional practice. Completion of covered services shall not exceed twelve (12) months from the time you enroll with the Plan.

Performance of a surgery or other procedure that your previous plan authorized as part of a documented course of treatment and that has been recommended and documented by the non-participating provider to occur within 180 days of the time you enroll with the Plan.

Please contact us at 1-888-584-5830 to request continuing care or to obtain a copy of our Continuity of Care policy. Normally, eligibility to receive continuity of care is based on your medical condition. Eligibility is not based strictly upon the name of your condition. If your request is approved, you will be financially responsible only for applicable Copayments under this plan. We will request that the non-participating provider agree to the same contractual terms and conditions that are imposed upon participating providers providing similar services, including payment terms. If the non-participating provider does not accept the terms and conditions, the Plan is not required to continue that provider’s services. The Plan is not required to provide continuity of care as described in this section to a newly covered subscriber who was covered under an individual subscriber agreement and undergoing a treatment on the effective date of his or her Healthy Kids Santa Barbara coverage. Continuity of care does not provide coverage for benefits not otherwise covered under this agreement.

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All such notifications by a Subscriber may be made to any Plan office. All such notifications shall be forwarded to the Plan's Dental Director for action. The Dental Director shall respond in writing to the Subcriber within a dentally appropriate period of time given the dental condition involved, and in no event more than five (5) days after submission of such notification to the Plan. If we determine that you do not meet the criteria for continuity of care and you disagree with our determination, see the Plan’s Grievance and Appeals Process in this booklet.

Continuity of Care for Termination of Provider The Plan will provide continuity of care for covered services rendered to you by a provider whose participation has terminated if you were receiving this care from this provider prior to the termination and if you have one of the following conditions:

An acute dental condition. Completion of covered services shall be provided for the duration of the acute condition. A serious chronic condition. Completion of covered services shall be provided for a period of time necessary to complete a

course of treatment and to arrange for a safe transfer to another provider, as determined by the Plan in consultation with you and the terminated provider and consistent with good professional practice. Completion of covered services shall not exceed twelve (12) months from the time you enroll with the Plan.

Performance of a surgery or other procedure that we have authorized as part of a documented course of treatment and that has been recommended and documented by the terminated provider to occur within 180 days of the provider’s contract termination date.

Continuity of care will not apply to providers who have been terminated due to medical disciplinary cause or reason, fraud, or other criminal activity. You must be under the care of the participating provider at the time of our termination of the provider’s participation. The terminated provider must agree in writing to provide services to you in accordance with the terms and conditions, including reimbursement rates, of his/her agreement with the Plan prior to termination. If the provider does not agree with these contractual terms and conditions and reimbursement rates, we are not required to continue the provider’s services beyond the contract termination date. Please contact us at 1-888-584-5830 to request continuing care or to obtain a copy of our Continuity of Care policy. Normally, eligibility to receive continuity of care is based on your dental health condition. Continuity of care does not provide coverage for benefits not otherwise covered under this agreement. If your request is approved, you will be financially responsible only for applicable Copayments under this plan. If we determine that you do not meet the criteria for continuity of care and you disagree with our determination, see the Plan’s Grievance and Appeals Process in this booklet.

Prior Authorization for Services Your primary care dentist will coordinate your dental care needs and, when necessary, will arrange specialty services for you. In some cases, Premier must authorize the specialty services before you receive the services. Your primary care dentist will obtain the necessary referrals and authorizations for you. Some specialty services, such as emergency care, do not require prior authorization before you receive the services. If you see a specialist or receive specialty services before you receive the required authorization, you will be responsible to pay for the cost of the treatment (this does not apply to emergency treatment). If Premier denies a request for specialty services, Premier will send you a letter explaining the reason for the denial and how you can appeal the decision if you do not agree with the denial.

Referrals to Specialists Your primary care dentist may refer you to another dentist for consultation or specialized treatment. Your primary care dentist will submit a referral request to Premier for authorization to see a specialist. If the requested referral is approved, Premier shall specify in the notice, the specific dental care service approved. If the requested referral is denied or modified, the notice shall include a clear and concise explanation of the reasons for the decisions. All services must be authorized before the date the services are provided, except for services provided for emergency dental care. If the services are not authorized before they are provided, they will not be a covered benefit, even if the services are needed.

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Premier processes emergency referrals immediately by calling a specialist to coordinate the scheduling of an appointment for the Subscriber with the specialist. Routine referrals are processed in a timely fashion appropriate for the Subscriber's condition, not to exceed five (5) business days of receipt. Referrals affecting care where the Subscriber faces an imminent and serious threat to his/her health or could jeopardize the Subscriber's ability to regain maximum function shall be made in a timely fashion appropriate for the Subscriber's condition, not to exceed 72-hours after Premier's receipt of the necessary documentation requested by Premier to make the determination. The Plan reserves the right to determine the facility and Plan provider from which Covered Services requiring specialty care are obtained. If your request for a referral is denied, you may appeal the decision by following Premier’s Grievance and Appeal Process.

