Common use of Coordination of Benefits Clause in Contracts

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits If you have medical coverage under any other Health Benefits Plan, other public or private group programs, or pre-paid plan any other health insurance policy, the benefits provided or insurance plan designed payable hereunder shall be reduced to fully integrate with the extent that benefits are available to you under such other plans. If this plan is the “primary” plan, Delta Dental will policy or program. The rules establishing the order of benefit determination between this Agreement and any other plan covering a Member not reduce Benefits. If this plan on COBRA continuation on whose behalf a claim is the “secondary” made are as follows:  Employee/Dependent Rule  The plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee covers you as an employee is primary over a plan covering the Enrollee employee, pays first.  The plan, which covers you as a dependent. 2) Dependent, pays second.  Birthday Rule for Dependent children of parents who are not separated or divorced  The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiaryplan, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of which covers the parent whose birthday falls earlier in a year are determined before those of the plan of year, pays first. The plan, which covers the parent whose birthday falls later in that the year; but b) if , pays second. The birthday order is determined by the month and the day of birth, not the year of birth.  If both parents have the same birthdaymonth and day of birth, the benefits of plan that Covered the parent longer, will pay claims first. The plan covering one parent longer are determined before those of which covered the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender time pays second.  Dependent children of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, parents  The plan of the parent decreed by a court of law to have responsibility for medical coverage pays first.  In the absence of a court order: o The plan covering the Enrollee as a dependent of the parent with legal physical custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the child pays first. o The plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent Spouse of the parent with such financial responsibility will be determined before physical custody (i.e., the benefits stepparent) pays second. o The plan of any other policy covering the parent not having physical custody of the child pays third.  Active/Inactive Employee  The plan, which covers you as an active employee (or Dependent of an active employee), pays first.  The plan, which covers you as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither retired or laid-off nor retired are determined before those employee (or Dependent of a plan covering that insured person as a retired or laid-off or retired employee), pays second. The same would hold true if an insured person is  Longer/Shorter Employment  In the case where you are the Subscriber under more than one group health insurance policy, then the plan that has Covered you for a dependent longer period of time will pay first. A change of insurance carrier by the group employer does not constitute the start of a person new plan.  No Coordination Provision  In spite of the rules listed above, the plan that has no provision regarding coordination of benefits will pay first.  If you are covered as under a retiree motor vehicle or an employeehomeowner’s insurance policy which provides benefits for medical expenses resulting from a motor vehicle accident or accident in your own home, you shall not be entitled to benefits under this Agreement for injuries arising out of such accident to the extent they are covered by the motor vehicle or home owner’s insurance policy. If we have provided such benefits, we shall have the right to recover any benefits we have provided from you or from the motor vehicle or homeowner’s insurance to the extent they are available under the motor vehicle or homeowner’s insurance policy. In no event shall the Covered Benefits received under this Agreement and all other plan does not have plans combined exceed the total reasonable actual expenses for the services provided under this rule, and if, as a result, the plans do not agree on the order Agreement. For purposes of coordination of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal  We may release, request, or state law also is covered under another planobtain claim information from any individual or organization. In addition, the following will be the order of benefit determination. a) First, the any Member claiming benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not from us shall furnish us with any information which we may require.  We have the rule described aboveright, and ifif we make overpayments because of your failure to report other coverage or any other reason, as a resultto recover such excess payment from any individual to whom, the plans do not agree on the order of benefitsor for whom, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cansuch payments were made.  We will not be made obligated to pay for non-Covered Services or Covered Benefits not obtained in accordance compliance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only planour policies and procedures.

Coordination of Benefits. i. Delta Dental coordinates A. In the dental event that any Enrollee hereunder is entitled to benefits under another benefit program than that described in this Contract, the following Coordination of Benefits provision shall determine the sequence and the extent of payment of the expense for benefits provided under this dental plan with your benefits under Contract. Such other benefit program may include any other Company-sponsored program including any group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” Blue Cross/Blue Shield plan, Delta Dental will Program or other group prepayment program, group coverage through Health Maintenance Organization and other group practice and individual practice plans, or any Company-sponsored or association or other entity-sponsored insurance program in which the Enrollee is enrolled. Blanket student accident insurance shall not reduce Benefitsbe coordinated. If this plan Health programs of any kind shall not be coordinated when the Employee or other individual pays the entire cost thereof or when the program provides any periodic payment or any other payment by the program to Enrollees which is not related to the “secondary” plan, Delta Dental may reduce Benefits so that value of the total benefits paid Service provided to each Enrollee on account of illness or provided by all plans do not exceed 100% of total allowable expenseinjury. ii. How does Delta Dental determine B. When a claimant is covered under another benefit program to which Plan is this Article applies, the “primary” plan?first of the following rules which applies will be followed to establish the order of determining liability of this or any other programs: 1) . The plan program covering the Enrollee as an employee is Employee or member will be considered primary over a plan covering and will determine its benefits before the program which covers the Enrollee as a dependentDependent. The primary program may be any of the programs described as an “other benefit program” under Paragraph A of this Article. 2) The plan . If the claimant is a covered dependent child of different persons called parents, the program covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined the Calendar Year will be considered primary and will determine its benefits before those of the plan program covering the dependent child of the parent whose birthday falls later in that year; but b) if the Calendar Year except for dependent children of separated or divorced parents to which the rules in Subparagraph 3 of this Paragraph apply. If both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan program covering the other parent for a the longest period will determine its benefits before the program covering the parent for the shorter period of time. c) However, if period. If the other plan program does not have the birthday rule described abovein this subparagraph, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefitsEmployee, the rule in of the other plan determines will determine the order of benefits. 4) In 3. When the case of claimant is a covered dependent child of legally divorced or separated or divorced parents, the plan program covering the Enrollee as a parent having custody of the dependent child will be considered primary and will determine its benefits first; then the program of the spouse of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over dependent child, and finally, the plan covering the Enrollee as a dependent program of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent not having custody of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If . However, if the specific terms of a court decree order state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the dependent child, that program will be considered primary and its benefits will be determined first. The prior sentence shall not apply with respect to any period during which any benefits are actually paid or provided before a program has actual knowledge of the plans court order. 4. The program covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person Enrollee as an employee who is neither laid-off nor retired are determined Employee or as a Dependent of an Employee will determine its benefits before those of a plan covering that insured person one which covers the Enrollee as a laid-off or retired employee. The same would hold true if an insured person is a dependent Employee or as the Dependent of a person covered as a retiree or an employeesuch person. If the other plan does not have this rulea rule concerning laid-off or retired Employee, and if, as a resultresult each plan determines its benefits after the other, then the provisions of this subparagraph shall not apply. 5. In situations not described in Subparagraphs 1, 2, 3 and 4 of this Paragraph, the plans do not agree on program under which the order Enrollee has been enrolled for the longest period of benefits, this rule 6) is ignoredtime will determine its benefits first. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) 6. If the other plan program does not have contain provisions establishing the rule described above, and if, as a result, the plans do not agree on the same order of determining liability for benefits or is one which is “excess” or always “secondary”, Delta Dental shall determine and pay its benefits in the following manner. If Delta Dental should be the first to determine its benefits, it shall pay without regard to coverage under the other program in accordance with Paragraph C of this rule 7) is ignored. 8) Article. If none of Delta Dental should not have been the above rules determines the order of first to determine its benefits, it shall nevertheless, pay in accordance with Paragraph C of this Article but the amount of benefits payable shall be determined in accordance with Paragraph D of this Article as if Delta Dental were not the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot first to determine its benefits. If payment is to be made in accordance with Paragraph D of this Article, such payment shall be the above for Pediatric Benefitslimit of the liability of Delta Dental. If the other program does not provide the information needed by Delta Dental to determine its benefits within thirty (30) days after it is requested to do so, Delta Dental shall assume that the benefits of a plan that the other program are identical to its own, and shall pay its benefits accordingly. However, Delta Dental shall adjust any payments it makes based on such assumption whenever information becomes available as to actual benefits of the other plan. C. When Delta Dental is a medical plan covering dental as a benefit the first to determine its benefits, benefits hereunder will be primary paid without regard to coverage under any other program. D. When Delta Dental is not the first to determine its benefits, and there are remaining expenses of the type allowable hereunder, Delta Dental shall pay only the amount by which its benefits under this Contract exceed the amount of benefits payable under the other program or the amount of such remaining expenses, whichever is less. In no event, shall Delta Dental pay more than the remaining Dentist charges after the first plan pays which would be allowable for Maximum Plan Allowance calculations or the Allowed Amount whichever is less. E. For the purpose of determining the applicability and implementing the terms of this provision of this program or any provision of similar purpose of any other program, Delta Dental may, without the consent of or notice to any person, except for those situations where consent or notice is required by Article 25 of the New York General Business Law, release to or obtain from any insurance company or other organization or person any information, with respect to any person demand or make payment which it deems to be necessary for such purposes, and in so acting, Delta Dental shall be free from any liability that might arise in relation to such action. Any person claiming benefits under this program shall furnish to Delta Dental such information as may be necessary to implement this provision. Notwithstanding the foregoing, to the extent that a dental only planHIPAA Business Associate Addendum between Delta Dental and Company is in effect, and applicable to the disclosure, any disclosure of information by Delta Dental shall be in accordance with that Business Associate Addendum.

Coordination of Benefits. i. Delta The Group Medical and Dental coordinates Plans shall include the dental Benefits under this dental plan with your following coordination of benefits provisions: 1) If a covered employee or family member is eligible to receive benefits under any another group plan (i.e., a plan that is not administered by Delta Air Lines, Inc.), benefits from the Plan administered by Delta Airlines, Inc. will be coordinated with the benefits from the other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed more than 100% of total the “allowable expenses” incurred during a calendar year will be paid jointly by the plans. An “allowable expense” is any necessary, reasonable and customary item of expense covered in full or in part by any one of the group plans involved. A “plan” is considered to be any group insurance coverage or other arrangement for coverage of individuals in a group (including Medicaid and Medicare) which provides medical or dental benefits or services on an insured or uninsured basis. The Group Medical and Dental Plans referenced herein will be coordinated with any national health insurance plan(s). ii. How does Delta Dental determine which Plan is the “primary” plan? 12) The plan covering rules below establish the Enrollee order in which benefits will be determined: a) The benefits of a Plan which covers the person for whom claim is made other than as an employee is primary over a plan covering the Enrollee dependent will be determined before a Plan which covers that person as a dependent. 2b) The plan covering benefits of a Plan which covers the Enrollee as an employee person for whom claim is primary over a plan covering the insured person made as a dependent; except dependent of a person whose day of birth occurs first in a calendar year will be determined before a Plan which covers that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured a person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent whose day of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls birth occurs later in that year; but bexcept that: (a) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan Plan does not have the birthday this rule, its alternate rule described above, but instead has a rule based on the gender of the parent, will govern; and if, as a result, the plans do not agree on the order of benefits, the rule (b) in the other plan determines the order of benefits. 4) In the case of a dependent child of legally divorced or separated or divorced parents, the plan covering rules in subparagraph c. will apply. c) If there is a court decree which establishes financial responsibility for medical, dental or other health care of the Enrollee child, the benefits of the Plan which covers the child as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) so responsible will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the determined before any other plan; otherwise: (1) The benefits of a plan covering Plan which covers the child as a dependent of the parent with such financial responsibility custody will be determined before the benefits of any other policy covering a Plan which covers the child as a dependent childof a stepparent or a parent without custody. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6(2) The benefits of a plan covering an insured person Plan which covers the child as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered stepparent will be determined before a plan which covers the child as a retiree or an employeedependent of the parent without custody. If In any case, upon request by the other plan does not have this ruleparent with custody of the child, and if, as a result, payment will be made directly to the plans provider of care for medical expenses incurred for the child. d) When the above rules do not agree on establish the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) Firstorder, the benefits of a plan covering Plan which has covered the insured person for whom claim is made for the longer period of time will be determined before a Plan which has covered the person for the shorter period of time; except that: (1) The benefits of a Plan which covers the person as a laid off or retired employee, or his dependent, will be determined after a Plan which covers the person as an employee (employee, other than a laid off or as that insured person’s retired employee, or his dependent). b) Second, the benefits under the continuation coverage. c(2) If the other plan Plan does not have the rule described abovein subparagraph d. (1) which results in each Plan determining its benefits after the other, and if, as a result, the plans do then subparagraph d. (1) will not agree on the order of benefits, this rule 7) is ignoredapply. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

Coordination of Benefits. i. 6.1 If a group insurance policy or any other group health Benefits plan, including another Delta Dental coordinates plan, entitles a person to receive or be reimbursed for the cost of dental services, which are also Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If plan, and if this plan is the “primary” planunder the rules described below, Delta Dental will provide Benefits as if the other plan did not reduce Benefitsexist. If the other plan is “primary” under these rules, then Delta Dental will coordinate Benefits under this plan with the primary plan in accordance with California law (California Health and Safety Code 1374.19 (2007). 6.2 If the other plan mainly covers services or expenses other than dental care, this plan is the “secondaryprimary.” planOtherwise, Delta Dental may reduce Benefits so that will use the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental following rules to determine which Plan plan is the “primary” plan?”: 1(a) The plan covering that covers the Enrollee person as an employee other than a Dependent is primary over a the plan covering that covers the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if Dependent, with the insured following exception: If the person is also a Medicare beneficiary, Beneficiary and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a(i) secondary to the plan covering the insured person as a dependentDependent; and b(ii) primary to the plan covering the insured person as other than a dependent Dependent (e.g. for example, a retired employee), then the benefits Benefits of the plan covering the insured person as a dependent Dependent are determined before those the Benefits of the plan covering that insured the person as other than a dependentDependent. 