Obtaining a Second Opinion Sometimes you may have questions about your condition or your primary care dentist’s recommended treatment plan. You may want to get a second opinion. You may request a second opinion for any reason, including the following:

You question the reasonableness or necessity of a recommended procedure; You have questions about a diagnosis or a treatment plan for a chronic condition or a condition that could cause loss of life,

loss of limb, loss of bodily function, or substantial impairment; Your provider’s advice is not clear, or it is complex and confusing; Your provider is unable to diagnose the condition or the diagnosis is in doubt due to conflicting test results; The treatment plan in progress has not improved your dental condition within an appropriate period of time; You have attempted to follow the treatment plan or consulted with your initial provider regarding your concerns about the

diagnosis or the treatment plan. Subcribers or providers may request a second opinion for Covered Services by contacting Premier. After you or your primary care dentist have requested permission to obtain a second opinion, Premier will authorize or deny your request in an expeditious manner. If your dental condition poses an imminent and serious threat to your health, including but not limited to, the potential loss of life, limb, or other major bodily function or if a delay would be detrimental to your ability to regain maximum function; your request for a second opinion will be processed within 72 hours after Premier receives your request. If your request to obtain a second opinion is authorized, you must receive services from a Plan provider within our dental network. If there is no qualified provider in our network, Premier will authorize a second opinion from a non-participating provider. You will be responsible for paying all Copayments for the second opinion. If your request to obtain a second opinion is denied and you would like to appeal our decision, please refer to Premier’s Grievance and Appeals Process in this booklet. This is a summary of Premier’s policy regarding second opinions. To obtain a copy of our policy, please contact us at 1-888-584-5830.

Utilization Review Claims for Covered Services may be reviewed to establish that the services were Medically Necessary and consistent with the condition reported and with generally accepted standards of medical, dental, and surgical practice in the area where performed.

Getting Urgent Care Urgent care services are services needed to prevent serious deterioration of your health resulting from an unforeseen illness or injury for which treatment cannot be delayed. Premier covers urgent care services any time you are outside our service area or on nights and weekends when you are inside our service area. To be covered by Premier, the urgent care service must be needed because the illness or injury will become much more serious, if you wait for a regular doctor's appointment. On your first visit, talk to your primary care dentist about what he or she wants you to do when the office is closed and you feel urgent care may be needed. To obtain urgent care when you are inside Premier’s services area on nights and weekends, the Subscriber must notify his or her Primary Care Dentist, describe the urgent condition, and make an appointment to see his or her dentist within 24 hours. Urgent Care means dental care required within a short time frame, usually within 24 hours, in order to prevent a serious deterioration of a Subscriber’s health due to illness or injury. If the dentist is unable to see the Subscriber within the 24-hour period, the Subscriber must immediately contact Premier and Premier will arrange alternative dental care.

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To obtain urgent care when you are outside Premier’s services area, You may seek treatment from the nearest available dentist or emergency facility as circumstances dictate. Services that Premier determines not to meet the definition of Urgent Care as defined above, will not be covered. Non-Plan Providers may require the Subscriber to make immediate full payment for services or may allow the Subscriber to pay any applicable Copayments and bill Premier for the unpaid balance. If the Subscriber has to pay any portion of the bill, Premier will reimburse the Subscriber for services that meet the definition of Emergency Dental Care or Urgent Care as defined above. If the Subscriber pays a bill, a copy of the bill should be submitted to the following address: Premier Access Insurance Company, Attention: Claims Department, P. O. Box: 659010, Sacramento, CA 95865-9010. Once the Subscriber has received Urgent Care, the Subscriber must contact his or her Primary Care Dentist (if the Subscriber's own Primary Care Dentist did not perform the dental care) for follow-up care. The Subscriber will receive all follow-up care from his or her own Primary Care Dentist.

Getting Emergency Services An emergency is a dental condition, including severe pain, manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

• Placing the Subscriber’s dental health in serious jeopardy, or • Causing serious impairment to the Subscriber’s dental functions, or • Causing serious dysfunction of any of the Subscriber’s bodily organs or parts.

Emergency dental care services are available to you twenty-four (24) hours a day, both inside and outside our service area. If you are outside our service area, treatment for emergencies includes urgently needed services to prevent serious deterioration of your dental health resulting from unforeseen illness or injury for which treatment cannot be delayed until you return to the service area. If You require emergency care, whether inside or outside of Premier's Service Area, You may seek treatment from the nearest available dentist or emergency facility as circumstances dictate. Emergency care is available to subcribers twenty-four (24) hours a day, seven (7) days a week. You may receive emergency services from any willing provider without any requirement for prior authorization. Premier's contracted Providers are required to provide after-hours care for their patients. Premier also maintains its own after-hours emergency services to assist a subcriber. If You have any questions, please call Premier at 888-584-5830.

What to Do If You Are Not Sure If You Have an Emergency If you are not sure whether you have an emergency or require urgent care during regular Provider office hours or after business hours, you should first contact your Primary Care Dentist. If your Primary Care Dentist is unavailable, you may contact Premier twenty-four (24) hour answering service at 1-800-870-4290 or contact a Premier’s Member Services Representative by calling 1-888-584-5830.

Non-Covered Services Premier does not cover dental services that are not emergencies or urgent if you reasonably should have known that an emergency or urgent care situation did not exist. You will be responsible for all charges related to these services.

Follow-Up Care After receiving any emergency or urgent care services, you will need to call your primary care dentist for follow-up care.

Copayments You will be required to pay a small amount of money for some services. This is called a Copayment. You are responsible to pay the Copayment to the dental provider at the time services are provided. There are no Copayments for the preventive and diagnostic services listed in the Benefits section of this certificate. Additionally, there are no Copayments for Subscribers who are determined by the Healthy Kids Santa Barbara to be American Indians or Alaska Natives. For information pertaining to Copayment waivers for American Indians or Alaskan Natives, please refer to the Healthy Kids Santa Barbara Handbook or contact the Healthy Kids Santa Barbara at (877) 814-1861. The annual Copayment maximum that you have in your Healthy Kids Santa Barbara health plan does not apply to dental benefits. No deductibles are charged for dental benefits. The HFP has increased copayments for applicable covered services for members who are in Income Categories B & C. This copayment increase does not apply to members in Income Category A. Please refer to the inside cover of this COI booklet to read more about the HFP Income Categories.