3(b) Except as stated in paragraph 4), when this The plan and another plan cover the same which covers a child as a dependent Dependent of different persons, called parents: a) the benefits of the plan of the a parent whose birthday falls occurs earlier in a calendar year are determined before those of is primary over the plan which covers a child as a Dependent of the a parent whose birthday falls occurs later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent a calendar year (except for a shorter period of timeDependent child whose parents are separated or divorced as described in (c) below). (c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent Dependent child of whose parents are legally separated or divorced parentsdivorced: (i) If the parent with custody has not remarried, the plan covering that covers the Enrollee child as a dependent Dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be is primary over the plan covering which covers the Enrollee child as a dependent Dependent of the parent without legal custody. . (ii) If the parent with custody has remarried, the plan which covers the child as a Dependent of the parent with custody is primary over the plan which covers the child as a Dependent of the step-parent, and the plan which covers the child as a Dependent of the step-parent is primary over the policy or plan which covers the child as a Dependent of the parent without custody. (iii) If there is a court decree establishing that establishes financial responsibility for the health care expenses with respect to the childdental services which are Benefits under this plan, then notwithstanding (i) and (ii), the benefits of a plan covering which covers the child as a dependent Dependent of the parent with such financial responsibility will be determined before the benefits of is primary over any other policy covering plan which covers the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) 6.3 The benefits Benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured employee (or Dependent of such person) shall be determined after the Benefits of any other plan covering such person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) 6.4 If an insured a person whose coverage is provided under a right of continuation pursuant to federal or state law also requiring continuation is covered under another more than one plan, the following will Benefits order shall be the order of benefit determination.determined as follows: (a) First, The Benefits of the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent)Dependent shall be primary. (b) Second, the benefits The Benefits under the continuation coveragecoverage shall be secondary. c) 6.5 If the other primary plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made determined by the rules described in accordance with the above for Pediatric Benefitsthis Article 6, the benefits of a plan that has covered the person longer shall be primary. 6.6 An Enrollee will provide Delta Dental with any information about the person that is a medical plan covering dental as a benefit needed to administer this Article, and Delta Dental may release any information to or obtain any information from any insurance company or other organization in order to coordinate the Benefits of an Enrollee. Delta Dental in its sole discretion will determine whether any reimbursement is warranted to an insurance company or other organization under this provision, and it is agreed that any such reimbursement paid by Delta Dental will be primary Benefits under this Contract. Delta Dental has the right to recover the value of any Benefits provided by Delta Dental which exceed its obligations under the terms of this provision from a dental only planDelta Dental Dentist, Enrollee, insurance company or other organization, as Delta Dental chooses.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will shall be primary to a dental only plan.

Coordination of Benefits. i. Delta Dental coordinates the dental 9.01 Benefits under this dental plan Certificate will be coordinated with your all group health policies and/or other HMO benefits available to the Member under any other group policy or pre-paid plan certificate that also has a coordination of benefits provision. The priority of responsibility under the coordinating insurance policies or insurance plan designed to fully integrate with other planscertificates will be determined in the following manner as prescribed under Act No. If this plan is 64 of the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% Public Acts of total allowable expense.1984: ii. How does Delta Dental determine which Plan is the “primary” plan? 1(a) The plan covering benefits of a policy or certificate that covers the Enrollee as an employee person on whose expense the claim is primary over a plan covering the Enrollee based other than as a dependent. 2) The plan covering Dependent, shall be determined before the Enrollee as an employee is primary over benefits of a plan covering policy or certificate which covers the insured person as a dependent; except Dependent. (b) Except as otherwise provided in subsection (c), if two (2) policies or certificates cover a person on whose expenses the claim is based as a Dependent, the benefits of the policy or certificate of the person whose birthday anniversary occurs earlier in the calendar year shall be determined before the benefits of the policy or certificate of the person whose birthday anniversary occurs later in the calendar year. If the birthday anniversaries are identical, the benefits of a policy or certificate that has covered the person on whose expenses the claim is based for the longer period of time shall be determined before the benefits of a policy or certificate that has covered the person for the shorter period of time. However, if either policy or certificate is lawfully issued in another state and does not have the insured person is also a Medicare beneficiarycoordination of benefits procedure regarding Dependents based on birthday anniversaries as provided in this subsection, and as a result of each policy or certificate determines its benefits after the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthdayother, the coordination of benefits of procedure set forth in the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan policy or certificate that does not have the birthday rule described above, but instead has a rule coordination of benefits procedure based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines birthday anniversaries shall determine the order of benefits. 4(c) In the case of a dependent person for whom claim is made as a Dependent minor child, benefits shall be determined according to the following: i. Except as provided in paragraph iii. below, if the parents of the minor child of are legally separated or divorced parentsdivorced, the plan covering the Enrollee as a dependent of and the parent with legal custody of the child has not remarried, the benefits of the policy or certificate that covers the minor child as a dependent Dependent of the custodial parent’s spouse (i.e. step-parent) will parent shall be primary over determined before the plan covering benefits of a policy or certificate that covers the Enrollee minor child as a dependent Dependent of the non-custodial parent. ii. Except as provided in paragraph iii. below, if the parents of the minor child are divorced, and the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the childcustody has remarried, the benefits of a plan covering policy or certificate that covers the minor child as a dependent Dependent of the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the spouse of the custodial parent, and the benefits of a policy or certificate that covers the minor child as a Dependent of the spouse of the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the non- custodial parent. iii. If the parents of the minor child are divorced, and the decree of divorce places financial responsibility for the medical, dental, or other health care expenses of the minor child upon, either the custodial or the non-custodial parent, the benefits of the policy or certificate that covers the minor child as a Dependent of the parent with such financial responsibility will shall be determined before the benefits of any other policy covering or certificate that covers the minor child as a dependent childDependent. 59.02 If Section 9.01 (a), (b) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the and (c) above do not establish an order of benefit determination rules outlined determination, the benefits of a policy or certificate in paragraph 3).connection with a group disability benefit plan that group disability plan has covered the person on whose expenses the claim is based for the longer period of time shall be determined before the benefits of a policy or certificate that has covered the person for the shorter period of time, subject to the following: 6(a) The benefits of a plan policy or certificate covering an insured the person as an employee who on whose expenses the claim is neither laid-off nor retired are determined before those of a plan covering that insured person based as a laid-off or retired employee. The same would hold true if an insured person is employee or a dependent Dependent of a laid-off or retired employee shall be determined after the benefits of any other policy or certificate covering the person covered other than as a retiree laid-off or an retired employee or Dependent of a laid-off or retired employee. If the other plan . (b) Subsection (a) shall not apply if either policy or certificate is lawfully issued in another state and does not have this rule, and ifa provision regarding laid-off or retired employees and, as a result, each policy or certificate determines its benefits after the plans do not agree on the order of benefits, this rule 6) is ignoredother. 7) If an insured person whose coverage 9.03 Benefits under this Certificate shall not be reduced or otherwise limited because of the existence of another non-group contract that is provided under issued as a right hospital indemnity, surgical indemnity, specified disease, or other policy of continuation pursuant to federal or state law also is covered under another plandisability policies as defined in Section 3400 of the Insurance Code of 1956, Act 218 of the following will be Public Acts of 1956, being Section 500.3400 of the order of benefit determinationMichigan Compiled Laws. a) First, the 9.04 Health care benefits and services rendered as a result of a plan covering motor vehicle accident are not covered to the insured person as an employee (or as that insured person’s dependent)extent there is coverage under any other policy. b) Second, 9.05 The Plan is not required to pay claims or coordinate benefits for services that are not provided or authorized by the benefits Plan and that are not Authorized Benefits and Services under the continuation coveragethis Certificate. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

Coordination of Benefits. i. Delta Dental coordinates 12.1 The Plan will coordinate benefits with any other health plan (as defined below) covering a Member which allows for coordination of benefits. The Employer Group and Members agree to provide the dental Plan with such information and assistance as the Plan may require to enable it to coordinate benefits. 12.2 The rules establishing the order of benefit determination between this Agreement and any other health plan covering the Member on whose behalf a claim is made are set forth below. None of these rules will serve as a barrier to the Member’s first receiving Benefits under this dental plan with your benefits under Agreement from the Plan. Further, in no event shall a Member be required, as a result of these rules, to pay any amount other than as required by this Agreement for any Benefit. 12.3 The term “health plan” as used in this Agreement is defined to include any health care service plan, nonprofit hospital service plan, insurer, group practice, individual practice or other prepayment plan, employee benefit plan, employer organization plan, union welfare plan, labor-management trustee plan, and any other group governmental or pre-paid plan private program which provides or insurance plan designed arranges for the provision of, or pays, reimburses, or indemnifies for the cost of, any health care services, whether pursuant to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid statutory requirement or provided by all plans do not exceed 100% of total allowable expenseprovision or otherwise. ii. How 12.4 If another health plan does Delta Dental determine not provide for coordination of benefits, the Plan shall always have primary responsibility for the provision of Benefits covered by this Agreement. 12.5 For those health plans which Plan provide for coordination of benefits, the following rules establishing the order of benefits determination shall apply: 12.5.1 The benefits of a health plan which covers the person on whose expenses claim is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee based other than as a dependent. 2) The Dependent shall be determined before the benefits of a health plan covering the Enrollee as an employee is primary over a plan covering the insured which covers such person as a dependent; Dependent, except that if the insured person is also a Medicare beneficiary, beneficiary and as a result of the rule rules established by Title XVIII of for the Social Security Act Medicare Program and implementing regulations, Medicare is: (a) secondary to the health plan covering the insured person as a dependent; and and (b) primary to the health plan covering the insured person as other than a dependent Dependent (e.g. a e.g., retired employee), then the benefits of the health plan covering the insured person as a dependent Dependent are determined before those of the health plan covering that insured person as other than a dependentDependent. 3) 12.5.2 Except as stated in paragraph 4), when this plan and another plan cover the same child for cases of a person for whom a claim is made as a dependent of different persons, called parents: a) the benefits of the plan of the parent Dependent child whose birthday falls earlier in a year parents are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthdayseparated or divorced, the benefits of a health plan which covers the plan covering one parent longer are person on whose expenses claim is based as a Dependent of a person whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be determined before those the benefits of the a health plan covering the other parent for which covers such person as a shorter period Dependent of time. c) Howevera person whose date of birth, if the other excluding year of birth, occurs later in a calendar year. If either health plan does not have the birthday rule described aboveprovision of this Section regarding Dependents, but instead has a rule based on which results either in each health plan determining its benefits before the gender other or in each health plan determining its benefits after the other, the provisions of the parentthis Section shall not apply, and if, as a result, the plans do not agree on the order of benefits, the rule set forth in the other health plan determines which does not have the provisions of this Section shall determine the order of benefits. 4) 12.5.3 In the case of a dependent person for whom claim is made as a Dependent child of legally whose parents are separated or divorced parentsand the parent with custody of the child has not remarried, the benefits of a health plan covering which covers the Enrollee child as a dependent Dependent of the parent with legal custody or of the child shall be determined before the benefits of a health plan which covers the child as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent Dependent of the parent without legal custody. If . 12.5.4 In the case of a person for whom claim is made as a Dependent child whose parents are divorced and the parent with custody of the child has remarried, the benefits of a health plan which covers the child as a Dependent of the parent with custody shall be determined before the benefits of a health plan which covers that child as a Dependent of the stepparent, and the benefits of a health plan which covers the child as a Dependent of the stepparent shall be determined before the benefits of a health plan which covers the child as a Dependent of the parent without custody. 12.5.5 In the case of a person for whom claim is made as a Dependent child whose parents are separated or divorced, where there is a court decree establishing which would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to the child, then, notwithstanding Sections 12.5.3 and 12.5.4, above, the benefits of a health plan covering which covers the child as a dependent Dependent of the parent with such financial responsibility will shall be determined before the benefits of any other policy covering health plan which covers the child as a dependent Dependent child. 5) 12.5.6 If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of plan does not have a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a provision regarding laid-off or retired employee. The same would hold true if an insured person is employees, which results in each health plan determining its benefits after the other, then the rule under Section 12.5.5 shall not apply; 12.5.7 If a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another health plan, the following will shall be the order of benefit determination. : (a) Firstfirst, the benefits of a health plan covering the insured person as an employee (employee, member, or subscriber, or as that insured person’s dependent). persons’ Dependent; and (b) Secondsecond, the benefits under the continuation coverage. c) . If the other health plan does not have the rule rules described above, and if, as a result, the health plans do not agree on the order of benefits, the rule under this rule 7) is Section shall be ignored. 8) If none of the above . 12.5.8 When rules determines the 12.5.1 through 12.5.7 do not establish an order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefitsbenefit determination, the benefits of a health plan that which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a medical health plan covering dental as a benefit will be primary to a dental only plan.which has covered such person the shorter period of time:

Coordination of Benefits. i. Delta Dental coordinates the dental 9.01 Benefits under this dental plan Certificate will be coordinated with your all group health policies and/or other HMO benefits available to the Member under any other group policy or pre-paid plan certificate that also has a coordination of benefits provision. The priority of responsibility under the coordinating insurance policies or insurance plan designed to fully integrate with other planscertificates will be determined in the following manner as prescribed under Act No. If this plan is 64 of the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% Public Acts of total allowable expense.1984: ii. How does Delta Dental determine which Plan is the “primary” plan? 1(a) The plan covering benefits of a policy or certificate that covers the Enrollee as an employee person on whose expense the claim is primary over a plan covering the Enrollee based other than as a dependent. 2) The plan covering Dependent, shall be determined before the Enrollee as an employee is primary over benefits of a plan covering policy or certificate which covers the insured person as a dependent; except Dependent. (b) Except as otherwise provided in subsection (c), if two (2) policies or certificates cover a person on whose expenses the claim is based as a Dependent, the benefits of the policy or certificate of the person whose birthday anniversary occurs earlier in the calendar year shall be determined before the benefits of the policy or certificate of the person whose birthday anniversary occurs later in the calendar year. If the birthday anniversaries are identical, the benefits of a policy or certificate that has covered the person on whose expenses the claim is based for the longer period of time shall be determined before the benefits of a policy or certificate that has covered the person for the shorter period of time. However, if either policy or certificate is lawfully issued in another state and does not have the insured person is also a Medicare beneficiarycoordination of benefits procedure regarding Dependents based on birthday anniversaries as provided in this subsection, and as a result of each policy or certificate determines its benefits after the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthdayother, the coordination of benefits of procedure set forth in the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan policy or certificate that does not have the birthday rule described above, but instead has a rule coordination of benefits procedure based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines birthday anniversaries shall determine the order of benefits. 