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Your monthly premium and copayments are determined by your income category. To read about the HFP Income Categories please go to the HFP website: http://www.healthyfamilies.ca.gov/Downloads/Applications.aspx

Subscriber Liabilities Generally, the only amount a Subscriber pays for covered services is the required copayment. You may have to pay for services you receive that are NOT covered services, such as:

non-emergency services received in the emergency room; non-emergency or non-urgent services received outside of Premier’s service area if you did not get authorization from

Premier before receiving such services; specialty services you receive if you did not get a required referral or authorization from Premier before receiving such

services (see page 7, Referrals to Specialists); services from a non-participating provider, unless the services are for situations allowed in this Certificate of Insurance

booklet (for example, emergency services, urgent services outside of the plan’s service area, or specialty services approved by the plan (see page 6, Choosing a Primary Care Dental Provider); or

services you received that are greater than the limits described in this Certificate of Insurance booklet unless authorized by Premier.

If Premier does not pay a non-participating provider for covered services, you do not have to paythe non-participating provider for the cost of the covered services. Covered services are those services that are provided according to this Certificate of Insurance Booklet. The non-participating provider must bill Premier, not you, for any covered service. But remember, services from a non-participating provider are not “covered services” unless they fall within the situations allowed by this Certificate of Insurance booklet. Premier is responsible to pay for all covered services including emergency services. You are not responsible to pay a provider for any amount owed by the health plan for any covered service. Your dentist may charge you a $10.00 fee if you fail to cancel an appointment at least 24 hours prior to the appointment. This fee will be waived if it was not reasonably possible for you to cancel your appointment. If you receive a bill for a covered service from any provider, whether participating or non-participating, contact Premier’s Member Services Department at 1-888-584-5830.

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Dental Plan Covered Benefits Matrix

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERED BENEFITS AND IS A SUMMARY ONLY. THE BENEFIT DESCRIPTION SECTION SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERED BENEFITS AND LIMITATIONS. The HFP has increased copayments for applicable covered services for members who are in Income Categories B & C. This copayment increase does not apply to members in Income Category A. Please refer to the inside cover of this COI booklet to read more about the HFP Income Categories.

BENEFITS* SERVICES

COST TO SUBSCRIBER

(COPAYMENT) Income Categor A

Cost to Member (copayment)

Income Categories B & C

Diagnostic and

Preventive Care

Initial and periodic oral examinations, Consultations, including specialist consultations, Topical fluoride treatment, Preventive dental education and oral hygiene instruction, Roentgenology (x-rays), Prophylaxis services (cleanings), Space maintainers, Dental sealant treatments.

No charge No copayment

Restorative Dentistry (Fillings)

Amalgam, composite resin, acrylic, synthetic or plastic restorations for the treatment of caries, Micro filled resin restorations which are noncosmetic, Replacement of a restoration, Use of pins in conjunction with a restoration, Sedative base and sedative fillings.

No charge No copayment

Oral Surgery

Extractions, including surgical extractions, Removal of impacted teeth, Biopsy of oral tissues, Alveolectomies, Excision of cysts and neoplasms, Treatment of palatal torus, Treatment of mandibular torus, Frenectomy, Incision and drainage of abscesses, Post-operative services, including exams, suture removal and treatment of complications, Root recovery (separate procedure).

No charge, except $5.00 Copayment

for the removal of impacted teeth for a bony impaction

$5.00 Copayment per root recovery

No copayment, except $10 copayment

for the removal of impacted teeth for a bony impaction

$10 copayment per root recovery

Endodontic Direct pulp capping, Pulpotomy and vital pulpotomy, Apexification filling with calcium hydroxide, Root amputation, Root canal therapy, including culture canal, Retreatment of previous root canal therapy, Apicoectomy, Vitality tests.

No charge, except $5.00 Copayment

per canal for root canal therapy or retreatment of previous root canal therapy

$5.00 Copayment per root for an apicoectomy

No copayment, except $10 copayment

per canal for root canal therapy or retreatment of previous root canal therapy

$10 copayment per root for an apicoectomy

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BENEFITS* SERVICES

COST TO SUBSCRIBER

(COPAYMENT) Income Categor A

Cost to Member (copayment)

Income Categories B & C

Periodontics Emergency treatment, including treatment for periodontal abscess and acute periodontitis, Periodontal scaling and root planing, and subgingival curettage, Gingivectomy, Osseous or muco-gingival surgery.

No charge, except $5.00 Copayment

per quadrant for osseous or muco-gingival surgery

No copayment, except $10 copayment

per quadrant for osseous or muco-gingival surgery

Crown and Fixed Bridge

Crowns, including those made of acrylic, acrylic with metal, porcelain, porcelain with metal, full metal, gold onlay or three quarter crown, and stainless steel, Related dowel pins, Fixed bridges, which are cast, porcelain baked with metal, or plastic processed to gold, Recementation of crowns, bridges, inlays and onlays, Cast post and core, including cast retention under crowns, Repair or replacement of crowns, abutments or pontics

No charge, except $5.00 Copayment

for porcelain crowns, porcelain fused to metal crowns, full metal crowns, and gold onlays or 3/4 crowns.