4(c) In the case of a dependent person for whom claim is made as a Dependent minor child, benefits shall be determined according to the following: i. Except as provided in paragraph iii. below, if the parents of the minor child of are legally separated or divorced parentsdivorced, the plan covering the Enrollee as a dependent of and the parent with legal custody of the child has not remarried, the benefits of the policy or certificate that covers the minor child as a dependent Dependent of the custodial parent’s spouse (i.e. step-parent) will parent shall be primary over determined before the plan covering benefits of a policy or certificate that covers the Enrollee minor child as a dependent Dependent of the non-custodial parent. ii. Except as provided in paragraph iii. below, if the parents of the minor child are divorced, and the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the childcustody has remarried, the benefits of a plan covering policy or certificate that covers the minor child as a dependent Dependent of the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the spouse of the custodial parent, and the benefits of a policy or certificate that covers the minor child as a Dependent of the spouse of the custodial parent shall be determined before the benefits of a policy or certificate that covers the minor child as a Dependent of the non-custodial parent. iii. If the parents of the minor child are divorced, and the decree of divorce places financial responsibility for the medical, dental, or other health care expenses of the minor child upon, either the custodial or the non-custodial parent, the benefits of the policy or certificate that covers the minor child as a Dependent of the parent with such financial responsibility will shall be determined before the benefits of any other policy covering or certificate that covers the minor child as a dependent childDependent. 59.02 If Section 9.01 (a), (b) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the and (c) above do not establish an order of benefit determination rules outlined determination, the benefits of a policy or certificate in paragraph 3).connection with a group disability benefit plan that group disability plan has covered the person on whose expenses the claim is based for the longer period of time shall be determined before the benefits of a policy or certificate that has covered the person for the shorter period of time, subject to the following: 6(a) The benefits of a plan policy or certificate covering an insured the person as an employee who on whose expenses the claim is neither laid-off nor retired are determined before those of a plan covering that insured person based as a laid-off or retired employee. The same would hold true if an insured person is employee or a dependent Dependent of a laid-off or retired employee shall be determined after the benefits of any other policy or certificate covering the person covered other than as a retiree laid-off or an retired employee or Dependent of a laid-off or retired employee. If the other plan . (b) Subsection (a) shall not apply if either policy or certificate is lawfully issued in another state and does not have this rule, and ifa provision regarding laid-off or retired employees and, as a result, each policy or certificate determines its benefits after the plans do not agree on the order of benefits, this rule 6) is ignoredother. 7) If an insured person whose coverage 9.03 Benefits under this Certificate shall not be reduced or otherwise limited because of the existence of another non-group contract that is provided under issued as a right hospital indemnity, surgical indemnity, specified disease, or other policy of continuation pursuant to federal or state law also is covered under another plandisability policies as defined in Section 3400 of the Insurance Code of 1956, Act 218 of the following will be Public Acts of 1956, being Section 500.3400 of the order of benefit determinationMichigan Compiled Laws. a) First, the 9.04 Health care benefits and services rendered as a result of a plan covering motor vehicle accident are not covered to the insured person as an employee (or as that insured person’s dependent)extent there is coverage under any other policy. b) Second, 9.05 The Plan is not required to pay claims or coordinate benefits for services that are not provided or authorized by the benefits Plan and that are not Authorized Benefits and Services under the continuation coveragethis Certificate. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits If you have medical coverage under any other Health Benefits Plan, other public or private group programs, or pre-paid plan any other health insurance policy, the benefits provided or insurance plan designed payable hereunder shall be reduced to fully integrate with the extent that benefits are available to you under such other plans. If this plan is the “primary” plan, Delta Dental will policy or program. The rules establishing the order of benefit determination between this Agreement and any other plan covering a Member not reduce Benefits. If this plan on COBRA continuation on whose behalf a claim is the “secondary” made are as follows:  Employee/Dependent Rule  The plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee covers you as an employee is primary over a plan covering the Enrollee employee, pays first.  The plan, which covers you as a dependent. 2) Dependent, pays second.  Birthday Rule for Dependent children of parents who are not separated or divorced  The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiaryplan, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of which covers the parent whose birthday falls earlier in a year are determined before those of the plan of year, pays first. The plan, which covers the parent whose birthday falls later in that the year; but b) if , pays second. The birthday order is determined by the month and the day of birth, not the year of birth.  If both parents have the same birthdaymonth and day of birth, the benefits of plan that Covered the parent longer, will pay claims first. The plan covering one parent longer are determined before those of which covered the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender time pays second.  Dependent children of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, parents  The plan of the parent decreed by a court of law to have responsibility for medical coverage pays first.  In the absence of a court order: o The plan covering the Enrollee as a dependent of the parent with legal physical custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the child pays first. o The plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent Spouse of the parent with such financial responsibility will be determined before physical custody (i.e., the benefits stepparent) pays second. o The plan of any other policy covering the parent not having physical custody of the child pays third. PHPGSAHDHPHIX_Off_2016 SERF# PBHP-130007152 - Off  Active/Inactive Employee  The plan, which covers you as an active employee (or Dependent of an active employee), pays first.  The plan, which covers you as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither retired or laid-off nor retired are determined before those employee (or Dependent of a plan covering that insured person as a retired or laid-off or retired employee), pays second. The same would hold true if an insured person is  Longer/Shorter Employment  In the case where you are the Subscriber under more than one group health insurance policy, then the plan that has Covered you for a dependent longer period of time will pay first. A change of insurance carrier by the group employer does not constitute the start of a person new plan.  No Coordination Provision  In spite of the rules listed above, the plan that has no provision regarding coordination of benefits will pay first.  If you are covered as under a retiree motor vehicle or an employeehomeowner’s insurance policy which provides benefits for medical expenses resulting from a motor vehicle accident or accident in your own home, you shall not be entitled to benefits under this Agreement for injuries arising out of such accident to the extent they are covered by the motor vehicle or home owner’s insurance policy. If we have provided such benefits, we shall have the right to recover any benefits we have provided from you or from the motor vehicle or homeowner’s insurance to the extent they are available under the motor vehicle or homeowner’s insurance policy.  If you or your Dependents are Covered by COBRA continuation and are also Covered by another group plan, you shall receive our Covered Benefits to the extent that we will be secondary payer of all eligible charges, subject to the terms, conditions, exclusions and limitations of this Agreement. In no event shall the Covered Benefits received under this Agreement and all other plan does not have plans combined exceed the total reasonable actual expenses for the services provided under this rule, and if, as a result, the plans do not agree on the order Agreement. For purposes of coordination of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal  We may release, request, or state law also is covered under another planobtain claim information from any individual or organization. In addition, the following will be the order of benefit determination. a) First, the any Member claiming benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not from us shall furnish us with any information which we may require.  We have the rule described aboveright, and ifif we make overpayments because of your failure to report other coverage or any other reason, as a resultto recover such excess payment from any individual to whom, the plans do not agree on the order of benefitsor for whom, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cansuch payments were made. PHPGSAHDHPHIX_Off_2016  We will not be made obligated to pay for non-Covered Services or Covered Benefits not obtained in accordance compliance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only planour policies and procedures.