$5.00 Copayment per pontic.

The Copayment for any precious (noble) metals used in any crown or bridge will be the full cost of the actual precious metal used.

No copayment, except $10 copayment

for porcelain crowns, porcelain fused to metal crowns, full metal crowns, and gold onlays or 3/4 crowns.

$10 copayment per pontic.

The copayment for any precious (noble) metals used in any crown or bridge will be the full cost of the actual precious metal used.

Removable Prosthetics

Dentures, full maxillary, full mandibular, partial upper, partial lower, teeth, and clasps, Office or laboratory relines or rebases, Denture repair, Denture adjustment, Tissue conditioning, Denture duplication, Stayplates.

No charge, except: $5.00 Copayment

for a complete maxillary or mandibular denture

$5.00 Copayment for partial acrylic upper or lower denture with clasps

$5.00 Copayment for partial upper or lower denture with chrome cobalt alloy lingual or palatal bar, clasps and acrylic saddles

$5.00 Copayment for removable unilateral partial denture

$5.00 Copayment for reline of upper, lower or partial denture when performed by a Laboratory

$5.00 Copayment

No copayment, except: $10 copayment

for a complete maxillary or mandibular denture

$10 copayment for partial acrylic upper or lower denture with clasps

$10 copayment for partial upper or lower denture with chrome cobalt alloy lingual or palatal bar, clasps and acrylic saddles

$10 copayment for removable unilateral partial denture

$10 copayment for reline of upper, lower or partial denture when performed by a Laboratory

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BENEFITS* SERVICES

COST TO SUBSCRIBER

(COPAYMENT) Income Categor A

Cost to Member (copayment)

Income Categories B & C

for denture duplication

$10 copayment for denture duplication

Other Benefits

Local anesthetics, Oral sedatives when dispensed in a dental office by a practitioner acting within the scope of licensure, Nitrous oxide when dispensed in a dental office by a practitioner acting within the scope of licensure, Emergency treatment, palliative treatment, Coordination of benefits with Subscriber’s health plan in the event hospitalization or outpatient surgery setting is medically appropriate for dental services.

No Charge No Charge

Orthodontia Services

Not a Healthy Kids Santa Barbara covered benefit Services are provided to Subscribers under the age of 19 through the California Children’s Services Program (CCS) when condition meets the CCS program criteria

Not applicable Not applicable

Deductibles No deductibles will be charged for covered benefits

Lifetime Maximums

No lifetime maximum limits on benefits apply under this plan

* Benefits are provided if Premier determines them to be medically necessary.

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Benefits This section lists the dental benefits and services you are allowed to obtain through Premier when the services are necessary for your dental health consistent with professionally recognized standards of practice, subject to the exceptions and limitations listed here and in the Exclusions section of this CERTIFICATE. The HFP has increased copayments for applicable covered services for members who are in Income Categories B & C. This copayment increase does not apply to members in Income Category A. Please refer to the inside cover of this COI booklet to read more about the HFP Income Categories.

Diagnostic and Preventive Benefits Cost to Subscriber No Copayment Description Benefit includes:

Initial and periodic oral examinations Consultations, including specialist consultations Topical fluoride treatment Preventive dental education and oral hygiene instruction Roentgenology (x-rays) Prophylaxis services (cleanings) (once every six months) Dental sealant treatments Space Maintainers, including removable acrylic and fixed ban type

Limitations Roentgenology (x-rays) is limited as follows:

Bitewing x-rays in conjunction with periodic examinations are limited to one series of four films in any 6 consecutive month period. Isolated bitewing or periapical films are allowed on an emergency or episodic basis

Full mouth x-rays in conjunction with periodic examinations are limited to once every 24 consecutive months Panoramic film x-rays are limited to once every 24 consecutive months

Prophylaxis services (cleanings) are limited to two in a 12-month period (once every six months). Dental sealant treatments are limited to permanent first and second molars only.

Restorative Dentistry Cost to Subscriber No Copayment Description Restorations include:

Amalgam, composite resin, acrylic, synthetic or plastic restorations for the treatment of caries Micro filled resin restorations which are non-cosmetic. Replacement of a restoration Use of pins in conjunction with a restoration Sedative base and sedative fillings

Limitations Restorations are limited to the following:

For the treatment of caries, if the tooth can be restored with amalgam, composite resin, acrylic, synthetic or plastic restorations; any other restoration such as a crown or jacket is considered optional.

Composite resin or acrylic restorations in posterior teeth are optional. Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as recurrent caries or

fracture, and replacement is dentally necessary

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Oral Surgery Cost to Subscriber No Copayment, except: $5 or $10 Copayment for the removal of impacted teeth for a bony impaction (no Copayment for the removal of a soft tissue

impaction) $5 or $10 Copayment per root recovery Description Oral surgery includes:

Extractions, including surgical extractions Removal of impacted teeth Biopsy of oral tissues Alveolectomies Excision of cysts and neoplasms Treatment of palatal torus Treatment of mandibular torus Frenectomy Incision and drainage of abscesses Post-operative services, including exams, suture removal and treatment of complications Root recovery (separate procedure)

Limitation The surgical removal of impacted teeth is a covered benefit only when evidence of pathology exists.

Endodontic Cost to Subscriber No Copayment, except $5 or $10 Copayment per root canal therapy $5 or $10 Copayment per canal for retreatment of previous root canal $5 or $10 Copayment for an apicoectomy when performed as a separate procedure Description Endodonitcs benefits include:

Direct pulp capping Pulpotomy and vital pulpotomy Apexification filling with calcium hydroxide Root amputation Root canal therapy, including culture canal and limited retreatment of previous root canal therapy as specified below Apicoectomy Vitality tests

Limitations Root canal therapy, including culture canal, is limited as follows:

Retreatment of root canals is a covered benefit only if clinical or radiographic signs of abscess formation are present and/or the patient is experiencing symptoms.

Removal or retreatment of silver points, overfills, underfills, incomplete fills, or broken instruments lodged in a canal, in the absence of pathology, is not a covered benefit.

Periodontics Cost to Subscriber No Copayment, except $5 or $10 Copayment per quadrant for osseous or muco-gingival surgery Description Periodontics benefits include:

Emergency treatment, including treatment for periodontal abscess and acute periodontitis Periodontal scaling and root planing, and subgingival curettage Gingivectomy

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Osseous or muco-gingival surgery Limitation Periodontal scaling and root planing, and subgingival curettage are limited to five (5) quadrant treatments in any 12 consecutive months.

Crown and Fixed Bridge Cost to Subscriber No Copayment, except $5 or $10 Copayment for porcelain crowns, porcelain fused to metal crowns, full metal crowns, and gold onlays or 3/4 crowns. $5 or $10 Copayment per pontic. The Copayment for any precious (noble) metals used in any crown or bridge will be the full cost of the actual precious metal used. Description Crown and fixed bridge benefits include:

Crowns, including those made of acrylic, acrylic with metal, porcelain, porcelain with metal, full metal, gold onlay or three quarter crown, and stainless steel

Related dowel pins Fixed bridges, which are cast, porcelain baked with metal, or plastic processed to gold Recementation of crowns, bridges, inlays and onlays Cast post and core, including cast retention under crowns Repair or replacement of crowns, abutments or pontics

Limitation The crown benefit is limited as follows:

Replacement of each unit is limited to once every 36 consecutive months, except when the crown is no longer functional as determined by the Plan.

Only acrylic crowns and stainless steel crowns are a benefit for children under 12 years of age. If other types of crowns are chosen as an optional benefit for children under 12 years of age, the covered dental benefit level will be that of an acrylic crown.

Crowns will be covered only if there is not enough retentive quality left in the tooth to hold a filling. For example, if the buccal or lingual walls are either fractured or decayed to the extent that they will not hold a filling.

Veneers posterior to the second bicuspid are considered optional. An allowance will be made for a cast full crown. The fixed bridge benefit is limited as follows:

Fixed bridges will be used only when a partial cannot satisfactorily restore the case. If fixed bridges are used when a partial could satisfactorily restore the case, it is considered optional treatment.

A fixed bridge is covered when it is necessary to replace a missing permanent anterior tooth in a person 16 years of age or older and the patient’s oral health and general dental condition permits. For children under the age of 16, it is considered optional dental treatment. If performed on a Subscriber under the age of 16, the applicant must pay the difference in cost between the fixed bridge and a space maintainer.

Fixed bridges used to replace missing posterior teeth are considered optional when the abutment teeth are dentally sound and would be crowned only for the purpose of supporting a pontic.

Fixed bridges are optional when provided in connection with a partial denture on the same arch. Replacement of an existing fixed bridge is covered only when it cannot be made satisfactory by repair. The program allows up to five units of crown or bridgework per arch. Upon the sixth unit, the treatment is considered full mouth reconstruction, which is optional treatment.

Removable Prosthetics Cost to Subscriber No Copayment, except: $5 or $10 Copayment for a complete maxillary denture $5 or $10 Copayment for a complete mandibular denture $5 or $10 Copayment for partial acrylic upper or lower denture with clasps $5 or $10 Copayment for partial upper or lower denture with chrome cobalt alloy lingual or palatal bar, clasps and acrylic saddles $5 or $10 Copayment for removable unilateral partial denture $5 or $10 Copayment for reline of upper, lower or partial denture when performed by a Laboratory $5 or $10 Copayment for denture duplication

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Description The removable prosthetics benefit includes:

Dentures, full maxillary, full mandibular, partial upper, partial lower, teeth, and clasps Office or laboratory relines or rebases Denture repair Denture adjustment Tissue conditioning Denture duplication Stayplates

Limitations The removable prosthetics benefit is limited as follows:

Partial dentures will not be replaced within 36 consecutive months, unless: 1. It is necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible, or 2. The denture is unsatisfactory and cannot be made satisfactory.

The covered dental benefit for partial dentures will be limited to the charges for a cast chrome or acrylic denture if this would satisfactorily restore an arch. If a more elaborate or precision appliance is chosen by the patient and the dentist, and is not necessary to satisfactorily restore an arch, the patient will be responsible for all additional charges.

A removable partial denture is considered an adequate restoration of a case when teeth are missing on both sides of the dental arch. Other treatments of such cases are considered optional.

Full upper and/or lower dentures are not to be replaced within 36 consecutive months unless the existing denture is unsatisfactory and cannot be made satisfactory by reline or repair.

The covered dental benefit for complete dentures will be limited to the benefit level for a standard procedure. If a more personalized or specialized treatment is chosen by the patient and the dentist, the patient will be responsible for all additional charges.