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits If you have medical coverage under any other Health Benefits Plan, other public or private group programs, or pre-paid plan any other health insurance policy, the benefits provided or insurance plan designed payable hereunder shall be reduced to fully integrate with the extent that benefits are available to you under such other plans. If this plan is the “primary” plan, Delta Dental will policy or program. The rules establishing the order of benefit determination between this Agreement and any other plan covering a Member not reduce Benefits. If this plan on COBRA continuation on whose behalf a claim is the “secondary” made are as follows: ⮚ Employee/Dependent Rule • The plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee covers you as an employee is primary over a plan covering the Enrollee employee, pays first. • The plan, which covers you as a dependent. 2) Dependent, pays second. ⮚ Birthday Rule for Dependent children of parents who are not separated or divorced • The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiaryplan, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of which covers the parent whose birthday falls earlier in a year are determined before those of the plan of year, pays first. The plan, which covers the parent whose birthday falls later in that the year; but b) if , pays second. The birthday order is determined by the month and the day of birth, not the year of birth. • If both parents have the same birthdaymonth and day of birth, the benefits of plan that Covered the parent longer, will pay claims first. The plan covering one parent longer are determined before those of which covered the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender time pays second. ⮚ Dependent children of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, parents • The plan of the parent decreed by a court of law to have responsibility for medical coverage pays first. • In the absence of a court order: o The plan covering the Enrollee as a dependent of the parent with legal physical custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the child pays first. o The plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent Spouse of the parent with such financial responsibility will be determined before physical custody (i.e., the benefits stepparent) pays second. o The plan of any other policy covering the parent not having physical custody of the child pays third. ⮚ Active/Inactive Employee • The plan, which covers you as an active employee (or Dependent of an active employee), pays first. • The plan, which covers you as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither retired or laid-off nor retired are determined before those employee (or Dependent of a plan covering that insured person as a retired or laid-off or retired employee), pays second. The same would hold true if an insured person is ⮚ Longer/Shorter Employment • In the case where you are the Subscriber under more than one group health insurance policy, then the plan that has Covered you for a dependent longer period of time will pay first. A change of insurance carrier by the group employer does not constitute the start of a person new plan. ⮚ No Coordination Provision • In spite of the rules listed above, the plan that has no provision regarding coordination of benefits will pay first. ⮚ If you are covered as under a retiree motor vehicle or an employeehomeowner’s insurance policy which provides benefits for medical expenses resulting from a motor vehicle accident or accident in your own home, you shall not be entitled to benefits under this Agreement for injuries arising out of such accident to the extent they are covered by the motor vehicle or home owner’s insurance policy. If we have provided such benefits, we shall have the right to recover any benefits we have provided from you or from the motor vehicle or homeowner’s insurance to the extent they are available under the motor vehicle or homeowner’s insurance policy. In no event shall the Covered Benefits received under this Agreement and all other plan does not have plans combined exceed the total reasonable actual expenses for the services provided under this rule, and if, as a result, the plans do not agree on the order Agreement. For purposes of coordination of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal ⮚ We may release, request, or state law also is covered under another planobtain claim information from any individual or organization. In addition, the following will be the order of benefit determination. a) First, the any Member claiming benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not from us shall furnish us with any information which we may require. ⮚ We have the rule described aboveright, and ifif we make overpayments because of your failure to report other coverage or any other reason, as a resultto recover such excess payment from any individual to whom, the plans do not agree on the order of benefitsor for whom, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cansuch payments were made. ⮚ We will not be made obligated to pay for non-Covered Services or Covered Benefits not obtained in accordance compliance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only planour policies and procedures.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits If you have medical coverage under any other Health Benefits Plan, other public or private group programs, or pre-paid plan any other health insurance policy, the benefits provided or insurance plan designed payable hereunder shall be reduced to fully integrate with the extent that benefits are available to you under such other plans. If this plan is the “primary” plan, Delta Dental will policy or program. The rules establishing the order of benefit determination between this Agreement and any other plan covering a Member not reduce Benefits. If this plan on COBRA continuation on whose behalf a claim is the “secondary” made are as follows:  Employee/Dependent Rule  The plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee covers you as an employee is primary over a plan covering the Enrollee employee, pays first.  The plan, which covers you as a dependent. 2) Dependent, pays second.  Birthday Rule for Dependent children of parents who are not separated or divorced  The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiaryplan, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of which covers the parent whose birthday falls earlier in a year are determined before those of the plan of year, pays first. The plan, which covers the parent whose birthday falls later in that the year; but b) if , pays second. The birthday order is determined by the month and the day of birth, not the year of birth.  If both parents have the same birthdaymonth and day of birth, the benefits of plan that Covered the parent longer, will pay claims first. The plan covering one parent longer are determined before those of which covered the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender time pays second.  Dependent children of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, parents  The plan of the parent decreed by a court of law to have responsibility for medical coverage pays first.  In the absence of a court order: o The plan covering the Enrollee as a dependent of the parent with legal physical custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the child pays first. o The plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent Spouse of the parent with such financial responsibility will be determined before physical custody (i.e., the benefits stepparent) pays second. o The plan of any other policy covering the parent not having physical custody of the child pays third.  Active/Inactive Employee  The plan, which covers you as an active employee (or Dependent of an active employee), pays first.  The plan, which covers you as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither retired or laid-off nor retired are determined before those employee (or Dependent of a plan covering that insured person as a retired or laid-off or retired employee), pays second. The same would hold true if an insured person is  Longer/Shorter Employment  In the case where you are the Subscriber under more than one group health insurance policy, then the plan that has Covered you for a dependent longer period of time will pay first. A change of insurance carrier by the group employer does not constitute the start of a person new plan. .  No Coordination Provision  In spite of the rules listed above, the plan that has no provision regarding coordination of benefits will pay first.  If you are covered as under a retiree motor vehicle or an employeehomeowner’s insurance policy which provides benefits for medical expenses resulting from a motor vehicle accident or accident in your own home, you shall not be entitled to benefits under this Agreement for injuries arising out of such accident to the extent they are covered by the motor vehicle or home owner’s insurance policy. If we have provided such benefits, we shall have the right to recover any benefits we have provided from you or from the motor vehicle or homeowner’s insurance to the extent they are available under the motor vehicle or homeowner’s insurance policy.  If you or your Dependents are Covered by COBRA continuation and are also Covered by another group plan, you shall receive our Covered Benefits to the extent that we will be secondary payer of all eligible charges, subject to the terms, conditions, exclusions and limitations of this Agreement. In no event shall the Covered Benefits received under this Agreement and all other plan does not have plans combined exceed the total reasonable actual expenses for the services provided under this rule, and if, as a result, the plans do not agree on the order Agreement. For purposes of coordination of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal  We may release, request, or state law also is covered under another planobtain claim information from any individual or organization. In addition, the following will be the order of benefit determination. a) First, the any Member claiming benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not from us shall furnish us with any information which we may require.  We have the rule described aboveright, and ifif we make overpayments because of your failure to report other coverage or any other reason, as a resultto recover such excess payment from any individual to whom, the plans do not agree on the order of benefitsor for whom, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cansuch payments were made.  We will not be made obligated to pay for non-Covered Services or Covered Benefits not obtained in accordance compliance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only planour policies and procedures.