Office or laboratory relines or rebases are limited to one (1) per arch in any 12 consecutive months. Tissue conditioning is limited to two per denture Implants are considered an optional benefit Stayplates are a benefit only when used as anterior space maintainers for children

Other Benefits Cost to Subscriber No Copayment Description Other dental benefits include:

Local anesthetics Oral sedatives when dispensed in a dental office by a practitioner acting within the scope of their licensure Nitrous oxide when dispensed in a dental office by a practitioner acting within the scope of their licensure Emergency treatment, palliative treatment

Coordination of benefits with Subscriber’s health plan in the event hospitalization or outpatient surgery setting is medically appropriate for dental services

Orthodontic Benefits Orthodontic treatment is not a benefit of this dental plan. However, orthodontic treatment may be provided by the California Children’s Services (CCS) program if the Subscriber meets the eligibility requirements for medically necessary orthodontia coverage under the CCS program. For more information about the CCS program, see “Coordination of Services” below.

Coordination of Services California Children’s Services (CCS) As part of the services provided through the Healthy Kids Santa Barbara, Subscribers needing specialized medical care may be eligible for services through the California Children’s Services (CCS) Program. CCS is a California medical program that treats children with certain physically handicapping conditions and who need specialized medical care. This program is available to all children in California whose families meet certain medical, financial and residential eligibility requirements. All children enrolled in Healthy Kids Santa Barbara are deemed to have met the financial eligibility requirements of the CCS Program. Services provided through the CCS Program are coordinated by the county CCS office.

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If a Subscriber’s primary care provider suspects or identifies a possible CCS eligible condition, he or she must refer the Subscriber to the local CCS program. Premier can assist with this referral. Premier will also make a referral to CCS when a primary care provider refers the Subscriber to a specialist or where there is an inpatient admission which appears to involve care for a CCS eligible condition. The CCS program, will determine if the Subscriber’s condition is eligible for CCS services. If the CCS program determines that the condition is a CCS eligible condition, the Subscriber will remain enrolled in Healthy Kids Santa Barbara. He or she will be referred to, and should receive treatment for the CCS eligible condition through, the specialized network of CCS providers and/or CCS approved specialty centers. These CCS providers and specialty centers are highly trained to treat CCS eligible conditions. CCS services must be received from CCS paneled providers. Payment for CCS eligible services obtained from non-CCS paneled providers will be the responsibility of the Subscriber’s legal guardian. Premier will continue to provide primary care, prevention services, and any other services that are not related to the CCS eligible condition, as described in this booklet. Premier will also work with the CCS program and providers to coordinate care provided by both the CCS program and Premier. If a condition is determined not to be eligible for CCS Program services, the Subscriber will continue to receive all medically necessary services from Premier. Although all children enrolled in Healthy Kids Santa Barbara are determined to be financially eligible for the CCS Program, the CCS office must verify residential status for each child in the CCS Program. If a Subscriber is referred to the CCS Program, the Subscriber’s legal guardian will be asked to complete a short application to verify residential status and ensure coordination of the Subscriber’s care after the referral has been made. Additional information about the CCS Program can be obtained by calling Premier’s Member Services toll-free at 1-888-584-5830 or by calling your local county CCS Program.

Excluded Benefits The following dental benefits are excluded under Premier: 1. Services which, in the opinion of the attending dentist, are not necessary to the Subscriber’s dental health. 2. Procedures, appliances, or restorations to correct congenital or developmental malformations are not covered benefits unless

specifically listed in the Benefits section above. 3. Cosmetic dental care. 4. General anesthesia or intravenous/conscious sedation unless specifically listed as a benefit or is given by a dentist for covered oral

surgery. 5. Experimental or investigational services, including any treatment, therapy, procedure or drug or drug usage, facility or facility

usage, equipment or equipment usage, device or device usage, or supply which is not recognized as being in accordance with generally accepted professional standards or for which the safety and efficacy have not been determined for use in the treatment for which the item or service in question is recommended or prescribed.

6. Services which were provided without cost to the Subscriber by State government or an agency thereof, or any municipality, county or other subdivisions.

7. Hospital charges of any kind. 8. Major surgery for fractures and dislocations. 9. Loss or theft of dentures or bridgework. 10. Dental expenses incurred in connection with any dental procedures started after termination of coverage or prior to the date the

Subscriber became eligible for such services. 11. Any service that is not specifically listed as a covered benefit. 12. Malignancies. 13. Dispensing of drugs not normally supplied in a dental office. 14. Additional treatment costs incurred because a dental procedure is unable to be performed in the dentist’s office due to the general

health and physical limitations of the Subscriber. 15. The cost of precious metals used in any form of dental benefits. 16. The surgical removal of implants. 17. Services of a pedodontist/pediatric dentist, except when the Subscriber is unable to be treated by his or her panel provider, or

treatment by a pedodontist/pediatric dentist is medically necessary, or his or her panel provider is a pedodontist/pediatric dentist. Note: There is a $5.00 Copayment for children under six years of age, who are unable to be treated by their panel provider and who have been referred to a pedodontist/pediatric dentist.

18. Dental Services that are received in an emergency care setting for conditions that are not emergencies if the subscriber reasonably should have known that an emergency care situation did not exist.

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Grievances and Appeals Process Our commitment to you is to ensure not only quality of care, but also quality in the treatment process. This quality of treatment extends from the professional services provided by Premier providers to the courtesy extended you by our telephone representatives.