Coordination of Benefits. i. 6.1 If a group insurance policy or any other group health benefits program, including another Delta Dental coordinates program, entitles a person to receive or be reimbursed for the cost of dental services which are also Benefits under this dental plan with your benefits program, and if this program is "primary" under any the rules described below, Delta will provide Benefits as if the other group or pre-paid plan or insurance plan designed to fully integrate with other plansprogram did not exist. If the other program is "primary" under these rules, then Delta will provide Benefits under this plan program only to the extent that the other program does not fully provide the dental services. 6.2 If the other program mainly covers services or expenses other than dental care, this program is the “"primary” plan". Otherwise, Delta Dental will not reduce Benefits. If this plan is use the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental following rules to determine which Plan program is the “"primary” plan?": 1(a) The plan covering program which covers the Enrollee person as an employee other than a dependent is primary over a plan covering the Enrollee as a dependent. 2) The plan covering program which covers the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if , with the insured following exception: If the person is also a Medicare beneficiary, Beneficiary and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a(i) secondary to the plan program covering the insured person as a dependent; and b(ii) primary to the plan program covering the insured person as other than a dependent (e.g. for example, a retired employee), then the benefits Benefits of the plan program covering the insured person as a dependent are determined before those the Benefits of the plan program covering that insured the person as other than a dependent. 3(b) Except as stated in paragraph 4), when this plan and another plan cover the same The program which covers a child as a dependent of different persons, called parents: a) the benefits of the plan of the a parent whose birthday falls occurs earlier in a calendar year are determined before those is primary over the program which covers a child as a dependent of the plan of the a parent whose birthday falls occurs later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent a calendar year (except for a shorter period of timedependent child whose parents are separated or divorced as described in (c) below). (c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of whose parents are legally separated or divorced parentsdivorced: (i) If the parent with custody has not remarried, the plan covering program which covers the Enrollee child as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be is primary over the plan covering program which covers the Enrollee child as a dependent of the parent without legal custody. . (ii) If the parent with custody has remarried, the program which covers the child as a dependent of the parent with custody is primary over the program which covers the child as a dependent of the step-parent, and the program which covers the child as a dependent of the step-parent is primary over the policy or program which covers the child as a dependent of the parent without custody. (iii) If there is a court decree establishing that establishes financial responsibility for the health care expenses with respect to the childdental services which are Benefits under this program, then notwithstanding (i) and (ii), the benefits of a plan covering program which covers the child as a dependent of the parent with such financial responsibility will be determined before the benefits of is primary over any other policy covering program which covers the child as a dependent child. 5) If the specific terms 6.3 The Benefits of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans program covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a employee (or dependent of a such person) shall be determined after the Benefits of any other program covering such person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) 6.4 If an insured a person whose coverage is provided under a right of continuation pursuant to federal or state law also requiring continuation is covered under another planmore than one program, the following will Benefit order shall be the order of benefit determination.determined as follows: (a) First, The Benefits of the benefits of a plan program covering the insured person as an employee (or as that insured person’s dependent)dependent shall be primary. (b) Second, the benefits The Benefits under the continuation coveragecoverage shall be secondary. c) 6.5 If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination primary program cannot be made determined by the rules described in accordance with the above for Pediatric Benefitsthis Article 6, the benefits of a plan that is a medical plan covering dental as a benefit will program which has covered the person longer shall be primary to a dental only planprimary.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits If you have medical coverage under any other Health Benefits Plan, other public or private group programs, or pre-paid plan any other health insurance policy, the benefits provided or insurance plan designed payable hereunder shall be reduced to fully integrate with the extent that benefits are available to you under such other plans. If this plan is the “primary” plan, Delta Dental will policy or program. The rules establishing the order of benefit determination between this Agreement and any other plan covering a Member not reduce Benefits. If this plan on COBRA continuation on whose behalf a claim is the “secondary” made are as follows:  Employee/Dependent Rule  The plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee covers you as an employee is primary over a plan covering the Enrollee employee, pays first.  The plan, which covers you as a dependent. 2) Dependent, pays second.  Birthday Rule for Dependent children of parents who are not separated or divorced  The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiaryplan, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of which covers the parent whose birthday falls earlier in a year are determined before those of the plan of year, pays first. The plan, which covers the parent whose birthday falls later in that the year; but b) if , pays second. The birthday order is determined by the month and the day of birth, not the year of birth.  If both parents have the same birthdaymonth and day of birth, the benefits of plan that Covered the parent longer, will pay claims first. The plan covering one parent longer are determined before those of which covered the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender time pays second.  Dependent children of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, parents  The plan of the parent decreed by a court of law to have responsibility for medical coverage pays first.  In the absence of a court order: o The plan covering the Enrollee as a dependent of the parent with legal physical custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the child pays first. o The plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent Spouse/Domestic Partner of the parent with such financial responsibility will be determined before physical custody (i.e., the benefits stepparent) pays second. o The plan of any other policy covering the parent not having physical custody of the child pays third.  Active/Inactive Employee  The plan, which covers you as an active employee (or Dependent of an active employee), pays first.  The plan, which covers you as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither retired or laid-off nor retired are determined before those employee (or Dependent of a plan covering that insured person as a retired or laid-off or retired employee), pays second. The same would hold true if an insured person is  Longer/Shorter Employment  In the case where you are the Subscriber under more than one group health insurance policy, then the plan that has Covered you for a dependent longer period of time will pay first. A change of insurance carrier by the group employer does not constitute the start of a person new plan.  No Coordination Provision  In spite of the rules listed above, the plan that has no provision regarding coordination of benefits will pay first.  If you are covered as under a retiree motor vehicle or an employeehomeowner’s insurance policy which provides benefits for medical expenses resulting from a motor vehicle accident or accident in your own home, you shall not be entitled to benefits under this Agreement for injuries arising out of such accident to the extent they are covered by the motor vehicle or home owner’s insurance policy. If we have provided such benefits, we shall have the right to recover any benefits we have provided from you or from the motor vehicle or homeowner’s insurance to the extent they are available under the motor vehicle or homeowner’s insurance policy.  If you or your Dependents are Covered by COBRA continuation and are also Covered by another group plan, you shall receive our Covered Benefits to the extent that we will be secondary payer of all eligible charges, subject to the terms, conditions, exclusions and limitations of this Agreement. In no event shall the Covered Benefits received under this Agreement and all other plan does not have plans combined exceed the total reasonable actual expenses for the services provided under this rule, and if, as a result, the plans do not agree on the order Agreement. For purposes of coordination of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal  We may release, request, or state law also is covered under another planobtain claim information from any individual or organization. In addition, the following will be the order of benefit determination. a) First, the any Member claiming benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not from us shall furnish us with any information which we may require.  We have the rule described aboveright, and ifif we make overpayments because of your failure to report other coverage or any other reason, as a resultto recover such excess payment from any individual to whom, the plans do not agree on the order of benefitsor for whom, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cansuch payments were made.  We will not be made obligated to pay for non-Covered Services or Covered Benefits not obtained in accordance compliance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only planour policies and procedures.

Coordination of Benefits. i. Delta Dental coordinates Most health care programs, including this Hospitalization Program contain a coordination of benefits provision. This provision is used when you, your spouse or your covered dependents are eligible for payment under more than one health care plan. The object of coordination of benefits is to ensure that your covered expenses will be paid, while preventing duplicate benefit payments. Here is how the dental coordination of benefits provision works:  When your other coverage does not mention "coordination of benefits," then that coverage pays first. Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided payable by all plans do not exceed 100% of total allowable expense. iithe other coverage will be taken into account in determining if additional benefit payments can be made under your plan. How does Delta Dental determine which Plan  When the person who received care is the “primary” plan? 1) The plan covering the Enrollee covered as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiaryunder one contract, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee)under another, then the benefits of employee coverage pays first.  When a dependent child is covered under two health plans, the health plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a the calendar year are determined before those of the plan of the parent whose birthday falls later in that year; but b) pays first. But, if both parents have the same birthday, the health plan which covered the parent longer will be the primary plan. If the dependent child's parents are separated or divorced, the following applies: − The parent with custody of the child pays first. − The coverage of the parent with custody pays first but the stepparent's coverage pays before the coverage of the parent who does not have custody. − Regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child's health care expenses, the coverage of that parent pays first.  When none of the above circumstances applies, the coverage you have had for the longest time pays first, provided that: − The benefits of the plan covering one parent longer are determined before those of the a health plan covering the person as an employee other parent for than a shorter period laid- off or retired employee or as the dependent of time. c) However, such person shall be determined before the benefits of a plan covering the person as a laid-off or retired employee or as a dependent of such person and if the − The other health plan does not have the birthday rule described abovethis provision regarding laid-off or retired employees, but instead has a rule based on the gender of the parent, and ifand, as a result, the plans do not agree on the order of benefits, the then this rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parentsis disregarded. If you receive more than you should have when your benefits are coordinated, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) you will be primary over the plan covering the Enrollee as a dependent of the parent without legal custodyexpected to repay any overpayment. If there is a court decree establishing financial responsibility for the In general, subrogation means that if you incur health care expenses with respect to the childfor injuries caused by another person or organization, the person or organization causing the accident may be responsible for paying these expenses. For example, if you or one of your dependents receives Hospital Program benefits of a plan covering for injuries caused by another person or organization, the child as a dependent Fund, or Highmark on behalf of the parent with such financial responsibility will be determined before Fund has the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the childright through subrogation, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If to seek repayment from the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignoredperson or organization or any applicable insurance company for benefits already paid. See Section 14 for details about subrogation. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

Coordination of Benefits. i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid If a participant is covered by another employer’s benefit plan or insurance plan designed to fully integrate another group type health benefit plan, there may be some duplication of benefit coverage between this Plan and the other plan. The Plan coordinates benefits with other plansplans to prevent duplication of payments for the same services. If this This section describes how Coordination of Benefits (COB) works under the Plan. To determine how the plans coordinate benefits, one plan is the considered “primary” and the other is considered “secondary”. The primary plan pays benefits first, up to that plan, Delta Dental ’s limits. The secondary plan will not reduce Benefitspay benefits until the primary plan pays or denies a claim. In no instance will the primary and secondary plans pay, in total, more than the actual cost of the healthcare services. If this the other plan is does not include a coordination of benefits or non-duplication provision, that plan will be primary. The following are the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine provisions for determining which Plan is the plan will be “primary” plan? 1) The plan covering the Enrollee ”: Description Primary Secondary Active Employee Teamsters Local 170 Other Health Plan Note: If employee is Health and Welfare Fund covered as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary“employee” under two plans, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person employee for the longest period of time is considered the primary plan. Dependent spouse with other Other Health Plan Teamsters Local170 coverage as a dependent; and b) primary to “active employee” Health and Welfare Fund Active Employee & Spouse Follow birthday rule* Follow birthday rule* with children: both parents’ health plans cover children Active Employee, divorced or Follow court decree Follow court decree separated, both parents’ health plans cover children with court order *Under the plan covering the insured person as other than a dependent (e.g. a retired employee)birthday rule, then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier earliest in a the calendar year are determined before those of is the plan of the parent whose birthday falls later in that year; but b) if child’s primary plan. If both parents have the same birthday, the benefits of parent who has been covered longer has the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if primary plan. If the other plan does not have the birthday rule described aboverule, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, then the rule in the other plan determines the order of benefits. 4) In the case of will determine which is primary. • If parents are divorced or separated and both parents’ plans cover a dependent child, benefits for the child of legally separated or divorced parentsare determined in this order: • First, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent custody; • Then, the plan of the custodial parent’s stepparent (spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child); and • Finally, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits parent not having custody of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter termchild. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.