If you have questions about the services you receive from a Premier provider, we recommend that you first discuss the matter with your provider. If you continue to have a concern regarding any service you received, call Premier’s Member Services at 1-888-584-5830 (TDD/TTY for the hearing impaired at 1-800-735-2929.

Grievances You may file a grievance with Premier Access Insurance Company at any time. You can obtain a copy of Premier’s Grievance Policy and Procedure by calling our Member Services number in the above paragraph. To begin the grievance process, you can call, write, in person, or fax Premier at: Premier Access Insurance Company, Inc., Complaint/Grievance Dept., P. O. Box: 255039, Sacramento, CA 95865-5039, telephone number: 888-584-5830, fax number: (916) 646-9000, e-mail at GrievanceDept@premierlife.com or website www.premierppo.com. A grievance form is attached to this Certificate as Attachment "A" and is available by calling Member Services at 1-888-584-5830. Staff will be available at Premier to assist Subscribers in completion of this form. Premier will acknowledge receipt of your grievance within five (5) days and will send you a decision letter within thirty (30) days. Premier’s grievance process is in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

General Information Coordination of Benefits This dental plan coverage is not designed to duplicate any dental benefits. Coverage provided under this program is secondary to all other coverage, except Denti-Cal. Benefits paid under this program are determined after benefits have been paid as a result of a member’s enrollment in any other dental care program. If dental services are eligible for reimbursement by insurance or covered under any other insurance, health care service plan, or dental care service plan, Premier shall provide services at the time of need, and the member or member’s legal guardian will cooperate to assure that Premier is reimbursed for such benefits. By enrolling in Premier each member agrees to complete and submit to Premier such consents, releases, assignments and any other document reasonably requested by Premier in order to assure and obtain reimbursement and to coordinate coverage with other dental plans or insurance policies. The payable benefits will be reduced when benefits are available to a member under such other plan or policy whether or not claim is made for the same. The fact that a member has double coverage under Premier will in no way reduce member’s obligation to make all required copayments. When a primary dental benefit plan is coordinating its benefits with one or more secondary dental benefits plans, it shall pay the maximum amount required by its contract with the enrollee or subscriber. A health care service plan covering dental services or a specialized health care service plan contract covering dental services, when acting as a secondary dental benefit plan, shall pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage, or the enrollee’s total out-of-pocket cost payable under the primary dental benefit plan for benefits covered under the secondary plan. Be sure to advise your provider of all programs under which you have coverage so that you will receive all benefits to which you are entitled. For further information, contact Premier’s Member Service department.

Third Party Recovery Process and Subscriber Responsibilities The Subscriber agrees that, if benefits of this Agreement are provided to treat an injury or illness caused by the wrongful act or omission of another person or third party, provided that the Subscriber is made whole for all other damages resulting from the wrongful act or omission before Premier is entitled to reimbursement, Subscriber shall:

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Reimburse Premier for the reasonable cost of services paid by Premier to the extent permitted by California Civil Code section 3040 immediately upon collection of damages by him or her, whether by action or law, settlement or otherwise; and

Fully cooperate with Premier’s effectuation of its lien rights for the reasonable value of services provided by Premier to the extent permitted under California Civil Code section 3040. Premier’s lien may be filed with the person whose act caused the injuries, his or her agent or the court.

Premier shall be entitled to payment, reimbursement, and subrogation in third party recoveries and Subscriber shall cooperate to fully and completely effectuate and protect the rights of Premier including prompt notification of a case involving possible recovery from a third party.

Non-Duplication of Benefits with Workers’ Compensation Pursuant to any Workers’ Compensation or Employer’s Liability Law or other legislation of similar purpose or import, a third party is responsible for all or part of the cost of dental services provided by Premier will provide the benefits of this Agreement at the time of need. The Subscriber will agree to provide Premier with a lien to the extent of the reasonable value of the services provided by Premier. The lien may be filed with the responsible third party, his or her agent, or the court. For purposes of this subsection, reasonable value will be determined to be the usual, customary, or reasonable charge for services in the geographic area where the services are rendered. By accepting coverage under this Agreement, Subscribers agree to cooperate in protecting the interest of Premier under this provision and to execute and to deliver to Premier or its nominee any and all assignments or other documents which may be necessary or proper to fully and completely effectuate and protect the rights of Premier or its nominee. Subscribers also agree to fully cooperate with Premier and not take any action that would prejudice the rights of Premier under this provision.

Coordination of Benefits By enrolling in Premier, each Subscriber agrees to complete and submit to Premier such consents, releases, assignments and any other document reasonably requested by Premier in order to assure and obtain reimbursement and to coordinate coverage with other dental benefit plans or insurance policies. The payable benefits will be reduced when benefits are available to a Subscriber under such other plan or policy whether or not claim is made for the same. The fact that a Subscriber has double coverage under Premier will in no way reduce Subscriber’s obligation to make all required Copayments.

Limitations of Other Coverage This dental coverage is not designed to duplicate any benefits to which Subscribers are entitled under government programs, including CHAMPUS, Medi-Cal or Workers’ Compensation. By executing an enrollment application, a Subscriber agrees to complete and submit to Premier such consents, releases, assignments, and other documents reasonably requested by Premier or order to obtain or assure CHAMPUS or Medi-Cal reimbursement or reimbursement under the Workers’ Compensation Law.

Provider Payment Premier compensates its Providers in a variety of ways. Typically, Your Provider is paid his or her usual and customary rate less a discounted amount. Premier Providers are always required by Premier to provide services in a quality manner in accordance with detailed regulatory and contractual requirements. These requirements help reduce overall costs by providing quality care which emphasizes preventive health care access and utilization of effective treatment methods.

Reimbursement Provisions – If You Receive a Bill Except for applicable Copayments, in the event a Subscriber must pay a provider for Covered Services, including Emergency Dental Services or Urgent Care Services, provided and is entitled to be reimbursed, the Subscriber must submit a copy of the bill or invoice showing (1) the date of service, (2) a description of the services provided, (3) the provider’s name, office location, and telephone number, and (4) amount paid. Written notice of a claim must be given to Premier within 30 days after the occurrence or commencement of any covered service or supply, or as soon thereafter as reasonably possible, but no later than 180 days from the date of service. Any appeals related to the adjudication of claims by Premier must be submitted no later than 180 days from the date of the original / first Explanation of Payments related to that claim. Claims submitted more than 180 days after the date of service will not be considered for payment. Appeals submitted 180 days after the date of the original / first Explanation of Payments will not be considered by Premier. All claims and appeals must be sent to Premier Access Insurance Company to: Attention: Claims Department, P.O. Box: 659010, Sacramento, CA 95865-9010, or alternatively, a Subscriber may access Premier’s e-mail account at info@premierlife.com to obtain instructions regarding the procedures to invoice Premier. Upon receipt of the required information, Premier will pay the reimbursement amount, less any applicable Copayments. If you have any questions regarding the reimbursement of Covered Services paid by a Subscriber, please contact Member Services at 888-584-5830 or access Premier’s internet site at www.premierppo.com.

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Notifying You of Changes in Premier Throughout the year we may send you updates about changes in Premier. This can include updates for the Provider Directory, handbook, and certificate of insurance. We will keep you informed and are available to answer any questions you may have. Call us toll-free 1-888-584-5830 if you have any questions about changes in Premier.

Privacy Practices Except as permitted by law, Subscriber information is not released without your or your authorized representative’s consent. Subscriber-identifiable information is shared only with your consent or as otherwise permitted by law. Premier maintains policies regarding the confidentiality of Subscriber-identifiable information, including policies related to access to dental records, protection of personal health information in all settings, and the use of data for quality measurement. We may collect, use, and share medical information when medically necessary or for other purposes as permitted by law (such as for quality review and measurement and research.) All of Premier’s employees and Providers are required to maintain the confidentiality of Subscriber information. This obligation is addressed in policies, procedures, and confidentiality agreements. All Providers with whom we contract are subject to our confidentiality requirements. In accordance with applicable law, you have the right to review your own medical information and you have the right to authorize the release of this information to others. A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED UPON REQUEST. To request a copy, please call Premier’s Member Services Department.

Organ and Tissue Donation Donating organs and tissues provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability. If you are interested in organ donation, please speak with your physician. Organ donation begins at the hospital when a patient is pronounced brain dead and identified as a potential organ donor. An organ procurement organization will become involved to coordinate the activities. The Department of Health and Human Services' Internet website (http://www.organdonor.gov) has additional information on donating your organs and tissues.

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ATTACHMENT A

Grievance Form

Premier Access Insurance Company (“Premier”) takes very seriously the problems raised by its enrollees and endeavors to reach solutions acceptable to all concerned. To facilitate these efforts, please provide us with the following information. If you need assistance in completing this form, please contact any Premier Member Services Representative at 1-888-584-5830. Name: Address: City: State: ZIP Code: Telephone: ( ) Nature of Grievance -- Please be as specific as possible and include the date(s) of service and name(s) of provider of service. Please use additional sheets if more space is needed.

Please mail or email this form to:

Premier Access Insurance Company

Attention: Grievance Department P. O. BOX 255039

Sacramento, CA 95865-5039

GrievanceDept@PremierLife.com

DO NOT WRITE BELOW THIS LINE FOR COMPANY USE ONLY

GRIEVANCE RECEIVED BY: _______________________________________________________________________________ DATE RECEIVED: _________________________________________________________________________________________ TIME RECEIVED: _________________________________________________________________________________________ GRIEVANCE LOG COMPLETED BY: ________________________________________________________________________

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Formulario de Queja o Reclamación por Agravio

La Compañía de Seguros Access Dental (el plan “Premier”) toma muy en serio los problemas que tienen sus Personas Afiliadas, y se esfuerza para lograr soluciones aceptables para todas las partes involucradas. A fin de facilitar estos esfuerzos, por favor, proporciónenos la siguiente información. Si necesita ayuda para completar este formulario, por favor, comuníquese con cualquier Representante del Servicio de Atención a las Personas Afiliadas al plan Premier,al 1-888-715-0760, ó con un(a) representante de cualquier Proveedor del plan Premier. Nombre: Domicilio: Ciudad: _________________________ Estado: Código Postal: Teléfono: (_____) Índole de la Queja – Por favor sea lo más específico(a) posible e incluya la(s) fecha(s) de servicio y el/los nombre(s) del/de los proveedor(es) del servicio. Por favor, use hojas adicionales, si necesita más espacio.

Por favor envíe este formulario por correo a:

Premier Access Insurance Company Attention: Grievance Department

P. O. BOX 255039 Sacramento, CA 95865-5039

GrievanceDept@PremierLife.com

NO ESCRIBA DEBAJO DE ESTA LÍNEA SOLAMENTE PARA USO DE LA COMPAÑÍA

GRIEVANCE BY: DATE RECEIVED: TIME RECEIVED: GRIEVANCE LOG COMPLETED BY: