Res 2665 11/4/1980RESOLUTION NO. (;W
RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE
A RENEWAL AND REVISION OF THE CONTRACT BETWEEN THE
CITY OF WICHITA FALLS AND BLUE CROSS BLUE SHIELD OF
TEXAS FOR EMPLOYEE HEALTH INSURANCE.
BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF
WICHITA FALLS, TEXAS, THAT:
That certain proposal , a copy of which is attached hereto,
between the City of Wichita Falls and Blue Cross Blue Shield of
Texas, calling for revisions in the health insurance program
presently provided to the employees of the City of Wichita Falls
is hereby approved, and the City Manager is authorized to execute
a contract, in accordance with the proposal and the annual renewals
thereof, for the City of Wichita Falls.
PASSED AND APPROVED this the 4th of November, 1980.
C
V /!
MAY O R
z
ATTEST:
A-67149 L,02../ •
City blerk
Qa-
0,04
GROUP HOSPITAL SERVICE, INC.
Herein called the Carrier)
Dallas,Texas
1 has issued this
lNon-Cancellable
I EXPERIENCE RATED GROUP COMPREHENSIVE
BLUE CROSS AND BLUE SHIELD CONTRACT
I
to the Employer named in the application herefor and thereby the Carrier agrees to provide
I the benefits detailed herein, all in accordance with the conditions and provisions hereof,
including those set out on the following pages which are a part of this contract as fully as if
recited over the signatures hereto affixed.
IThis contract is issued in consideration of the application herefor made by the Employer and
of the timely payment of premiums as provided for herein. It will become effective on the
Contract Date stipulated in such application and will be continued in force, subject to the
Employer's right of termination, for so long as the minimum employee participation is main-
tained, as set out in Article VII,Section A,Subsection 3.
IN WITNESS WHEREOF, the Carrier has caused this contract to be executed at its Home
Office in Dallas,Texas.
L
L
President .
4„, -,...:
Secretary E '1
Countersigned:
LRegistrar
L
1- Form No. CBCBS-2 STOCK NO. 2200.000-AL580
ARTICLE I — DEFINITIONS
i
AS USED HEREIN:
1 A. EMPLOYER means, in addition to the person, firm, or institution named in the application herefor,
one or more subsidiaries or affiliates listed as such under Eligibility Regulations in the Schedule.
1 B. EMPLOYEE means a person who regularly renders personal services, not less than one hundred
twenty (120) hours per month in the business of the Employer, and who (except in the case of a
proprietor, partner, or corporation officer or director) is compensated for such services by salary
1 or wages.
C. DEPENDENT means:
1 1. An employee's spouse or
2. Any unmarried child who is either under twenty-five (25) years of age or disabled; provided
that in the case of a disabled child twenty-five (25) years of age or older, such child is depen-
1 dent upon the employee for more than one-half of his support as defined by the Internal
Revenue Code of the United States.
Disabled" means any medically determinable physical or mental condition which prevents the
child from engaging in self-sustaining employment; provided that the disability commences prior
to such child's attainment of age twenty-five (25) and that satisfactory proof of such disability
and dependency is submitted by the employee within thirty-one (31) days following such child's
Iattainment of age twenty-five (25).
Child" means the natural child of the employee; a legally adopted child (including a child living
1 with the adopting parents during the period of probation); a stepchild residing in the employee's
household; or a child permanently residing in the household of which the employee is the head
and to whom the employee is legal guardian or related to the child by blood or marriage.
IAs a condition to the continued coverage of a child as a disabled dependent beyond the age of
twenty-five (25), the Carrier shall have the right to require periodic certification of the child's
physical or mental condition but not more frequently than annually after the two-year period
3 following the child's attainment of age twenty-five(25).
D. PARTICIPANT means an employee or a dependent, as above defined, whose coverage hereunder
Ihas become effective in accordance with Article II.
E. MEMBER HOSPITAL means any hospital located in the State of Texas with which Blue Cross of
l Texas has entered into a written Member Hospital Contract for the rendition of care for which
benefits are provided by Article V of this contract, or any hospital located outside the State of
Texas with which any other Blue Cross Plan has entered into such a contract.
i F. NONMEMBER HOSPITAL means any hospital other than a member hospital which is registered
with the American Hospital Association and approved by the Carrier for the rendition of services
on a nonmember hospital basis.
I G. THERAPEUTIC CENTER means an institution other than a member or nonmember hospital which
is approved as a therapeutic center by the Carrier.
H. PHYSICIAN means a person (other than a hospital resident or intern) who is a Doctor of Medicine,
Doctor of Osteopathy, Doctor of Podiatry, Doctor of Dentistry, Doctor of Optometry, or Doctor
of Chiropractic, or a psychologist who is certified and licensed by the Texas State Board of
IExaminers of Psychologists under Article 4512c of Vernon's Civil Statutes of the State of Texas,
rIERIMMILUMEMMEE
STOCK NO, 2201.000—AL479
Fn.m kin 79n1
1
eeAoldwa Lions 04 algeolldde OJB ley! suo feln6aa
Allllgl6l13 sm.! golynn SuoReollloeds jo alnpayoS ay; `a6eJanoO sly aapun luedlotTJed goea Jol
pue `Japunaaaq paaanoo aai(oldwe pea Jot 'ueaw Heys wnal ay; `;oeJluoo sly; Jepun 438418 u!
s! suOueollloeds 1O alnpayoS auo ueg1 wow 1! le14l pep!AOJd 'bale u! Alsno!naad auo aoeldai 04
1 ouis ay; pus JeAoldw3 ay; Aq o; paaJ6e AIlen;nw salnpayos paslnaJ Aue jo kale! ay;JO'o;away
u011eollddy s,JeAoldw3 ay; u! 6uueadde suol;eo!;loads to alnpayoS ay; sueaw 31f1a3HOS '0
1 03J0l
s! 4oeJwoo ay; se 6uol se J01 Ja4le0Ja14l Jeait yoea u! alep 6ulpuodsaJJoo ay; pue Jole eq U014
eollddy s,Je/coldw3 ay; u! pal;loads Jean( pue Asp `yluow ay; sueaw AUVSEI3AINNV 10da1NO0 'd
eep paquoo ay; uo 6uluul6aq `polaad Alyluow 6ulpaaoons pea sueaw HINOW IOVEilNOO 'O
Lc aagwaoaa
6ulpaaoons ixaU ay1 6ulpue pue G AJenuer 6uluul6aq Jean( pea sueaw 1:1`d3A UVaN31V0 'N
aOUaJJn3Oo
ay; aalle sAep (0c) u11411M ue!O!sAyd a Aq paJapuw aJeo J(Jessaoeu u! 'sasneo Jaylo
He 4o Ajluepuadapu! pue Al;oaJlp `6ul;lns8J AJnfu! Allpoq le;uaplooe sueaw 1V1N3OIOOV 'W
uollounlslp Jo uled lulof Jeln
glpuewoaodwe4 aleu!alla of weal ay; 1O uo!sn1000 ay; lO uollo0JJOO to edAl Aue epnlou! lou
saop) lu!of JeinglpuewoJodwal ay; to uo!loafu! pue `lo uo!sloxa 'lo uoReOOlslp 1O uo!;Onpaa b
s;onp pue spuel6 AJen11es `sasnuls AJossaooe 6u!nlonu! seJnpeooid leO!6JnS •£
slullnlia° 1O e6euleap pue uols!OUl •Z
s;sAo
pue sJOwnl `suOlsal lueu6llewaJd pue lueu6llew 'u6luaq 6u!pnIOU! `swseldoau 1O uOISIOx3 •
01 pal!w!I saanpaooJd leOl6Jns le!Oelolllxew sueaw AI:139af1S 1VUO 031:13AO0 '1
paleaal 6ulaq s! walled 0141 yOl14M Jot
RJnfu! JO ssaull! 0144 yl!M luals!suo3 pue AJesseoeu s! Aiddns JO eolnJes Lions papinoad `i alo1lJy
sly; 10 1 pue 'S `a SUOI;aas u! pais!! Aiddns Jo 8O!AJOS to wa1! Aue to bu1gs!uanl ay; sueaw 38b'O •>{
slseq lelluep!seJ a uo aJMO leuo!ln;l;su! anal-6u°' ap!noad 04 paleJedo pue pallets
paub!Sep lelldsoy 0141 to uopod a u! luawau1luoO apnlou! 40U saop WJal 844 :s!seq Jnoy (trZ)
Jno;-tlueMl a uo aJeo lelldsoy wJa;-1JO14s `alnoe JapuaJ 04 paleJedo pue pa;gels `pau6lsap s! 14O114M
Iel!dsoy 0141 lO uol;Jod a u! paleOOI uollepoww0OOe paq a u! luawau1luoO sueaw „waged pas„
Ja!JJe3 0144 Aq u0!SS!wpe lel!dsoq a paJap!suoO eq !legs uolsslwpe 0141 lel!dsoq 0141 u! s! ay aw!l
10 polaad ay; 6u!Jnp uo!lepoww000e paq a u! lual;ed paq a se pau1luOO s! lnq polaad Jnoy (L7Z)
Jnol-AluaMI e u!yl!M lel!dsoq Jagwawuou JO Jagwaw e wail pe6Jegos!p pue 01 pa;llwpe s! ;ua!led
e 11 •uolsslwpe lelldso14 a to gl6ua1 0144 6U!u!WJa;ap u! paaap!suoO eg !legs `eJnlJedep JO e6Jeyo
s!p jo Asp 8144 ;ou lnq `AJ;ua jo Aep aql •sJn3OO 1s.!1 JanayO1gM `ue!OlsAyd ay; Aq a6Jeyoslp JO
1 aaeo lelldsoy waned-peg 1O aOUenul;uoOSlp to awl;041 pue lua!led paq e se lel!dsoy Jagwawuou Jo
Jagwaw a mu! AJlue S,lued!O!;Jed e to aw11 841 uaaMlaq pouad 0141 sueaw NOISSIINad 1V11dSOH f
1 alol;ay S!41 10 1 pue `S 'a suoi4Oas ul pals!! Aiddns JO aO!AJOS 10 wa;i ue hied
loped a of 6ulgsluJnl uollnll;su! JO 'wJl1 `uosJad Jay;o JO ue!OlsAgd 'lel!dsoy e sueaw 831-1ddfS •1
sexa1l0 apo0 aoueJnsul ay1 Aq way;of p0U !SSe
6ulueaw 8144 aney !legs `u!OJay pass se oiloeJdoJ!g3 10 Jol3Oa pue 'AJlawold0 10 Jo1OOa `AJls!luaa
JO J01O0a 'AJlelpod 10 Jolooa `Ay1ed081S0 10 JO100a 'auloipafnJ 10 JO;OOJ sWJal 0141 •pale;ouuy
1 ARTICLE I— DEFINITIONS (Continued)
R. BED-PATIENT HOSPITAL EXPENSE means charges incurred for the items of service or supply
listed below for the care of a participant; provided that for nonmember hospitals such charges
are reasonable; and provided further that such items are: (a) furnished at the direction or pre-
scription of a physician; (b) provided by a member hospital or a nonmember hospital; and (c)
furnished to and used by the participant during a hospital admission. Bed-Patient Hospital
Expense incurred by the mother for delivery of a child shall be deemed to include routine well-
baby nursery care of the newborn child during the mother's hospital admission for the delivery.
An expense shall be deemed to have been incurred on the date of rendition of the service for
1
which the charge is made.
1. Room accommodation charges, provided that if the patient is confined in a private room
the excess of the room accommodation charge over the hospital's average semiprivate
room accommodation charge will not be considered hereunder for any purpose.
2. All other care in the nature of usual hospital services which are necessary and consistent
with the condition of the patient.
S. OUTPATIENT HOSPITAL EXPENSE means charges incurred for items of service or supply for
the care of a participant, provided that such items are: (a) furnished at the direction or pre-
scription of a physician; (b) provided by a member hospital, a nonmember hospital or a thera-
peutic center; and (c) furnished to and used by the participant during an outpatient visit; and
provided further that for nonmember hospitals and therapeutic centers, such charges are reason-
I
able. An expense shall be deemed to have been incurred on the date of rendition of the service
for which the charge is made.
T. OTHER MEDICAL EXPENSE means charges incurred for the items of service or supply listed
below for the care of a participant, provided such charges are reasonable and such items are:
a) furnished by or at the direction or prescription of a physician and (b) are not included as an
item of Bed-Patient Hospital Expense or Outpatient Hospital Expense under Section R or S of
1
this Article I. An expense shall be deemed to have been incurred on the date of rendition of the
service for which the charge is made.
1. Services of physicians.
2. Services of a certified registered nurse-anesthetist.
3. Services of a private-duty registered nurse or licensed vocational nurse not related to the
patient by blood or marriage.
4. Services of a licensed professional physical therapist.
5. Diagnostic x-ray and laboratory procedures.
6. Radiation therapy.
7. Drugs and medicines purchased for use outside a hospital which require a written prescrip-
tion for purchase, but only if "Applied For" is indicated in item 7 of the Schedule.
8. Rental of durable medical equipment required for therapeutic use unless purchase of such
equipment is required by the Carrier. The term "durable medical equipment" shall not
include equipment primarily designed for alleviation of pain or provision of patient comfort.
9. Professional ground ambulance service used to and from the nearest hospital appropriately
J equipped and staffed for treatment of the participant's condition when rendered in connec-
tion with outpatient care following accidental injury occurring immediately prior to the
hospital visit or in connection with bed-patient care.
Q 11.11111111111alIII M1111111111111111111111111111111E
0 0
STOCK NO, 2202.000-AL479
1
1
1
1
1
1
l
1
oueu6aad 4o suol eolldwoo ueyl aayno`Aoueubaad io uol lpuoo
1 ay; 10 luawleaa} ao4 ;uedlol;aed a of paaapuaa saolnaas pue aaeo SUeaw 3HJVO AlINEI31VW 'A
1
alglssod lou sl LiIalq
algeln a yolgM ul uo! e1sa6 4o pouad a bupnp 6uwn000 Aoueubaid 4o uol;eulwaaT snoauel
uods pue `Aoueubaad oldo}oa ;o uo!TeulwaaI `uoiloas ueaaesao Rq Aoueubaid 4o uol1eulwaal •Z
I 1. uol}oesgns sly} Li! paugap se Aoueubaid to suoReolldwoo Jo luawleaq paaapls
uoo aq lou !legs Aoueubaid 4o uogeuiwaa} le paaapuaa saliddns pue saolnaas •Aoueu6aad
o uo!Ieolldwoo #ou!4sip ,cIleol6olosou a 6ul}n1l}suoo iou Aoueu6aid Iinol;alp e 4o }uawa6e
I
uew aql t4 IM paleloosse suolllpuoo ae'lwls pue `elsdweloa-aid `wnaepinea6 slsawaaadAy
ssau){ols 6uluaow `Aoueubeid ;o polaad ay' 6upnp Tsai paglaosaid-uelolsAyd `6ulijods
leuolse000 `aogel asle4 apnloul you 'legs Inq `AIlaanas aigeaedwoo to suolllpuoo leolbans
pue leolpaw aellwls pue 'uol4aoge passlw `uol1esuadwooap oelpaeo `sasoaydau `swaydeu
se Lions `Aoueubaid Aq pasneo aae ao Aoueu6aad Aq pa1oage Alasaanpe ale 3nq Aoueubaid
woJI loul}slp aae sasoubelp aso1M (pa1eulwaaI iou sl Aoueubaid ay} uagM) suolilpuo0 .1.
i
Ueaw AONVNO3EJd dO SNOI1t1OI1dWOO 'fl
sayoinao pue (saoys Idaoxa) seoeaq olpadoy1a0 't I.
I iepunalay a6eaanoo
4o a1ep an'loalla s,luedlol1aed ay1 aa1fe 6ulouawwoo ssaui!l ao 6ulaan000 kinful le}uaplooe
fo ;no 6uISUe suolflpuoo fo UOI1081100 JO uol}elnalle ay1 aof paalnbaa seouelidde ol><aiosoad •£I.
i saapuedxa ewseld poolq pue ewseld poolq 'poop jo }soo 6uipn'oul `suolsnfsueai poolg 'el
UO!IeJIslulwpe Si! pue ua6Ax0 •1.1.
408Jay1 UOIIeJIS!Ulwpe pue sol}aLi}sauy •01.
I
iARTICLE II - ELIGIBILITY FOR COVERAGE; EFFECTIVE DATES
A. ELIGIBILITY FOR COVERAGE
1 1. Any employee of the classifications described under Eligibility Regulations in the Schedule
shall, upon the later of completion of the length of service therein specified or the contract
date, become eligible to apply for coverage hereunder for himself or for himself and his
1 family members as dependents.
2. Family members acquired after the effective date of the employee's coverage shall become
1
eligible on the date the family member becomes a dependent as defined in Article I, Section
C, of this contract.
3. Coverage of the employee shall be a condition precedent to coverage of his eligible
1
1
dependents.
B. APPLICATION FOR COVERAGE
Coverage of each eligible employee or dependent shall be contingent upon the employee's
making application therefor in accordance with the approved procedures established by the
Carrier; thereupon,subject to acceptance by the Carrier, coverage shall become effective in
1
accordance with the following sections of this Article II.
C. EFFECTIVE DATES— EMPLOYEES
l If the application is for coverage of an employee or of an employee and his eligible dependents,
and
1. If the employee is eligible on the contract date and if the application is made prior thereto,
1 the coverage shall become effective on the contract date.
2. If the employee becomes eligible on or after the contract date and if the application is
made after the contract date but within the first thirty (30) days following the date of eligibility,
I and
a. If "Standard Option" is specified under Effective Dates in the Schedule, the coverage
shall become effective on the employee's date of eligibility;
b. If"Option I" is specified under Effective Dates in the Schedule, the coverage shall become
effective on the second premium due date following the date that the application is made;
I c. If "Option II" is specified under Effective Dates in the Schedule, the coverage shall
become effective on the first premium due date following the date that the application
is made.
3. If the application is made more than thirty (30) days after the date such employee becomes
eligible, the coverage shall become effective on the later of the succeeding contract anni-
versary or the first premium due date occurring thirty (30) days after the application is made,
i provided that if the employee elects, or is required by the provisions of Section B of this
Article II to submit evidence of insurability satisfactory to the Carrier with his application,
the coverage shall become effective on the first premium due date following the date the
i
Carrier determines such evidence to be satisfactory.
4. Regardless of the above subsections of this Section C, if "Other" is specified under Effective
Dates in the Schedule, coverage shall become effective as set forth thereunder.
i D. EFFECTIVE DATES—DEPENDENTS
If the application is for coverage of a dependent of an employee already having coverage under
ithis contract, and
j I , A
p lc
STOCK NO, 2203.000-AL479
Form No. 2203
1
1
l
paniwgns si uoi;eoiTI;ou yons amp ay; 6u!MO!
amp anp wniwaJd puooas ay; o; qmq amp ay; woiT anp swn!waad Ike ppwaJ (Z)
pue `y;Jiq ;o amp ay; woa; sy;uow (61.) uaa;Jiy; uey; Jowl '/;ioedeo
le6ai ;o aouasge ey; ui Ideoxe 'wane ou ui pue algissod AmeuoseaJ seen se uoos se
pamwgns seen uoi;eoi;i;ou ay; ;eq; pue y;Jiq ;o amp 6U!MOuol. sicep (1.E) auo-ATJiy;
uiy;inn uoi;eoi;i;ou ;pwgns o; algissod Aigeuoseai Tou sem ;i ley; Moys (q) Jo y;Jiq
o ale') 6u!MoIIo; step (1.6) auo-A;iiy; Tsai; ay; uiy;inn uoi;eoi;i;ou ;iwgns (e) Jay;ia (i.)
snw aaAoidwa ay; 'cep (Inc) ;sJi;-A;Jiy; yons 6U Mofo; Pella
ui aq o; 86eJano0 Jo; ;ey; papinoad :y;Jiq ;O amp ey; 6u!MoIIo; Aep (1s1.6) ;sJIT-A;Jiy; ay;
y6noJy; y;aiq ;o amp ay; woi; ;oa{;a ui aq Heys amp ani;oa;;a s,aaAo1dwa ay;Ja;;e uaoq puyo
e To a6eJanoo 'a uoi;oas siy; ;o 'anoge`Z uoi;Oesgng ;o suoisinoJd ay; 6uipue;sy;iM;oN •E
apew s! uoi;eo!Idde
ay; Ja;;e sAep (p£) A;Jiy; ;seal ;e 6u!JJn000 AJesJaniuue ;oeJ;uoO 6uipaaoons ay; (Z)
Jo :uoi;eoigdde
NI ;o ;d!aoei Ja;;e sAep (06) ATauiu ;seal ;e 6u!JJn000 amp anp wn!waJd ;sJ!; ay; (I.)
sa;ep 6U!M011o;
ey; }o JeiIJee ay; uo eni;oa;;a awooaq Heys a6eJanoo ay; 'uoi;eo!Idde ;o a;ep ay; uo
paid ui aseaJOUI ue ui seop a6eaanoo ay; 01 ;uapuadap ay; ;o uoi;ippe ay; n •q
wn,waJd ui aseaJOU!
ue U! pa;insai aney Tou pInoM TUapuadap ay; ;o uoipppe ay; yOiyM uo a;ep ;sJi; ay; (Z)
Jo `;uapuadap ay; ;o A;i!igi6!1a ;o amp ay! (U)
Ja;eI ay; uo ani;Gala awooaq Heys 96eJan00 ay; `uo!Teo!Idde ;o aTep ay; uo
wniwaad ui aseaaou! ue ui ;InsaJ ;ou saop abeaanoo ay; o; ;uapuadap ay; lo uoipppe aqT ;i •e
sMolio; se anf;Oa};a awooaq Heys a6eJanoo ay; `algi6iia
sewooaq ;uapuadap ay; a;ep ay; JaT;e sAep (00) ATJiy; uey; OJOW apew Si uoiTeD!Idde ay; 11
A;!Iiq 6!Ie To amp s,;uapuadap ay; uo ani1oa;;a awooaq Heys
a6eJ8n0o `i(1!I!q 6iia ;o amp ay; 6u!MOIlo; sAep (06) A;Jiy; Tsai; ay; uiy;!M ;nq a;ep ;oeJ;uo3
ay; Jolla apew Si uOgeo!idde pue amp ;oequoo ay; Jeuue Jo uo algi6ga Si ;uapuadap ay; 11
1
ARTICLE III - PREMIUMS
1 A. The premium rates initially effective shall be shown under "Premiums" in the Employer's Applica-
tion, and continuance of the coverage hereunder shall be contingent upon payment of the
premiums by the Employer at the Home Office of the Carrier in Dallas, Texas, in accordance with
1
the following provisions: the first premium is due on the contract date; subsequent premiums
are, during the continuance of this contract, payable in advance. The Carrier may refuse to accept
any payment which does not represent a total monthly premium.
1 B. This contract shall be nonassessable. It does not share in the earnings of the Carrier, but the
Carrier reserves the right to change the premium rates on any contract anniversary, as applicable
to the succeeding year, commencing with the contract anniversary stipulated in the Application,
1 provided that:
1. If the Carrier does not change the premium rates on any of the above contract anniversaries,
1
it shall have the right to change premium rates once on any premium due date occurring
between such contract anniversary and the next succeeding contract anniversary and such
change shall be applicable to the contract months succeeding such premium due date;
l 2. In the event price controls are established by the state or federal governments while this
contract is in effect, the Carrier reserves the right to adjust premium rates on any premium
due date occurring between the date of imposition of such controls and the contract anni-
1
following termination of such controls.
l
Any such change shall be made uniformly applicable to all employees within any sub-group or
1
other classification under this contract.
C. Premiums may be paid on a monthly, quarterly, semiannual, or annual basis as the Employer
lmay
elect, but without discount.
1 ' D. The premium to be paid hereunder shall be determined by multiplying the number of employees
covered for each classification by the rate then applicable for that classification, and totalling
l the extensions thus obtained; provided, however, that for participants whose coverage becomes
effective in accordance with Article II on other than the first day of a contract month,no premium
shall be due for any portion of the contract month in which the coverage becomes effective.
IE. A grace period of thirty-one (31) days, without interest charge, shall be allowed for the payment
of each premium except the first. If any premium is not paid within the grace period, this contract
shall terminate at the end of such grace period, except that the contract shall terminate at an
1 earlier date (which is not prior to the end of the period for which premiums have been paid)
provided the Employer shall have given the Carrier written notice of such earlier date of termina-
tion in accordance with the provisions of Article VII,Section A. If the contract terminates during
J
or at the end of the grace period, the Employer shall be liable to the Carrier for payment of a pro
rata premium for the time the contract was in force during the grace period. The allowance of
the grace period is applicable only to the total premium, and shall not be construed so as to
i
extend the coverage of any employee for whom a premium has not been paid as a part of the
group remittance.
I
i L: ta,9 , V misinsummimmummt
Fnrm Nn 92114 STOCK NO. 2204.000-AL479
1
i .
ARTICLE IV— PAYMENT OF BENEFITS; COORDINATION OF BENEFITS
A. Payment of benefits by the Carrier to the supplier supplying the care or to the employee, as the
I Carrier may elect, shall constitute full discharge of all responsibility of the Carrier to the employee
on account of care rendered to any participant under this contract.
B. It is understood and agreed that the allowances set out in Article V for services and supplies
rendered by a supplier other than a member or nonmember hospital or therapeutic center are
not intended to and do not fix the value of the services of the supplier nor in any way relate to
or regulate such value; that the supplier is privileged to make its regular charges and that the
stipulated amounts are merely to apply as credits thereon.
C. Any benefits hereunder, payable to the employee, shall, if unpaid at his death, be paid to the
surviving spouse of the employee, as beneficiary; if there is no surviving spouse, then such bene-
fits shall be paid to the employee's estate.
E
D. The benefits provided hereunder are not assignable.
E. It is hereby declared to be the intent of the Employer and the Carrier that the availability of the
benefits herein specified shall be contingent upon the absence of other coverage. Any other
contract or policy or employee welfare benefit plan under which the participant holds protec-
tion for hospitalization and/or medical-surgical expenses by virtue of his membership in or
relation to a particular group shall be considered "other coverage" within the meaning hereof,
1 whether the benefits are in the nature of indemnity or prepaid services. The term shall likewise
be deemed to include any governmental program existing by statutory authority under which he
is entitled to hospitalization and/or medical-surgical benefits. The term shall not be deemed
C
to include any coverage held by the participant for hospitalization and/or medical-surgical
expenses which is written as a part of or in conjunction with any automobile casualty insurance
policy. When, therefore, other coverage applies, the benefits of this contract shall be coordi-
nated therewith and determined in accordance with the following subsections of this Section E:
i_1. The benefits of this contract shall be modified by the provisions of this Section E only when
the Carrier is the "Secondary Carrier." The Carrier is the "Secondary Carrier" when the other
f coverage has provisions which state that it will provide its full benefits regardless of the bene-
fits of this contract or when the other coverage has provisions corresponding to the provisions
of this Section E and:
I a. The patient is classified as employee or primary insured under the other coverage and as
dependent under this contract, or
L b. The patient is classified as a dependent under both the other coverage and this contract and
the person under whom coverage is held under the other coverage had greater earnings
during the calendar year preceding the year in which the claim involved is incurred than the
L person under whom coverage is held under this contract; provided that, notwithstanding
earnings, if the patient is a dependent child and persons under whom coverage is held are
not married to each other, the Carrier will not be the "Secondary Carrier" if the Carrier is
L notified prior to payment that the patient is classified as dependent of either the person
having custody of the patient or such person's spouse under this contract and as a
dependent of a person not having custody of the patient under the other coverage, or
Lc. The effective date of the patient's participation under the other coverage is earlier than the
effective date of his coverage hereunder,
or when the other coverage has provisions (hereafter referred to as "coordination of benefits
L. excess provisions") which state that it will not provide benefits for the portion of charges cov-
ered by the benefits of this contract and the above conditions would make the Carrier the
L 4,..,
co
Form No. 2205
STOCK No. 2205.000-AL479
1 saoanos Lions
to uo14euigwoo Aue waal aO `apew seen luewAed Lions wogM aol ao of wall ao uosaad Aue ao
aalueo o14nadeaay4 `ielidsoLi e `a6eaanoo aeylo 044 to aapinoJd JO aanssl ue wOal `pled aJOM
s4llaueq Lions wogM o4 AO l0 an14oedsaaal '3 uo14Oas s144 l0 suolslnoad 044 aapun peulwaejep se
uollebligo 044 to ssaoxa ul pled slllauaq JeA008J o4 awn Aue le peill4ua eq Heys aalaaea a41 •g
loaaa4. slllauaq
044 pue a6eaanoo Ja40 l0 OOualslxe 0144 6uluaa000O uo14ewaolul Hnl aalaaea 0141 04 ysluanl
i(aano0aa l0 41461a sly o4 4uepaoaad uol4lpuoO a se `Heys aapunaaay slllauaq 6ulwielo uosaad
ue pue :uosaad Aue 04 00140U JO 10 4UOSUOO 0144 lnoy41M `suolslnoad esa44 of walla anib 04
i(aesseoeu Algeuoseaa se uo14ewaolul Lions asealeJ 04 ao/pue ule4go 04 pallllue eq `aanaMoy
Heys 41 'aoanos anllellaoylne ue Aq 11 pa4sluanl uollewaolul 141!M eouepi000e Li! 3 uollOas
s1144 l0 suolslnoad 044 0l walla eAl6 04 Apo lnq `peJanooslp I! 41 aapun eigeAed slllauaq
am JO a6eaanoo aa144o 'lo eoualslxe 044 aanooslp 04 uol;e6ligo ou sawnsse aalaaea 841 •L
aapunaaa144 sao4oel lllauaq 044 l0 Lioee 04 elea (Lid Aidde 04 peweep eq
II e s 3! 96eaanoo J81410 o s aua 4 03 sa dde lunowe aigllonpap e uaLiM 'swell Lions Ile
04 elea oad Aidde 04 pawaap eq iIIM /(am. 'lunowe paleOOiieun ue ul 801AJes 10 W84i auo ue44
l(OJOW J01 JO saolnaas pezlwel! 1.11e1J00 JOJ 86eaan00 Jamo Aq papinoad aae smeueq uaLiM •g
4Oealuoo s1144 to slllauaq
peulwJelep anoge 0141 of Ienba slllauaq epinoad 'um aalaaea ay} 'panionul se6ae14o 843
10 (%09) lueoJed A4lil ue144 ssai ienba loealuoo s1144 to slllauaq peulwaa4ep anoge ay} li •o
a6eaanoo aa410 am to slllauaq peulwaalep anoge
0141 JOAO panionul sabieyo 041 to ssaoxa a44 JO 4oea4uoO s1144 to slllauaq paulwJe4ep anoge
0141 to aessal 8144 01 ienba slllauaq epinoad II!M aalaaea 841 `panionul sa6aeLio 044 to (%09)
lueoaad x(4411 ue44 ssai ienba a6eaanoo aa44o aLil aapun slllauaq peulwJe4ep anoge 8141 ll 'q
panionul se6aeyo ayi to (%09) 4ueoaad A4lll 01 ienba slllauaq
award HIM aalaaea 844 `panionul se6aego 0144 to (0 00g) 4ueoaed A4lll peeoxe JO ienba
qoea abeaenoo aa440 ayi pue loea4uoo s!44 wog aapun slllauaq paulwaalap anoge ayi lI 'e
paulwaejep eq
4sa!l IIIM uolslnoad s!144 to aouasge ayi ul panionul seaaeyo 8144 aol papinoad uaaq aney pinoM
4e44 a6eaanoo aa4lo 0144 pue loea4uoo slyl 41o4 lO slllauaq 0141 'suolslnoad ssaoxa slllauaq
Jo uo14eulpaoo0 se14 a6eaanoo Jayl0 044 pue „aalaaea Aaepuo00s„ 0144 sl aelaaea 0144 uaLiM •9
a6eaanoo aa44o l0 aouasge 844 ul aapunaaay aigeAed
eq pinoM 1O!4M slllauaq ie4o4 l0 4unowe 844 aseaaoul 04 pana4suoo eq uo14oas slyl l0 suolsln
oad ayi !legs wane ou ul 1e44 `JOAOMOy 'papinoad `swel! Lions J01 sa6aeLio ayi to aapuiewaa
a4l Aed IIIM aalaaea 0144 pue `a6eaanoo aay4o JO 'loaaa4 A aiol1a`d aapun pepinoad sl lllauaq
Aue (OILiM J01 s8OIAJOS leol6ans-Ieolpew ao/pue uolleZlielldsoy to swat! Ile l0 se6aeyo 8(4
woal pa4onpep eq Heys abeaanoo Jaylo ayi to slllauaq 844 'suolslnoad ssaoxa slllauaq to uoll
eulpaoo0 aney 40U seop a6eaanoo Ja44o 0144 pue „aalaaea Aaepuo0as„ e144 sl aalaaea ay4 uaLiM t
Am( aepue eo auo Aue 6ulanp luediogaed e o4 pa14sluanl
saolnaas a44 04 uo14eieJ ul apew eq ile14s 3 uo14oas S!141 aapun slllauaq lO uolleulw.uJelaa •g
4Oealuoo lllauaq le4uap 4e141 aapun seolnaas aso44 J01 eigeliene Sae slllauaq
d! loealuoo 51144 aapun aige jene ale slllauaq yo114M JOl SOOIAJOS Aue J01 „aalaaea Aaepuo0as„
044 paaaplsuoo eq !legs aapJea 8144 `JeAoidw3 844 04 `sexej `seilea `Auedwoa eOueansui ylleeH
0111 dnoJO Aq JO aalaaea ay4 Aq penssl sl 10ea4uo0 lllauaq Ieluap ajeaedes e 4uana 044 ui •Z
paaapuaa
Sae apew sl wlelo yo14M J01 SODIAJOs 0144 a4ep 8144 uo eauels!xa ul slOel 0144 to slseq 044 uo
peulwaalep eq !legs 3 u0110aS 5!141 to suolslnoad 044 lo A4!I!4eolidde ayi „'aelaaea Aaepu00as„
penu!;uo0) SlId3N38 AO NOI1VNIOH000 `S11d3N39 d0 1N3INAVd —AI 31011at!
ARTICLE IV— PAYMENT OF BENEFITS; COORDINATION OF BENEFITS (Continued)
1 9. When benefits have been paid under other coverage, the Carrier shall have the right, in its
discretion, to pay over to the issuer or provider of such other coverage any portion of the
benefits available under this contract which the Carrier may determine to be due in order
to give effect to the intent of this Section E and corresponding coordination of benefits pro-
visions in such other coverage. The amount so paid shall be deemed to be benefits provided
under this contract, and to the extent thereof, the Carrier shall be fully discharged from
liability hereunder.
10. If the Carrier is the "Secondary Carrier" under this Section E but is unable to determine the
benefits of the other coverage for the charges involved, it will estimate in good faith the
benefits of the other coverage and provide the benefits of this contract on the basis of that
estimate. Payment under this Subsection 10 shall constitute full discharge of the liability of the
Carrier for the charges involved, subject only to adjustment in the event the Carrier later
determines the actual benefits of the other coverage prior to the expiration of the period
set forth in Article IX, Section I.
1
I
1
I
I
l
1
j
J
by
Form No. 2225 STOCK NO. 2225.000-AL779
1 ARTICLE V- BENEFITS PROVIDED
A. BENEFITS FOR BED-PATIENT HOSPITAL EXPENSE and certain Outpatient Hospital Expense
When any participant, while covered hereunder, shall incur:
1. Bed-Patient Hospital Expense during each hospital admission in excess of the deductible,
if any, stipulated in item 1 of the Schedule, except that the deductible will not be applied to
such Expense incurred during a hospital admission primarily for treatment of an accidental
injury, or
2. Outpatient Hospital Expense for treatment of an accidental injury occurring not more than
seventy-two (72) hours preceding the outpatient visit, or for minor surgery performed during
the course of the outpatient visit,
the Carrier will pay benefits equal to the amount determined by application of the percentage
stipulated in item 2 of the Schedule to the amount of Expense involved. The excess of the
Expense involved over the above determined benefit and deductible is the participant's
Coinsurance Amount."
B. BENEFITS FOR OTHER MEDICAL EXPENSE and certain Outpatient Hospital Expense
1. Benefit:
When any participant, while covered hereunder and during a calendar year, shall incur:
1) Other Medical Expense and/or (2) Outpatient Hospital Expense for which benefits are
not available under Section A of this Article V, in excess of the deductible stipulated in
item 4 of the Schedule, the Carrier will pay benefits equal to the amount determined by
application of the percentage stipulated in item 5 of the Schedule to such excess, except
that the deductible will not be applied to any item of the above Expense that is for treat-
ment of an accidental injury which was sustained during the calendar year involved or
during the last three months of the immediately preceding calendar year. Such Expense,
minus the deductible and the benefits of this Subsection 1, is the participant's "Coinsurance
Amount" of such Expense.
2. Exceptions:
The following exceptions to the above Benefit will be applicable:
a. Any Other Medical Expense or any Outpatient Hospital Expense incurred during the
last three months of a calendar year and applied towards satisfaction of the deductible
for such calendar year may be applied towards satisfaction of the deductible for the
next succeeding calendar year.
b. When the total number of participants specified in item 6 of the Schedule under the
coverage of one employee have each, individually, satisfied the deductible stipulated in
item 4 of the Schedule for a calendar year, any other participants under that employee's
coverage will not have to satisfy a deductible for that calendar year.
C. BENEFITS FOR COMPLICATIONS OF PREGNANCY
If a participant incurs expenses for treatment of complications of pregnancy, benefits under this
contract shall be payable on the same basis as for any other sickness.
D. BENEFITS FOR MATERNITY CARE
LBenefits for maternity care under this contract are available only if the obstetrical patient has met
requirements specified under items 9a or 9b of the Schedule, and then only intheeligibilityqpY
accordance with the following:
If obstetrical patient is an employee, the amount of benefits for maternity care shall be1. I the obstetrica p Y
determined on the same basis as for any other sickness.
I oaf
Form No. 2206 STOCK NO. 2206.000-AL479
uolsslwpe lelldsoy ay; to Tuawaouawwoo
ayi 4e !Della u! alnpayoS ail to swag} ail aapun aq Minn alnpayoS bleu Lions u! palelndlls amp
anllOalla ayi awoleq 6ulauawwoo suolsslwpe lendsog Jol slllauaq leLil ldaoxa `alnpayoS Mau
Lions u! paleind!is alep anilaalia ayl Jalle pue uo loealuoo sl14l aapun luedlollaed yoea of peep
uaa SGOIAJas Ile of AIdde IHM alnpayoS Mau ayl u! saoTOed abeaano0 ayl `suolle3l;loadS Jo
alnpayoS MaU e LiIIM peoeldaa s! loealuoo sly! aol uolleoliddy agl u! alnpayoS au'Juana ayi uI
slgeueg u! so5uego •L
30V171 3A00
dO NOIlVNIWa31 a0 `30V 3A00 dO IN31A130V-1d31:1 `S11d3N38 NI S3ONVHO dO lO3dd3 .0
alnpayoS eq4 to ZL wall u! uMOys lunowe ayl paaoxa
lou Heys loealuoo s!Lil aapun luedlollaed auo Aue 04 aigeiene slllauaq to lunowe lelol aQ1
sl!{aua8 wnwixeiilf 'Z
3 uolloas to Z uolloasgns aapun pled uaaq sal wnwlxew lllauaq
ay; (E) Jo `3 uolloas to L uolloasgns aapun palsnegxe uaaq aney sAep lllauaq aaeo o!a4e1Lio
csd ail (Z) `aol palldde uaaq lou aney aaeo olJ4elyaAsd Jo]. slllauaq (L) asneoaq Japunaaag
paaanoo lou oleo ople!goAsd aoi sasuadxa apnlou! lou !legs „slunowy aOUeansuloo„ Waal ayl
3 uolloas le4 aapun panionu! saoJeLio
aLi4 JO4 L uolloasgns sly! aapun panpaao eq !legs „slunowy aoueansulo0„ ou `loealuoo s!q4 to
3 uolloas `Al aloliJV iiepun Ja!J,ieo AJepuooasagl s! JapJeo 0144 uayM ley; pap!noad `.panlonu!
aeeA aepualeo ail 6ulanp luedlollaed Lions Aq paaanoul sasuadxa Jailo Ile aol algellene
slllauaq ay; 6ululwaalap to sesodand aol (%004) wooled paapunq auo awooaq AIleo!lewolne
j IIeLis alnpayoS ay; lo 9 pue Z swell U! palelndlls sabelueoJed 8144 `alnpayoS 0144 to 11 wall u!
r palelndlls lunowe ail lelol A alollay s!Lil aapun aeaA aepualeo e aol „slunowy aoueansulo0„
s,lued!opJed a ua1M `alnpayoS 0144 to 11 wall u! aol palldde s! uo!s!noad Allanoas ayl ll
uo!srnoJd XnJnoas •L
SIId3N38 Wf1INIXVIN `•NOISIAOlad Alll:1fO3S •d
aaeo Ieo!6ologoi(sd apnloul of pawaap eq !legs „aaeo O!ale!LioAsd„ Waal ail
alnpayoS 8144 lO (q)8 wall U! palelndlls 'cue i! `wnwlxew lllauaq 0141 paaoxa lou Heys
pue alnpayoS 0144 l0 9 wall U! palelndlls a6eluaoaad lllauaq 8144 l0 na!I u! alnpayoS aLil lO (e)8
Wall u! palelndlls a6eluaoaad lllauaq ayl 6Ulsn palelnOleo eq !legs ua44 pue „`Jod pellddy„
pe pew s! alnpayoS aLil to 8 Wal! 4! Aluo algellene eq !legs aea,( aepualeo auo Aue 6ulanp aaeo
oulelyoAsd aol lued!o!Ued e Aq paaanoul sasuadxa 804 '9 uolloas `n eIO!liV JO slllauaq 0141 •Z
amp o!JTelgoAsd Lions sanOw luedlollaed e golynn uo /(ep
soli ail uo 6ulouewwOO `paaanoul aae sasuadxa Lions g3!1M uo `alnpa14OS 0t44 to E wall U!
palelndlls aeeA aepualeo pea sAep to Jagwnu 0144 aol Apo algellene eq !legs aaeo o!ale!LiOAsd
JOl ;ued!Ogaed e Aq paaanoul asuadx3 lei!dsoH lua!led-pa8 .104 A 010!tJV s!Li4 JO slllauaq 0141 l
SNOIIVlhWh1 0I1=11VIHOASd '3
eigeolldde s! wnwlxew
lllauaq a yo!ynn of OJEO A;lwalew 104 sasuadxa Aue of palldde eq lou Heys `L uolloas
qns `a uolloas `I alol4Jy u! palelndlls seamy° uo!lepoww000e Woo UO UO!4e4!W!I 0141 (Z)
nnolaq 'd uolloas iapun „slunowy aOUeJnsulo0„ paaaplsuooLeqIOUHeyswnwlxewlllauaqLionsanoqepueJOAOoleoAl!waleW .col sasuadxa Auy (1)
ley;ldeoxa `palelndlls lunowe lllauaq wnw
xeW ay; 04 do algeolldde s! wnwlxew ay; y3!ynn 0l sasuadxa amen Alluwa;ew ay;Aed Il!M
a9lJJe0 ay; 'air-loops ay; to qpl Jo/pue ep1 wail noun palOalas s! „4!laua8 wnwlxew„ y •q
JO :ssauNO!s aay;o Sue Xi se s!seq awes ay; uo pau!WJa;ap eq Heys aaeo A4lwa;ew
col slllauaq `alnpayoS ay; to gpl Jo/pue eal wail aapun paloalas sI „4!laua8 aeInbab!„ y •e
l! pue;Uepuadap a s! walled Ieo!Jlalsgo ay;11 •Z
ARTICLE V— BENEFITS PROVIDED (Continued)
1 2. Replacement of Coverage:
a. Any participant holding Catastrophic Illness coverage issued by Blue Cross of Texas
and/or Blue Shield of Texas, immediately prior to his coverage effective date under this
1 contract, who then has an established benefit period in effect, or could upon proper claim
have such a benefit period in effect on such date, shall continue to receive benefits for
the same condition in accordance with the prior Catastrophic Illness coverage for the
1
remainder of that benefit period or until the maximum benefit has been received, which-
ever occurs first, provided, however, that such benefits shall not duplicate, but shall be
considered supplemental to the benefits provided by this contract, applying only to the
charges in excess of the benefits of this contract, and provided further that any excess
for which Catastrophic Illness benefits are so provided shall not be considered as "Coin-
surance Amounts" under Section F of this Article V.
b. If this contract replaces Major Medical coverage issued by the Carrier to the Employer,
1 Major Medical benefits under the prior Major Medical coverage will not be available for
any expense incurred on or after the contract date, except as specified in c, below. Any
expenses incurred by the participants between (1) September 30 of the calendar year
i preceding the contract date and (2) the contract date, which were applied toward satis-
faction of the Major Medical deductible of the prior coverage, will be applied toward
satisfaction of the Other Medical Expense deductible of this contract.
1 c. If this contract replaces prior Blue Cross and Blue Shield coverage issued to the Em-
ployer, benefits for expenses incurred during a hospital admission commencing while
the prior coverage was in effect and continuing after the contract date shall be provided
1 in accordance with the terms of the prior coverage until the participant is discharged
J from the hospital, as though the prior coverage had remained in effect.
d. Maternity Coverage. If:
1 1) a dependent is pregnant on the effective date of her coverage hereunder, and
2) coverage hereunder replaces any coverage she may have held with Blue Cross and
1
Blue Shield of Texas, and
3) the dependent held coverage for maternity benefits under the prior coverage, and
4) no benefits are available for such pregnancy under the prior coverage, and
1 5) benefits for maternity care of the dependent involved have been applied for in item 9b
of the Schedule,
then the waiting period, if any, specified under item 9b of the Schedule will be reduced by
the period of coverage for maternity benefits under the prior coverage.
i
3. Termination of Coverage
Termination of coverage shall not operate to deprive a participant of any benefits to which
he would otherwise be entitled for Bed-Patient Hospital Expense and Other Medical Expense
J
incurred during the course of a hospital admission commencing before the date of termina-
tion; except that benefits will be provided only for expenses incurred during that hospital
admission and prior to the 90th day following the date of termination.
1
j
00a
Form No. 2207 STOCK NO. 2207.000-AL479
ARTICLE VI — LIMITATIONS AND EXCLUSIONS
1 The benefits of this contract are not available for:
A. A hospital admission for diagnostic or evaluation procedures unless the tests could not have
been performed on an outpatient basis without adversely affecting the patient's physical condition
1 or the quality of medical care rendered, provided that Bed-Patient Hospital Expense, other than
room accommodation charges, incurred during the hospital admission shall be deemed to be
Other Medical Expense and benefits for such expense shall be provided accordingly;
1 B. Any services or supplies rendered in connection with a routine physical examination; or any ser-
vices or supplies which are not medically necessary for the diagnosis or treatment of an illness,
injury, or bodily malfunction;
1 C. Any hospital services or supplies furnished by any institution or facility other than a member
hospital, a nonmember hospital, or a therapeutic center (except that in accident cases, emergency
care furnished by any governmental or licensed hospital shall be subject to benefits as provided
1 in Article V);
D. Any services or supplies for which benefits are, or could upon proper claim be provided under
the Workers' Compensation law, or any other present or future laws enacted by the Legislature
of any state, or by the Congress of the United States, or the laws, regulations or established pro-
cedures of any county or municipality; provided, however, that the exclusions of this Section
D shall not be applicable to any coverage held by the participant for hospitalization and/or
1 medical-surgical expenses which is written as a part of or in conjunction with any automobile
insurance policy;
E. Any items of Other Medical Expense or Outpatient Hospital Expense incurred for dental care and
treatments, dental surgery, or dental appliances, (1) except for covered oral surgery, or (2) unless
l such services are made necessary by accidental bodily injury effected solely through external
means and occurring while the participant is covered hereunder; provided, however, that this
I Section E shall not be applicable to services and supplies rendered to a newborn child which are
necessary for treatment or correction of a congenital defect;
F. Eyeglasses including contact lenses, hearing aids, or examinations for the purpose of determining
ivisual acuity or level of hearing;
G. Services or supplies for cosmetic purposes, except for the correction of defects incurred through
traumatic injuries sustained by the participant while covered hereunder; provided, however, that
this Section G shall not be applicable to services and supplies rendered to a newborn child which
are necessary for treatment or correction of a congenital defect;
1 H. Travel, whether or not recommended by a physician, except as provided in Article I, Section T,
i Subsection 9;
I. Any services or supplies provided during the course of a hospital admission which commences
before the patient is covered as a participant hereunder or any services or supplies provided after
the termination of his coverage, except as provided in Article V, Section G, Subsection 3, of this
contract;
1
J. Services or supplies rendered to any person who requires them by reason of acting as a donor
of any organ or element of his body, unless such person is a participant hereunder;
K. Services or supplies not specifically defined as Bed-Patient Hospital Expense, Outpatient Hospital
1 Expense, or Other Medical Expense;
L. Any medical social services or occupational therapy services;
i M. Any services or supplies rendered to any participant for reduction of obesity or weight, including
surgical procedures.
u.
Form No. 2208 STOCK No. 2208.000-AL479
ARTICLE VII — TERMINATION OF COVERAGE
1 A. The coverage of all participants hereunder shall automatically terminate when this contract is
terminated in any manner, as follows:
1. By cancellation on any premium due date, at the request in writing of the Employer fur-
1 nished to the Carrier at its Home Office, not less than thirty (30) days in advance;
2. By default in premium payment, subject to the grace period provided in Article III;
3. By failure of the Employer to maintain enrollment of its employees hereunder at a level of
1 at least seventy-five percent (75%) of the total eligible number, with a minimum enrollment of
ten (10) employees; provided that the Carrier shall first notify the Employer of such enrollment
deficiency, and provided further that the contract shall not terminate if, within the thirty (30)
1 days following such notification, the deficiency is remedied. In the event of failure to remedy
the enrollment deficiency in such case, the date of termination of this contract shall be the
last day of the contract month following the month in which the deficiency notification is
furnished.
B. The coverage of any employee and his dependents included hereunder shall automatically ter-
minate upon:
1. The last day of the last period for which his portion of the group premium is paid to the
l Carrier; provided that the Employer may terminate the coverage of any employee on the last
day of any contract month for which premiums for such employee have been received by the
1 Carrier prior to the end of such month and any premiums for such employee that are appli-
cable to succeeding contract months will be refunded by the Carrier to the Employer upon
request.
2. The effective date of an amendment to this contract which terminates the coverage of any
class of employees to which he belongs.
C. The coverage of any dependent of an employee included hereunder shall automatically terminate
1 at the end of the contract month in which such dependent ceases to be a dependent as defined in
Article I, Section C, of this contract. In the event of termination of coverage under this section
due to death of the dependent, the Carrier will refund to the Employer premiums paid for the
dependent for contract months subsequent to the date of death, up to tweny-four (24) contract
months prior to notification to the Carrier of the death. In the event of termination of coverage
under this section for any other reason, refund to the Employer of premiums paid for the
dependent for contract months subsequent to the date of coverage termination shall be limited
Ito contract months following the date of notification to the Carrier of the termination of the
dependent.
D. Under no circumstances shall the Carrier be obligated to-notify any participant of the termination
of this contract or of his coverage hereunder.
E. Notwithstanding the above provisions of this Article VII, if the Employer is paying an employee's
J
premiums in whole or in part pursuant to the terms of a collective bargaining agreement and in
the event of cessation of work as the result of a labor dispute by its employees who are members
of the bargaining unit, coverage under this contract for such employees and their dependents
hereunder shall terminate on the last day of the contract month in which such cessation of work
Ibegan; except that coverage under this contract may be continued for such employee and depend-
ents for a period of up to six (6) additional contract months, provided that for each such addi-
tional contract month:
1 1. Coverage of at least seventy-five (75%) of the employees, who are members of the bargaining
unit and who cease working due to the labor dispute, is maintained; and
J
2. A single payment for the premiums due from such employees is remitted within the grace
period for such premium payment.
The Carrier reserves the right to adjust premium rates for such employees which shall be payable
for such additional contract months.
cif NIIIIIIIIIIIMIIIIIIIIIMEIEIIE.
STo K No. 2209.000-ALG74
ARTICLE VIII - CONVERSION PRIVILEGE
1 A. When coverage for an employee is terminated hereunder by reason of cessation of employment,
he shall have the right of conversion for all participants included thereunder to new individual
coverage as provided for in Section D, below.
B. When coverage for an employee is terminated hereunder by reason of death, his or her surviving
spouse, if then included as a dependent hereunder, shall have the right of conversion to new indi-
vidual coverage for himself or herself and the other previously included dependents as provided
for in Section D, below. When coverage for a dependent spouse is terminated hereunder by reason
of divorce from the employee, such spouse shall have the right of conversion to new individual
coverage for himself or herself as provided for in Section D, below.
C. When coverage for a dependent child is terminated hereunder by reason of marriage or attain-
ment of age twenty-five (25), he shall have the right of conversion to new individual coverage as
I
provided for in Section D, below.
D. Any person becoming eligible for conversion as provided for in the three preceding sections of
this Article VIII may, within thirty-one (31) days after termination of his coverage hereunder, submit
application for new individual hospitalization and medical-surgical coverage under the form or
forms of contracts then offered by the Carrier to conversion applicants. The contract applied for
will be issued, without requirement of evidence of insurability, at the conversion premium rates
then in effect. The individual contract will be made effective as of the day after the date of the
termination hereunder, and full recognition will be extended to the period of coverage hereunder
for the satisfaction of waiting periods and clauses respecting preexisting conditions as may be
contained in the individual contract.
1
I
l
j
I
j
rO
Form No. 2210 STOCK NO, 2210,000-AL479
ARTICLE IX- GENERAL PROVISIONS
1
A. CONTRACT; AMENDMENTS:
1. This contract and the Application of the Employer herefor, a copy of which is attached hereto,
and the applications of employees shall constitute the entire contract. All statements made by
1 the Employer or by the employees covered shall be deemed representations and not war-
I ranties, and no statement made by any employee covered shall be used in any contest or
in defense of a claim hereunder unless a copy of the instrument containing the statement
1 is or has been furnished to such person or to his beneficiary.
2. This contract may be amended or changed at any time, subject to the laws of the jurisdiction
in which it is delivered, without the consent of the employees covered hereunder or of their
1 beneficiaries, by written agreement between the Employer and the Carrier. Only the President,
a Vice President, the Secretary, or an Assistant Secretary of the Carrier has the power to
change, modify, or waive the provisions of this contract, and then only in writing done at the
Home Office. The Carrier shall not be bound by any promise or representation heretofore or
1 hereafter made by or to any agent other than specified above.
B. INCONTESTABILITY: This contract shall be incontestable after two years from date of issue
iexcept for nonpayment of premiums.
C. TIME LIMIT ON CERTAIN DEFENSES: After one year from the effective date of coverage for any
j employee, no misstatements, except fraudulent misstatements, made in his application for cover-
age shall be used to void his coverage or to deny a claim for benefits on account of care
rendered after the expiration of such one-year period.
1 D. REINSTATMENT: If default be made in the premium payments for this contract, the subsequent
acceptance of such premium by the Carrier or any of its duly authorized agents shall fully reinstate
the contract.
1 E. NOTICE OF CLAIM: The employee shall give or cause to be given written notice to the Home
Office of the Carrier at Dallas, Texas or its duly authorized agent within thirty (30) days or as
1 soon as reasonably possible after any participant receives any of the services for which benefits
are provided herein. Notice given to any member hospital at the time of admission therein as a
bed patient shall satisfy this requirement for care rendered by such hospital.
lF. CLAIM FORMS: The Carrier will furnish to the employee, the hospital, and/or the participant's
physician, upon receipt of a notice of claim or prior thereto, such forms as are usually furnished
by it for filing proof of loss. If such forms are not furnished within fifteen (15) days after the
giving of such notice, the participant shall be deemed to have complied with the requirements
of this contract as to proof of loss upon submitting, within the time fixed in the contract for filing
proofs of loss, written proof covering the occurrence, the character and the extent of the loss for
iwhich claim is made.
G. PROOFS OF LOSS: Except for Bed-Patient Hospital care rendered by a member hospital, written
proof of loss must be furnished to the Home Office of the Carrier at Dallas, Texas or its duly
authorized agent by the employee, except in the absence of legal capacity, prior to the end of
the calendar year following the year in which the services or supplies are furnished to the
participant involved; provided, however, that any expenses incurred during the last three (3)
1 months of a calendar year shall be deemed to have been incurred during the succeeding calendar
year for purposes of this Section G.
I H. TIME OF PAYMENT OF CLAIMS: Benefits payable under this contract for any loss will be paid
immediately upon receipt of due written proof of such loss.
ITEMINIMM111111111MIEM =__ , 11111EIMIMM11111111111111111111ME
Form No. 2211 STOCK No. 2211.000-AL479
1
I1
aolnaas aelnollaed
e 141lM uolloeuuoO uI aoualaadxa pue awl; leuolllppe 6up!nbeJ suoneolldwoo leolpaw JO
seouelswnoalo lensnun pue 'aoualaadxa pue bululea4 aellwls 14}lM Ai COOl 0144 ul suelolS,cgd Aq apew
IcIlaewolsn3 saolnaas aellwls ao4 sa6aeyo 0141 'aolnaas 0141 6ulaapuaa Ue1OisA14d ay} Aq apew AIlensn
1 SO3IAJOS aelllwls J04 sa6aey0 0141 aaplsuoo 'legs aalaae0 0144 `uelolsA14d e Aq paaapuaa aolnaas
e aol a6aeyO elgeuoseaa 0141 6ululwaalap ul :391d\1HO 318\1NOS\13d dO NOIl\1NIWf1313a D
waded oleudoadde lie jo uol4noaxa 6ulpnIoUI `Aaanooaa 0141 aanoas 01 Aaessaoau
aq (ew aana1e1M op 04 paaa6e aAey o4 pue aalaae0 am 01 AJOA000a Jo s1Li6la Lions pau6lsse GAEL'
o pawaap aq I1egs 'aseo Lions uI aapunaaaq s4l4auaq 6ulnlaoaa Aq `luedlol1aed Au\1 •papinaad os
S4IJauaq 0141 to wave 0141 of Apo ing `aapunaaag papinoad OJE smauaq LiolgM aol Aanfu! JO Ssaulll
uI §U!Unsaa 40e In11IIM Aue JO aouabil6au a04 uonezIUe6ao JO uosaad Aue }sule6e aalnboe Aew
lued!011aed Aue 1OILM AJ0AoO8a 40 sly6la 11e 01 pale6oagns eq lleys aalaae0 0141 :NOI1\10O1{8f1S •d
JGlJJCO a141 01 luawAed Lions puniaa `puewap uodn 'Heys
Agaaagl 6ullllaueq 1Uedlol}aed aa144o JO eeAo'dwa eql `pallllue A11e6a1 lou seM waned am g3lgM 04
aapuneJeq pied uaaq aney smeueq Ieyl paulwaalap eq Ileys 1! UayM pue :S11d3N38 dO GNfld3a •O
pue uol4ewaoJul Lions 40 aansoloslp 0141 6Ulpplga04 Mel 4o suolslnoad lie panleM aney o4
pawaap eq `aapunaaaq s4I4aueq aol wlelo bullaasse Aq ''legs slued!O!}aed Lions pue :ebeaanoo
S!ym aapun pepnloul luedlollaed Aue 4C) 9.1E0 JO 'luawleaa1 'sisoubeip a141 04 bulleIaa spaooaa jo
saldoo JO spaooaa pue uol4ewaolu! Ile aalaae0 ay; ysluan} 04 aalua3 ognedCJegl JO `Ielldsoy 'asanu
ue!OlsAyd 6ulpual4e Aue pezlaoylne aney 01 pawaap eq Ilegs `sluapuedep paaanoo sly pue flaswly
o leyaq uo 'eeAoldwe 8141 `aapunaaaq a6eaano3 a04 uo1leoildde ay; y4IM Uolloauuoo ul uolleu
Iwexe leolsA14d panleM 6ulney aalaae0 am 40 uogeaaplsuoo UI :NOIlVZIUGHlfld 3EIflSO1OSIO •N
le4ldsoq Lions 04 algelde3oe Aanful JO ssaulll aoJ Apo algellene aJE pue 'IUedlollaed ay} Aq pape es
lelldso1 0141 40 Suolleln6aa pue salmi an 04 loafgns aae sl!laue8 •SeOlnaas ao suo!Iepowwo3Oe
ysluan of aallddns ,cue 4o i(411lgeul ao4 aapunaaa14 Sayoele A1lIlglsuodsaa ou pue 'IoealuoO s!141
aapun sa3lnaas 6Ulnlaoaa luedlol4aed E ao4 6Ulaeo ul 'saaAoldwa JO s4Ua6e J!ay4 'ue!OlsALid `aalua0
onnedeaagl `le4ldsoq AUC Aq uolsslwo JO 4Oe Cue ao4 aigell eq lou Heys aalaae0 0141 :U31A1I\11OSIG
a6eaanoo Lions Li! Sa6Ue1O Uol4eulwaal pue aapUnaaa14 sauapuadap pue seeAoldwe to a6eaanoO
10al4a 04 papaau uo!1ewaolui lie aalaae0 ayl gsluanl Pegs aacoldw3 0141 :\11\1a 39\1EI3AO0 '1
AaealuoO ay} SaleOlpul AIaealO lxa4000 ay; ssalun aUlulwal ay}
epnIOU! 01 pawaap eq IIELiS aapua6 aullnOSew 0141 u! Unouoad leuosaad a 40 U1Oaay asn :1:13CIN3J •N
I eba11nlad uolsaanuo0„
pall!lua }OealuoO sly1 }o IIIA 0lolla\1 Jo suolslnoad 0141 pue `algeced GJE Sll;auaq 0144 woyM
01 'pallllua si ay y011-IM 01 smaueq am 01 se luawalels a 141101 6ulllas aleO1114aao lenpinlpui ue
aacoldwa paaanoo 14Oea aol aaAoIdw3 aye 01 anss! 11!M aalaae0 0141 :31\1Old11a30 1\1f1CIAIONI •f
apew s!
J w!E'o 14o!LiM ao) S00!AJeS 8141 4o uo!}lpuaa to amp ay; aalie sJEac aaa41 Uly4!M ly6noaq ssalun
panuOO slg4 aapun J0AOO8a o4 1gbnoaq eq Ilegs u! JO Mel le uol4Oe oN :SNOIIO`d 1\1031 'I
1
AMENDMENT NO.1
TO
Group Comprehensive Blue Cross and Blue Shield Contract No. 5448
The effective date of this amendment shall be November 1, 1980
1 Article III of this contract is amended by deleting the wording of this
Article in its entirety and substituting the following:
1 ARTICLE III - PREMIUMS
The term "Deposit Premium" as defined in the Minimum Funding Cost-Plus
Agreement between the Employer and Group Hospital Service, Inc. shall
constitute "Premiums."
1 Form No. V-3-002
Article VI of this contract is amended by deleting the wording of Section
F in its entirety and substituting the following:
F. Eyeglasses including contact lenses, hearing aids, or examinations
for the prescription or fitting thereof, or examinations for the
purpose of determining visual acuity or level of hearing;
Form No. V-6F-001
I
This amendment shall become effective on the date stipulated above, provided that (1) it is accepted in writing
by the Employer; (2) payment of the premium for the first month after the effective date is received by Group
Hospital Service, Inc.; and (3) in the event of any alteration of this amendment, such alteration is accepted in
writing by Group Hospital Service, Inc.
1
GROUP HOSPITAL SERVICE, INC.
r
By:
J//)
W. F.
J/(
H aa'c//hmeister, P s'ident
1202,
mil/•
Registrar
Date
j
Form No. 2217 Stock No. 2217.000-N479
ooa V
1 This Application Is Hereby Made to
GROUP HOSPITAL SERVICE, INC.
1
Dallas,Texas
by the Employer named below for a Group Comprehensive Blue Cross and Blue Shield Contract, Form No.
1
CBCBS-2, in accordance with the stipulations set out herein. The Contract Number shall be 514148
SCHEDULE OF SPECIFICATIONS
1 in any space means See Special Provisions. N.L. in any space means No Limit.XXX in any
space means Coverage Factor Inapplicable or Not Applied For.
COVERAGE FACTORS
Item BED-PATIENT HOSPITAL EXPENSE BENEFITS
1 No.
1 Deductible per admission XXX
2 Benefit Percentage 80
l3 Maximum number of days available for Psychiatric Care
OTHER MEDICAL EXPENSE BENEFITS
4 Deductible each calendar year 150.00
1 5 Benefit Percentage 80
3rofparticipantsrequiredforFamilyDeductible6NumbeoPP4Y
7 Out-of-Hospital Drugs p Applied For Not Applied For
8 Psychiatric Care p Applied For Not Applied For
a. Psychiatric Care Benefit Percentage 80
b. Maximum Psychiatric Care Benefit 1 ,000.00
1 ELIGIBILITY REQUIREMENTS FOR MATERNITY CARE BENEFITS
x" in a block means provision preceding is applicable to this contract)
9 a. EMPLOYEES
1 All employees are eligible for Maternity Care Benefits under this contract
p Applied For Not Applied For
9 b. DEPENDENTS
l Spouses of Employees p Applied For Not Applied For
Dependent Children Applied For Not Applied For
are eligible for Maternity Care Benefits under this contract if the obstetrical patient holds
i coverage for maternity care under this contract
continuously from conception to delivery (maternity waiting period)
at delivery
MATERNITY CARE BENEFITS FOR DEPENDENTS
10 a. Bed-Patient Hospital Expense(Applicable to Article V, Section A)
Regular Benefit
I Maximum Benefit Per Pregnancy XXX
b. Other Medical Expense (Applicable to Article V,Section B)
M Regular Benefit
i
Maximum Benefit Per Pregnancy XXX
SECURITY PROVISION
11 n Applied For Not Applied For Coinsurance Amount 1 ,000.00
i MAXIMUM BENEFITS
12 Maximum Lifetime Benefits available to each participant
1 ,000,000
Form No. CBCBS-2-App.1 Page 1 Stock No. 2212.000-N479
1 ELIGIBILITY REGULATIONS: Persons eligible to apply for coverage under the contract shall be the
employees of the Employer named below
1
60 period of nwhohavebeencontinuouslyemployedfornotlessthan _days. No peso o continuous
employment shall be required for employees otherwise eligible on the Contract Date Yes ®No.
EFFECTIVE DATES: The effective dates of individual applications are to be handled under the terms of:
El Standard Option fl Option I p Option II 0 Other (Specify under Special Provisions)
1 END OF SCHEDULE OF SPECIFICATIONS*************
CONTRACT DATES: The Contract Date is November_L__ 19 80 . The first contract
1 anniversary shall be November 1 1981—, whether or not the two dates are separated by
twelve months.
1
MINIMUM ENROLLMENT REQUIREMENTS:The Employer certifies that 917 employees are eligible
to make application for coverage at the date of this group application, and agrees that at least 75% of that
number (10 minimum) must make application for coverage before the Contract Date, otherwise this applica-
1
tion shall be deemed to have been withdrawn.
PREMIUMS:The Employer will provide payroll deduction facilities for the employee's portion of the premium
and make consolidated group premium remittances.The following shall be the initial monthly premium rates:
1 Employee, spouse
Employee Employee Employee and Employee and and dependent child
Only and Spouse Dependent child Dependent children or children
I
The above monthly premium rates shall be subject to change on the fi rst contract
anniversary. As of the Contract Date, the amount of Employer contribution is: total employee rate
1 with no contribution toward dependents.
S ECIA PROV SIO S: The following stipulations shall be cogsider d a pat of this application:
Amenament No. I to the contract has been reviewed by the Employer prior to
execution of this application and the contents of such amendment are acceptable.
Form No. V—SP-001
1
Minimum Funding Cost Plus Agreement — No Rates Billed.
i
The contract and the coverage provided thereunder shall become effective on the Contract Date stipulated
above under Contract Dates, provided that (1) this application is executed in duplicate; (2) payment of the
first month's premium is received by Group Hospital Service, Inc.; and (3) in the event of any alteration of
this application, such alteration is accepted in writing by Group Hospital Service, Inc.
jEmployer: City of Wichita Falls
1
Wichita Falls. Texas
Cit nd State)
by
t Backpignat dMa nager
Signed at . l 1 Witness:'
On 191 1 _
Representative of the Carrier
Form No. 2213 Page 2 Stock No. 2213.000-N479
1
c
GROUP HOSPITAL SERVICE, INC.
Herein called the Carrier)
Dallas, Texas
has issued this
Non-Cancellable
r EXPERIENCE RATED GROUP DENTAL CONTRACT
Herein called the Contract)
to the Employer named in the application herefor and thereby the Carrier agrees to provide the
benefits detailed herein, all in accordance with the conditions and provisions hereof, including
those set out on the following pages which are a part of this contract as fully as if recited over
1 the signatures hereto affixed.
This contract is issued in consideration of the application herefor made by the Employer and
of the timely payment of premiums as provided for herein. It will become effective on the
Contract Date stipulated in such application and will be continued in force, subject to the
Employer's right of termination, for so long as the minimum employee participation is maintained,
as set out in Article VII.
IN WITNESS WHEREOF, the Carrier has caused this contract to be executed at its Home Office
in Dallas, Texas.
L
d0Le I Q President
Secretary
Countersigned:Q 0.
Registrar
t _
L_
Form No. GOC-2
2800.000—AL580
1, ' ' .
LARTICLE I-DEFINITIONS
AS USED HEREIN:
L
A. EMPLOYER means, in addition to the person, firm or institution named in the application
herefor, any subsidiary or affiliate listed as such under Eligibility Regulations in the Schedule.
B. EMPLOYEE means a person who regularly renders personal services, not less than one
hundred twenty (120) hours per month in the business of the Employer, and who (except
in the case of a proprietor, partner, or corporation officer or director) is compensated
for such services by salary or wages.
LC. DEPENDENT means:
1. An employee's spouse or
2. Any unmarried child, who is either under twenty-five (25) years of age or disabled; pro-
Ivided that in the case of a disabled child twenty-five (25) years of age or older, such
child is dependent upon the Employee for more than one-half of his support as defined
by the Internal Revenue Code of the United States.
I Disabled" means any medically determinable physical or mental condition which prevents
the child from engaging in self-sustaining employment; provided that the disability corn-
mences prior to such child's attainment of age twenty-five (25) and that satisfactory proofIofsuchdisabilityanddependencyissubmittedbytheEmployeewithinthirty-one (31) days
following such child's attainment of age twenty-five (25).
Child" means the natural child of the employee; a legally adopted child (including a child
living with the adopting parents during the period of probation); a stepchild residing in the
Employee's household; or a child permanently residing in the household of which the
Employee is the head and to whom the Employee is legal guardian or related to the child
by blood or marriage.
As a condition to the continued coverage of a child as a disabled Dependent beyond the
L
age of twenty-five (25), the Carrier shall have the right to require periodic certification of
the child's physical or mental condition but not more frequently than annually after the
two-year period following the child's attainment of age twenty-five (25).
L
D. PARTICIPANT means an Employee or a Dependent, as above defined, whose application
for coverage hereunder has been accepted by the Carrier.
E. CONTRACT MONTH means each succeeding monthly period, beginning on the contract date.
L F. CONTRACT YEAR means each succeeding twelve-month period, beginning on the effective
date of coverage hereunder for the Employee concerned, whether the care invoking benefits
is rendered to the Employee or to a Dependent under his coverage.
LG. CONTRACT ANNIVERSARY means the month, day and year specified in the Application for
this contract and the corresponding date in each year thereafter for as long as this contract
is in force.
LH. SCHEDULE means the Schedule of Specifications appearing in the Employer's Application
for this contract, or the latest of any revised schedules mutually agreed to by the Employer
L
and the Carrier to replace one previously in effect, provided that if more than one Schedule
of Specifications is in effect under this contract, the term shall mean, for each Employee
covered hereunder, and for each Participant under his coverage, the Schedule of Specifica-
tions which has Eligibility Regulations that are applicable to such Employee.
LI. COVERED DENTAL EXPENSES means the professionally recognized Dental services or
appliances provided to a Participant by a Dentist on or after the effective date of coverage
for which the Employee acquires an obligation for payment.
L
L
Form No. 2801 2801.000—A L679
f-
I
F
I
I
la){oiu JO 'l'egoa `aaddoo 'ewoiyo 'deals ssaIuiels se
Lions `amen oisuialui 'epode ou to sielaw aseq to sAolle sueaw S1b13IN S11013 31:1d-NON 'd
wnuileld se Lions `amen
oisuialu! leioads to sew asogi JO sielaw amou to si(ojie sueaw S'Id13W Sf1OIO31:IdIW3S '0
Ielew piob %09 lseal le 6uiuieluoo sAolle sueaw 0100 'N
anisnioui `Gg aagweoaa 6uipaaoons
lxau a uo 6ui ua pue Aaenue e uo 6uiouewwoo oiled e l sueawLi3PPlfPy QO11:13d 1133N38 'W
sexal to apoa aouainsui aq1 to 0L•s aloilay Aq wayl of pau6isse 6uiueaw aql
aneq Heys `uiaaay pasn se Ayledoelsa to aolooa JO auioipaW to aolooa `Aalsiluaa to aolooa
swaal ayl •Ayledoalsa to aolooa e JO auioipaw to aolooa e si O M uosaad a apnIou! osJe
LHeys pue (eaa6ap 'a•W'a JO •s•a•a) ialsquaa to aolooa a si oynn uosaad a sueaw 1SIIN3a
quailed ayl of waey aIgeJedaaai luanaad of
lsiluaa e to uoilualle ale!pawwi aql 6uiainbaa suoilipuoo cweaodwal JO wed woe
L aleinaile of IGesseoeu saanpaooad leluaa Aue sueawJN3Wld3HI 3AI1VI'11Vd A3N30U IN3
sluawleaal ao saanpaooad Lions .iol paeu ayl
6u!leanaa 'cRuaaanouoo uoileuiwexa leluaa a woal 6uilinsaa saunas pauueld e u! lsiluaa e Aq
pewaolaad sluawleaal ao saanpaooad 'eluaa to aagwnu Aue sueaw 1N3WiV3li1 dO 3Sdf1OO 'r
L
CARTICLE II-ELIGIBILITY FOR COVERAGE; EFFECTIVE DATES
A. ELIGIBILITY FOR COVERAGE
1. Any Employee of the classifications described under Eligibility Regulations in the
Schedule shall, upon the later of completion of the length of service therein specified
f
or the contract date, become eligible to apply for coverage hereunder for himself or for
himself and his family members as Dependents.
2. Family members acquired after the effective date of the Employee's coverage shall
become eligible on the date the family member becomes a Dependent as defined in
Article I, Section C, of this contract.
3. Coverage of the Employee shall be a condition precedent to coverage of his eligible
Dependents.
1. B. APPLICATION FOR COVERAGE
Coverage of each eligible Employee or Dependent shall be contingent upon the Employee's
making application therefor in accordance with the approved procedures established by
I the Carrier;thereupon, subject to acceptance by the Carrier, coverage shall become effective
in accordance with the following sections of this Article II.
1_ C. EFFECTIVE DATES—EMPLOYEES
If the application is for coverage of an Employee or of an Employee and his eligible
Dependents, and
1. If the Employee is eligible on the contract date and if the application is made prior
thereto, the coverage shall become effective on the contract date.
1 2. If the Employee becomes eligible on or after the contract date and if the application is
made after the contract date but within the first thirty (30) days following the date of
eligibility, and
La. If "Standard Option" is specified under Effective Dates in the Schedule, the coverage
shall become effective on the Employee's date of eligibility;
i__b. If "Option I" is specified under Effective Dates in the Schedule, the coverage shall
become effective on the second premium due date following the date that the applica-
Ltion is made;
c. If "Option II" is specified under Effective Dates in the Schedule, the coverage shall
L become effective on the first premium due date following the date that the application
is made.
3. If the application is made more than thirty (30) days after the date such Employee
L becomes eligible, the coverage shall become effective on the succeeding contract
anniversary which occurs at least thirty (30) days after the application is made.
L 4. Regardless of the above subsections of this Section C, if "Other" is specified under Effec-
tive Dates in the Schedule, coverage shall become effective as set forth thereunder.
L
eW i
L
Form No. 2802 2802.000-AL679
F
1
F
U
pa;t!wgns s! uol;eolt!tou Lions step ay; 6u!nno!!ot
amp anp wn!waJd puoaas ay; o; y;a!q to a;ep ay; wait anp swn!waJd !!e ;!waa (Z)
I
pue 'y;a!q to a;ep ay; woo; sy;uow (u) uaa;a!y; uey; as;e! `tp!oedeo !e6ai
to aouesge ay; u! ;daoxa 'wane ou u! pue a!q!ssod A!geuoseaa seen se uoos se
pattlwgns seen uo!;eo!t!tou ay; teg; pue y;alq to a;ep 6u!nno!!ot step (Gs) auo-Ata!yt
U qpM uo!;eo!t!tou ;!wgns o; a!glssod t!geuoseaa tou sem t! tey; MOWS (q) JO Li;alq
to a;ep 6u!nno!!ot step (G£) auo-A;a!y; ;sa!t ay; u!y;!nn uolteolt!tou ;!wgns (e) aaLi;!a (G)
tsnw eeAo!dw3 ay; 'sep (;sGc) ;salt-A;aly; Lions 6uIMOHot page u! aq o;
a6eaanoo Jot ;BLit pap!noad a!q to a;ep ay; 6u!nno!Iot cep (;six) ;sa!1-41!y; ay; y6noay;
Li;a!q to a;ep ay; wait page u! aq Heys a;ep an!;oatta s,aato!dw3 ay; aa;te wog p!!qo e
to 86ea8noo `a uo!;oas s!Li; to `anoge 'Z uo!toasgns to suo!s!noad ay; 6u!pue;sy;!nn;oN •c
apew s! uo!;eo!!dde
ay; aa;te step (o£) A;a!yt ;sea! ;e 6u!aan000 Aaesaan!uue ;oea;uoo 6u!peaoons ay; (Z)
10 :uo!;eo!!dde
ay; to td!aoaa aa;te step (06) Ateulu ;sea! ;e bu!aan000 amp anp wn!waid tsa!t all (G)
satep 6u!nno!!ot all to aa!!aea ay; uo ant;oatta awooaq Heys a6eaenoo ay;
wn!waad u! aseaaau! ue u! t!nsaa saop a6eaanoo ay; o; ;uapuadaa ay;to uo!;!ppe ay;II •q
wn!waad u! aseaaau! ue
u! pat!nse., ane1 ;ou p!nonn tuapuedea ay; to uo!t!ppe ay; go!ynn uo amp ;salt ay; (Z)
JO ';uapuadaa ay; to Agi!q!6!!a to a;ep ay; (G)
to as;e!ay;uo an!;oatta awooaq Heys a6eaanoo ay; `uogea!!dde to a;ep all uo wn!wead
u! aseaaau! ue u! tinsel tou saop a6eaanoo ay; 04 ;uapuadaa ay; to uo!;!ppe ayt tI •e
snno!!ot se an!;oatta awooaq !lays a6eaanoo ay; `a!q!6!!a sawooaqLtuapuadaaay; a;ep ay; as;te step (0£) Ata!yt ueyt wow apew s! uo!;eo!Idde ay; t! •Z
A;!!!q!6!Ia to a;ep s,tuapuadaa ay; uo an!;oatta awooaq Heys 86eaanoo
At!!!q!6!!a to a;ep ay; 6u!nno!!ot step (OE) Ata!y; ;salt ay; u!ypnn ;nq atep toea;uoo ay;
aatte apew s! uoReo!!dde pue a;ep ;oea;uoo 0144 aa;te ao uo °K!6!!° s! ;uapuadaa ay; t! •1.
pue toeatuoo aapun
06eaanoo 6uney (peaa!e aei(o!dw3 ue to uapuadaa e a6eaanoo lot Si uo!;eo!!dde eta t!
S1N31N3d30—Salvo 3AI133d33 'a
ARTICLE III-PREMIUMS
A. The premium rates initially effective shall be shown under "Premiums" in the Employer's
1 Application, and continuance of the coverage hereunder shall be contingent upon payment
of the premiums by the Employer at the Home Office of the Carrier in Dallas, Texas, in
accordance with the following provisions: the first premium is due on the contract date;
1 subsequent premiums are, during the continuance of this contract, payable in advance. No
payment shall be accepted by the Carrier which does not represent a total monthly premium.
B. This contract shall be nonassessable. It does not share in the earnings of the Carrier, but
the Carrier reserves the right to change the premium rates on any contract anniversary, as
applicable to the succeeding year, commencing with the contract anniversary stipulated in
the Application, provided that:
1. If the Carrier does not anyathepremiumrateson of the above Contract Anniver-
saries,
Y
saries, it shall have the right to change premium rates once on any premium due date
1 occurring between such Contract Anniversary and the next succeeding Contract Anniver-
sary and such change shall be applicable to the Contract Months succeeding such
premium due date;
1 2. In the event price controls are established by the state or federal governments while this
contract is in effect, the Carrier reserves the right to adjust premium rates on any premium
due date occurring between the date of imposition of such controls and the Contract
Anniversary following termination of such controls.
Any such change shall be made uniformly applicable to all Employees within any subgroup
or other classification under this contract.
C. Premiums may be paid on a monthly, quarterly, semiannual, or annual basis as the Employer
may elect, but without discount. Unearned premiums for Employees whose coverage here-
under terminates at other than premium due dates shall be calculated and refunded from
the end of the Contract Month during which the Employee ceased to be eligible for coverage
hereunder.
D. The premium to be paid hereunder shall be determined by multiplying the number of
Employees covered for each classification by the rate then applicable for that classification,
and totalling the extensions thus obtained; provided, however, that for Participants whoss
coverage becomes effective in accordance with Article II on other than the first day of a
Contract Month, no premium shall be due for any portion of the Contract Month in which
the coverage becomes effective.
E. A grace period of thirty-one (31) days, without interest charge, shall be allowed for the pay-
ment of each premium except the first. If any premium is not paid within the grace period,
this contract shall terminate at the end of such grace period, except that the contract shall
terminate at an earlier date (which is not prior to the end of the period for which premiums
have been paid) provided the Employer shall have given the Carrier written notice of such
earlier date of termination in accordance with the provisions of Article VII, Section A. If the
contract terminates during or at the end of the grace period, the Employer shall be liable to
the Carrier for payment of a pro rata premium for the time the contract was in force during
1
the grace period. The allowance of the grace period is applicable only to the total premium,
and shall not be construed so as to extend the coverage of any Employee for whom a
premium has not been paid as a part of the group remittance.
1
ti .
Fnrm Nn. 2,Ing cm nnn_eI A70
1 ARTICLE IV—PAYMENT OF BENEFITS; COORDINATION OF BENEFITS
A. Subject to the qualifications, limitations and exclusions set forth herein, when obligated for
the provision of benefits hereunder, the Carrier will pay the Dentist's charges for services
rendered in accordance with Article V, provided, however, that:
1
1. If payment is based on a Schedule of Indemnity Allowances, such payment shall not
exceed the amount specified in the Schedule of Indemnity Allowances, or
2. If payment is made on a Usual, Customary and Reasonable Charge basis, the Carrier
reserves the right to predetermine any services for which benefits are payable, and
3. In all events such services must be performed by a Dentist as defined herein.
It is understood and agreed that the benefits as set out in Article V are not intended to and
do not fix the value of the services of the attending Dentist nor in any way relate to or regulate
such value; that the attending Dentist is privileged to make his regular charges and that the
stipulated amounts are merely to apply as credits thereon. All payments for Dental Proce-
dures as set forth in Article V are payable to the Dentist rendering the service or the Employee
as the Carrier may elect. Such payment in either event shall constitute full discharge of all
responsibility of the Carrier to the Employee for benefits on account of such services.
B. Any benefits hereunder, payable to the Employee, shall, if unpaid at his death, be paid to the
1
Dentist or to the surviving spouse of the Employee, as beneficiary; if there is no surviving
spouse, then such benefits may be paid to the Employee's estate.
C. The benefits provided hereunder are not assignable.
D. It is hereby declared to be the intent of the Employer and the Carrier that the availability of
the benefits herein specified shall be contingent upon the absence of other coverage. Any
other contract or policy or employee welfare benefit plan under which the Participant holds
protection for Dental expenses by virtue of his membership in or relation to a particular
group shall be considered "other coverage" within the meaning hereof, whether the
benefits are in the nature of indemnity or prepaid services. The term shall likewise be deemed
to include any governmental program existing by statutory authority under which he is
entitled to Dental benefits. The term shall not be deemed to include any coverage held by
the participant for Dental expenses which is written as a part of or in conjunction with any
1 automobile casualty insurance policy. When, therefore, other coverage applies, the benefits
of this contract shall be coordinated therewith and determined in accordance with the
following subsections of this Section D:
1. The benefits of this contract shall be modified by the provisions of this Section D only
when the Carrier is the "Secondary Carrier."The Carrier is the "Secondary Carrier" when
the other coverage has provisions which state that it will provide its full benefits regardless
of the benefits of this contract or when the other coverage has provisions corresponding
to the provisions of this Section D and:
J a. The patient is classified as Employee or primary insured under the other coverage and
as Dependent under this contract, or
b. The patient is classified as a Dependent under both the other coverage and this con-
tract and the person under whom coverage is held under the other coverage had
greater earnings during the calendar year preceding the year in which the claim
involved is incurred than the person under whom coverage is held under this contract;
provided that, notwithstanding earnings, if the patient is a Dependent child and persons
Form No. 2804 2804.000-AL679
1 0; e;eJ wd Aidde o; awaa a inn ; `;unowe a;eoo eun ue u! a3!AJas o wa;rauo uePPgll. 11 P II 11g
aaow JOI Jo 9801AJOS pezlwa;I ule;Jao Jo; a6EJOA0O .1811;o Aq pepinoJd ale s;l;auaq ua11M •g
oeJ;uoo sly;;o s;I;auaq
paulwJa;ap anoge ay; o; lenba s;l;auaq ep!noJd !Um aalJJeo ay; `panlonul sa6Jeyo ay;
1
o (%0s) ;ue3Jad AIM uey; ssal lenbe ;oeJ;uoo s!144 lo s;l;auaq pau!WJa;ep anoge ay;;l
06ea8noo Jag;o ay;;o s;l;auaq paulwaa;ap anoge ay;
Jano panlonul sa6aeyo ay; JO ssaoxa 8144 JO ;oeJ;uoo sly; ;o s;I;auaq pau!wJa;ap anoge
1 ay;;o aassei ay;04 lenba s;l;auaq epinoJd IHM JauJea ay; `panlonul se6Jego 811;;o (%0S)
uaoaad Aug uey; ssej lenba a6eaanoo aay;O ay;Japun s;l;auaq peulwJa;ap anoge ay;;i •q
1 panlonul sa6aeyo 814; ,0 (%0S) wowed Aug 04 lenba s;l;auaq
apinoJd lllM J0l.1Jea ay; `panlonul sa6aeyo ay; ;o (%0g) wowed Aug peaoxa JO lenba
pea a6eJano3 Ja11;o ay; pue ;oeJ;uoo sly; 11;oq Japun s;l;auaq peulwJe;ap anoge ay;dl •e
pau!wJa;ap eq;sal}
II!M uo!s!noJd sly; jo aouasge ay; u! panlonul se6Jeyo ay; Jo; papinoad uaaq 8ne14 mom
wig a6eaanoo Jay;O ay; pue ;oeJ;uoo sly; y;oq ;o s;l;auaq ay; `suolslnoad ssaoxa s;I;auaq
o uol;eulpa000 seq 86ea8noo Jay;o ay; pue „aouJe3 Aaepuooas„ ay; sl Jauae3 an uayM •S
1
a6eaanoo aay;o;o aouasge ay;u!aapunaaaq
1 elgeAed eq pinoM g3!gM s;I;auaq !Bpi. ;o ;unowe ay; aseaJOU! o; pang;suoo eq uol;oas
sly; ;o suolslnoad ay; Heys wane OU Ul IMO `JOAOMO1 `pepinoJd :swell yons JoJ sa6aeyo ay;
o Japulewaa ay; Aed HIM J8IJJe0 8144 pue `86ea0n00 J011 40 JO '108.1011 A 8101;ay Japun papin
1 cud sl ;l;auaq cue yo!gm JO} 983!AJOS le;Uaa ;o swa;I lie ;o sa6aeyo 011; woJJ pa;onpep
aq !lays 86ea8noo J81.11.0 ay; }o s;l;auaq 011; `suolslnoad ssaoxa s;I;auaq }o uol;eulp
J000 anal ;ou saop 96ea8noo aay;o 811; pue „JaiJJea AJepuooas„ ay; sI JapJea 011; uayM .p
1 Jean(Jepualeo auo(ue 6ul.1np;uedlol;Jed a o;payslwn;
SOOIAJOS ay; 04 uol;elan ul apew eq hays a uol;oas sly; Japun sp auaq Jo uol;eulwJa;aa •g
I oea;uoo ;I;auaq leo!bJns-leolpaw-uogezlle;ldsoq ;ey; Japun seolnJas asoy; Joj aige
Rene aJe s}l;auaq d! ;OeJ;uoo s!y; Japun aigellene ale s;l;auaq golyM Jo; seo!AJas Aue JOJ
JeiJJea AJepuooes„ ay; peJep!suoo eq IleIs J8!Jea 811; `JaAoldw3 all 04 `sexel `selIeo
1 Auedwoo a3UBJnsul 11;leaH v am dnwO pue 'Bowes le;IdsoH dnoio Aq Jo JaIJJea
ay; i(q panss! s! ;oeJ;uoo ;l;auaq Ie3!6Jns-leolpaw-uol;ezge;Idso11 a;eJedas B wane ay; ui •Z
paJapuaJ 8.19 apew sI wlelo golgM JO}8801AJas
ay; a;ep ay; uo aoua;slxa u! s;Oe; ay; ;o siseq ay; 110 peulwaaiep eq !legs a uol;oas
sly; ;o suolslnoad ay; ;o A;Ilige3Hdde a111 „•J0!JJea AJepuooas„ 0144 J8!Jea ay; a){ew
pinoM suol;lpuoo anoge 0144 pue ;OBJ;uoo sly; ;o s;l;auaq 8144 /(q paJano3 sa6Jeyo }o
i uol;JOd ay; Jo; s;I;auaq ap!noJd ;ou HIM ;! ;ey; a;e;s gol1M („suolslnoad ssaoxa s;I;auaq
10 uol;eulpa000„ se 04 p8JJaJeJ Ja;JeaJa11) suolslnoad 9914 06BJ8n00 Jay;o ay; uayM JO
I
JapunaJay a6eaanoo sly ;o a;ep and;oe;;a 811;U9144
JallJea sI a69J9A00 Jay;o 811; Japun uol;ed!ol;Jed s,;ual;ed ay; ;o amp 0n110014.8 041 •0
JO `a6eaanoo Jay;o ay; JOpun waged ay; ;o Apo;sno
i 6ulney ;ou uosJad e ;o ;uapuadaa B se pue ;OeJ;uoo sly; Japun asnods s,uosaad
yons Jo waged ay; jo Apo;sno 6ulney uosied ay; Jay;la ;o ;uapuadaa se pal;lsselo
s! waged ay; 1.e11; ;uawAed 0; Jo!Jd pal;I;ou s! J0IJJe3 ay; ;I „Ja!JJe3 AJepuo3as„
ay; eq ;ou IHM Ja!JJe3 ay; `aay;o pea o; pa!JJew ;ou OJe PIa11 s! 869J8n00 wo11M Japun
panuijuo0) S11d3N38 AO NOIJVNIab000 !S1113N38 AO 1N3INAVd — Al 310111:11/
J
ARTICLE IV — PAYMENT OF BENEFITS; COORDINATION OF BENEFITS (Continued)
all such items.When a deductible amount applies to the benefits of other coverage, it shall
be deemed to apply pro rata to each of the benefit factors thereunder.
7. The Carrier assumes no obligation to discover the existence of other coverage or the
benefits payable under it if discovered, but only to give effect to the provisions of this
Section D in accordance with information furnished it by an authoritative source. It shall,
however, be entitled to obtain and/or to release such information as reasonably necessary
to give effect to these provisions, without the consent of or notice to any person; and any
person claiming benefits hereunder shall, as a condition precedent to his right of recovery,
furnish to the Carrier full information concerning the existence of other coverage and the
benefits thereof.
8. The Carrier shall•be entitled at any time to recover benefits paid in excess of the obligation
as determined under the provisions of this Section D, irrespective of or to whom such
benefits were paid, from an issuer or provider of the other coverage, or any person
or firm to or for whom such payment was made, or from any combination of such sources.
coverage, the Carrier shall have the right, in its9. When benefits have been paid under other g 9 ,
discretion, to pay over to the issuer or provider of such other coverage any portion of the
benefits available under this contract which the Carrier may determine to be due in order
to give effect to the intent of this Section D and corresponding coordination of benefits pro-
visions in such other coverage. The amount so paid shall be deemed to be benefits
i provided under this contract, and to the extent thereof, the Carrier shall be fully dis-
charged from liability hereunder.
10. If the Carrier is the "Secondary Carrier" under this Section D but is unable to determine
the benefits of the other coverage for the charges involved, it will estimate in good faith the
benefits of the other coverage and provide the benefits of this contract on the basis of that
estimate. Payment under this Subsection 10 shall constitute full discharge of the liability
of the Carrier for the charges involved, subject only to adjustment in the event the Carrier
later determines the actual benefits of the other coverage prior to the expiration of the
period set forth in Article VIII, Section I.
t _
L
L
L
L
L
Form No. 2842 2842.000-A L 879
f
IARTICLE V-DENTAL BENEFITS PROVIDED
Section A
COVERED DENTAL EXPENSES
1. BASIC BENEFITS
i
If item 1 of the Schedule is indicated "Applied For," the following Covered Dental Expenses
will be paid up to the Dentist's charge, not to exceed: (a) If item 2 of the Schedule is indicated,
the percentage of the Dentist's Usual, Customary and Reasonable charge (UCR) as indicated
in item 3 of the Schedule, or (b) If item 4 of the Schedule is indicated, the indemnity allowance
of either High, Medium, or Low as indicated in item 5 of the Schedule.
a. ORAL EXAMINATIONS, including treatment plan, as follows:
y Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
00110 Initial Oral Examination (The UCR 9.00 $ 7.00 $ 5.00
first time a patient is seen by
I
the current Dentist)
00120 Periodic Oral Examination UCR 7.00 6.00 4.00
Routine follow-up examina-
tions) limited to one examina-
tiontion within any consecutive
six month period
00130 Emergency Oral Examination UCR 8.00 6.00 5.00
Examinations necessary as a
result of injury)
1 Benefits for Oral Examinations in conjunction with palliative treatment or adjustments of
prosthetic or orthodontic appliances are not payable. Benefits for Oral Examinations which
are limited in scope, such as an endodontic examination, are not payable.
b. PERIAPICAL AND BITEWING RADIOGRAPHS, within the specified time limits, as follows:
00210 Intraoral—Complete Series UCR 21.00 $ 17.00 $ 13.00
of all Tooth Areas(including
l bitewings). One series within
any consecutive three (3) year
L period
00220 Intraoral—Single Film, First UCR 4.00 3.00 2.00
Film (A single radiograph of a
L specific tooth or area)
00230 lntraoral —Each Additional UCR 2.00 2.00 1.00
Film (Additional films for com-
Lpletion of diagnosis or treatment
00240 Intraoral—Occlusal Film (A UCR 6.00 5.00 4.00
film used for locating and
L orienting fractures, impacted
and unerupted teeth, foreign
bodies, extensive cysts and
L tumors and stones in the
salivary ducts and glands)
L V
Form No. 2805 2805.000—AL679
F
F
F
f
i
I
1
09200 pue 09200
sepoo to uolleueldxa aas) wild
Icanans 'awe ieloed pue IIn IS
00'E1. 00'81 00'ZZ Hon leaaleW pue aolaalueoaalsod 06200
1
00'01. 0071. 00'L1. aofl suaild anod —s6ulnnall8 VLZ00
00'8 00'0L 00'EL aofl swl!d aaigi—s6upAell8 ELZ00
00'9 00'L 00'6 aofl swild omi—s6u!Mali9 ZLZ00
uolloalap saueo [Lapel
NI uaaMlaq] iewlxaadaalul
aol ylaal ail to suollaod
UMW o NI to a6ewi ue uielgo
of pasn will ydei6olpea)
wild leUO11!PPV yoe3
00'E 00'V on eon wild lsa!d `eibulS—6ulMal!8 OL300
wild
L
00'9 00'8 00'01. aofl ieUOiliPPV yoe3— ieaoeaix3 O92OO
seansodxa ieaoealul (q
payoeaa aq louueo ley].seam
L to pue seaae aa6aei lnoge
uollewao;u1. 6ululelgo aol
ylnow Ni lo ammo paoeid
will aw.yl!M apew aansodxa
L 00'L 00'01. 00'Z1. aOfl uy) wild lsa!d — lea0ea1x3 09200
Lmol maw 4.
eoueMoiid Alluwepui a geuoseaa pue einpeocud epo3
i o ainpayoS Aiewolsno lensnI
penui}uoO) a3QIAO1:Id S11d3N38 lv1N3a—A 313111V
ARTICLE V—DENTAL BENEFITS PROVIDED (Continued)
I Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
00310 Sialography (Intraoral and UCR 24.00 $ 19.00 $ 15.00
extraoral film usually used
with dye contrast for the
detection of blockage in the
salivary ducts)
00321 Temporomandibular Joint UCR 20.00 16.00 12.00
I Single Film) (Extraoral film
used for detection of
abnormalities of the TMJ)
1 00330 Panoramic—Maxilla and UCR 21.00 17.00 13.00
Mandible—Single Film (A
single continuous exposure of
Ethe oral cavity on an extra-oral
t film [a complete series]) Will
be considered a full mouth if
I accomplished in conjunction
with bitewings
00340 Cephalometric Film (Extraoral UCR 20.00 16.00 13.00
I film used by prosthodontists,
oral surgeons) Not covered
when used in conjunction with
I_
an Orthodontic Treatment Plan
Full-mouth radiograms are limited to one in any consecutive three (3) year period and bite-
wing radiograms are limited to one (1) in any consecutive six (6) month period. The proce-
dures for benefit codes 00220 and 00230, when accomplished in conjunction with one another,
will be deemed full-mouth x-rays and the combined schedule of indemnity for those proce-
dures shall not exceed the amount payable for a full-mouth radiogram.
rc. TOPICAL FLUORIDE APPLICATION (for Participants under age 19) limited to one appli-
cation in any consecutive six (6) month period, as follows:
L01210 Topical Application of Sodium UCR 6.00 $ 5.00 $ 4.00
Fluoride— Four Treatments
L
Excluding prophylaxis)
01211 Topical Application of Sodium UCR 16.00 13.00 10.00
Fluoride— Four Treatments
j Including prophylaxis)
L
01220 Topical Application of UCR 11.00 9.00 7.00
Stannous Fluoride—One
L Treatment (Excluding
prophylaxis)
L
L
L V
Form No. 2806 2806.000-AL679
1
039901-11!m uo!;ounfuoa u!
pasn s! apoo s!yl) y;ool yoe3
00'9 00'8 00'01- Hon y;ael leuo!;! py aoe daPI d 0E990
i(Joieaogel
Jo eo!;;o u1-) y;ool auo
aoeldad pue ain;uea le!;-led
00'SL 00'61- 00'173 Hon Jo a;aldwoO ua)lOJg J!edaa 03950
r Goleaogel
JO ao!;;o u!) pa6ewea
y}aal ON—aJnivaa Ie!lJed
I
00'31- 00'91- 00'03 Hon Jo alaldwoo ua>loag J!edau 01-990
00'9 00'L 00.6 Hon suMOJO ;uawaoab 03630
sAeluo
00'9 $ 00'L $ 00'6 $ asn sapnloul) sAelul ;uawaoab! 01-630
sM011o; se `S31:In1N3a d0 alyd3d 'e
I aJnpaowd
s!xelAydoJd ay; umm papnlou! aq 04 pawaap aq !legs s!xelAydoad e se Aep awes ay; uo pue
1-1}!M uo!;ounfuoo u! pawio;Jed 6u!leos pue a6e naino 'aseas!p IeTuopo!Jed jo ;uaw;eaal
jo asinoo e ;o ;Jed se pewJo;aad 6u!ueld low pue a6e;1aJno Jo4 algel!ene ;ou we s;!;aueg
Ja6unoA Jo
00.9 00'8 00'01- bon aft ;o sJeaA 6j) uaJpl!y0 03110
00'L $ 00'01. $ 00'31- $ Hon sllnPV OH- O
L sMollo; se 'looped y;uow (9) xis an!;noesuoo Aue
u! s!xelAydoJd auo o; pai!w!i `6u!ys!lod pue 6u!leos `6u!ueep 6u!pnpu! `SIXV'1AHdO8d 'P•
paienoo jou s! sle!Ja;ew an!;eJO;saJ u! Joipue a;sed s!xel(ydoid u! ep!Jonl;
o asn ayl •paJanoo }ou aae ao!;;o s,;s!4uap ay; ;o ap!s;no asn Jo; ap!JOn!; pus uo!;e.io;saJ
leu!; s ;o lueweoe!d o; Jo!Jd y;ooj e ;o uol;Jod pwedeid ay; 04 apuonl; ;o uo!}so!ldde iso!dol
1 s!xelAydoJd
6u!pnpul) }uew4eeJ
auo—a;egdsoyd ap!Jonld
00'1-1. 001171- O0'L L Hon ploy;o uo!;eo!Iddy !eo!dol LE31-0
s!xelAydoid
6u!pnpx3) ;uewieejl
L auo —a;eydsoyd ap!JOn13
0018 00'01- 00'EL lion ploy 40 uo!;eo!Iddy Ieo!dol OE310
6u!pnioul) wawiewi
auo—epuon1 j snouue3S
00'01- $ 00'E 1- $ 00'91. $ Hon 10 uo!;eo!Iddy leo!dol 1331-0
Lnnn wn!peIN y6!H
a3Uennoffb Ali!Uwapui eicieuoseeu pue aJnpeooad epoo
Jo a npayog Aiewo;sno °!ensn
penuliuo0) a301A0tid S11d3N38 1V1N3a—A 310111id
i
ARTICLE V-DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
05640 Replace Broken Tooth on UCR 14.00 $ 12.00 $ 9.00
Denture (Removable) -
No other Repairs
05650 Adding Tooth to Partial UCR 28.00 23.00 17.00
Denture to Replace Extracted
1
Tooth-Each Tooth (Not
involving clasp or
abutment tooth)
1
05660 Adding Tooth to Partial UCR 40.00 32.00 25.00
Denture to Replace Extracted
Tooth-Each Tooth
Involving clasp or
abutment tooth)
05670 Reattaching Damaged Clasp UCR 24.00 19.00 15.00
I on Denture
1 05680 Replacing Broken Clasp with UCR 34.00 27.00 21.00
New Clasp on Denture
05690 Each Additional Clasp with UCR 28.00 23.00 17.00
Rest (Used in conjunction
with code 05680)
j06930 Recement Bridge UCR 12.00 10.00 7.00
Benefits are not available for fixed bridge repairs nor recementing of crowns, bridges, or
inlays within six (6) months of original placement. The above procedures involving recemen-
tations and denture repairs shall be deemed to include all necessary balancing of occlusion,
relief of sore spots, and all other adjustments.
I f. EMERGENCY PALLIATIVE TREATMENT, as follows:
02940 Fillings (Sedative) UCR 6.00 $ 5.00 $ 4.00
09110 Palliative (Emergency)
Temporary Treatment of
Dental Pain UCR 8.00 6.00 5.00
Benefits are not available for permanent restoration nor temporary crowns.
i g. OPERATIVE DENTISTRY fillings consisting of resin, silver amalgam, and tooth color
synthetic restorations, as follows:
02110 Amalgam-One Surface, UCR 10.00 $ 8.00 $ 6.00
Deciduous (e.g.#K-O-AM)
02120 Amalgam-Two Surfaces, UCR 14.00 12.00 9.00
Deciduous (e.g. #K-MO-AM)
02130 Amalgam-Three Surfaces, UCR 18.00 14.00 11.00
Deciduous (e.g. #K-MOD-AM)
i
a' CI INEMEMEMERMEINEMEMINEMINEr.
Form No. 2807 2807.000-AL679
ARTICLE V- DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
02131 Amalgam- Four Surfaces, UCR 20.00 $ 16.00 $ 12.00
Deciduous (e.g.#K-MODL-AM)
02140 Amalgam-One Surface, UCR 12.00 9.00 7.00
Permanent (e.g. #19-0-AM)
02150 Amalgam-Two Surfaces, UCR 17.00 14.00 10.00
Permanent (e.g. #19-MO-AM)
02160 Amalgam-Three Surfaces, UCR 21.00 17.00 13.00
Permanent (e.g.#19-MOD-AM)
02161 Amalgam- Four or More UCR 24.00 19.00 15.00
Surfaces, Permanent
e.g. #19-MODBL-AM)
02190 Pin Retention-Exclusive of UCR 8.00 7.00 5.00 1
Amalgam
02210 Silicate Cement- Per UCR 14.00 11.00 6.00
Restoration (e.g. #8-MIF-Sil)
02310 Acrylic or Plastic UCR 16.00 13.00 10.00
02330 Composite Resin-One UCR 14.00 11.00 8.00 1
Surface (e.g. #24-M-Comp)
02331 Composite Resin-Two UCR 20.00 16.00 12.00 l
Surfaces (e.g. #24-ML-Comp)
02332 Composite Resin-Three UCR 28.00 23.00 17.00
Surfaces (e.g.#24-MLD-Comp)
02334 Pin Retention-Exclusive of UCR 8.00 7.00 5.00
Composite Resin or Plastic
02335 Composite Resin- (Involving UCR 27.00 22.00 17.00
Incisal Edge)
The above procedures for amalgam, silicate, plastic, and composite restorations shall be
deemed to include all necessary bases (except pulp cap), liners, local anesthetics, and
postoperative care. Benefits are not available for silicate, acrylic, or composite restoration i
of class 2 lesions.
h. SIMPLE EXTRACTIONS, as follows:
07110 Single Tooth UCR 13.00 $ 10.00 $ 8.00 I
07120 Each Additional Tooth (In UCR 12.00 10.00 7.00
conjunction with 07110)j
The above procedures shall be deemed to include postoperative care, local anesthetics,
sutures, and suture removal.
I
j ARTICLE V- DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
1 Code Procedure and Reasonable Indemnity Allowance
High Medium Low
1
i. ENDODONTIC TREATMENT, as follows:
03110 Pulp Cap-Direct- UCR 10.00 $ 8.00 $ 6.00
Excludes Final Restoration
1 The application of a drug
to the exposed pulp to
protect it from external
1
influences and to stimulate the
formation of secondary dentin)
03220 Vital Pulpotomy-Excludes UCR 14.00 12.00 9.00
1 Final Restoration (The removal
of the coronal portion of an
s
03310 Anterior
expoed
Root
vital
Canal Filling UCR 100.00 81.00 62.00
1 excludes final restoration)
i
03311 Anterior Root Canal Filling UCR 64.00 52.00 40.00
paste filled root canal)
03320 Bicuspid Root Canal Filling UCR 120.00 97.00 75.00
1 excludes final restoration)
03321 Bicuspid Root Canal Filling UCR 80.00 65.00 50.00
paste filled root canal)
1 03330 Molar Root Canal Filling UCR 152.00 123.00 95.00
excludes final restoration)
1 03331 Molar Root Canal Filling UCR 96.00 78.00 60.00
paste filled root canal)
03350 Apexification (treatment may UCR 64.00 52.00 40.00
I extend over a period of
6 to 18 months)
The above procedures shall be deemed to include all treatment radiographs taken during
the course of active root canal treatment and pre- and postoperative care treatment for a
period of 6 months.
Ij. FIXED OR REMOVABLE SPACE MAINTAINERS, as follows:
1
01510 Fixed-Unilateral Type UCR 36.00 $ 29.00 $ 22.00
01515 Fixed-Bilateral Type UCR 44.00 36.00 27.00
i
01520 Removable Unilateral Type UCR 60.00 49.00 37.00
01525 Removable Bilateral Type UCR 60.00 49.00 37.00
Form No. 2808 2808.000-AL679
i
paa!nbaa s! uo!luanaalu!
leo!6ans `uo!l!puo0 aaglo
JO uo!lean6lluoo loon of ano)
00'EL $ 00'91- $ 00'03 $ Eon paldna3—Li1001 10 uollOealx3 OLZLO
1 smoHol se luawleaal pue s!sou6e!p 10 6u!ls!suoo AH39H1S 1VHO 'e
1 alnpagoS 01-11 40 (Jr. wal! u! paleo!pu! se MOB ao `wn!paA `g6!H aayl!e to aouemolle
i(l!uwepu! aql `peleo!pu! s! alnpagoS equip 6 wal! ll (q) JO `alnpagoS egl 40 8 wal! u! paleo!pu!
se (Hon) a6aego algeuoseaa pue kiewolsno lensn s,ls!luaa all to a6eluaoaad NI 'pale°
pu! s! alnpagoS aql }o L Wel! 41 (e) :peaoxa of lou `a6aeLo s,ls!luaa aql of do pled ad II!M
1 sasuadx3 leluea paaanoo 6u!mollol and „`aod pa!Iddy„ paleo!pu! s! alnpagoS 04140 9 wal! 11
S1Id3N38 OISYB IvNOI1IDOd 'Z
ao!naas paaanoouou a aol
sl!s!n ao uo!lellnsuoo le!oads
sl!s!n an!leaadolsod apnlOui
i 00'9 00'8 00'01. H°n lou seoa) slleo lel!ds0H 0E1760
00.8 00'01. 00'EI. Hon site° asn0H 014760
00.91- 00'LE 00'9Z Hon e!saglsauy leaauao OZZ60
smo1Io1 Se `S301AH3S DISVE1 1:13H1O 'I
I paa!nbaH laodaH)
l
00'EL 00'91- 00'03 Hon MMos) enss!1 IBJO to Asdo!8 98ZLO
paa!nbe laodaH)
00'1.I. 00'EZ 00'82 Hon paeH) anss!1 Iwo 10 Asdo!8 983L0
I00'9 00'9 00'8 Hon size° O!lsou6e!a OLV00
po!aad gluow-anlaMl
Aue u! l!si au()) 1!s!‘
1 00'E $ 00'P $ 00'9 $ H°n goe3—51501 Al!lel!n dlnd 091700
SM01101 SE `SWVX3 A1:1O1VHOEIV1 GNV S1S31 '>I
Apnea Imo NT 10 uo!l!puoo aql u! a6uego palelaa aq1 to esneoaq paa!nbaa s! uo!leo!1!pow
Lions ssalun aau!elu!ew coeds 6u!ls!xe ue 10 uo!le0!1!pow aol JO luawleaal o!luopoglao 10
uonaldwoo aalle algel!ene lou aae sl!laua8 •suo!leO!IdWOO JO wed o!luopoglao aanlnl luanaad
1 01 Aaessa0au aae saanpa0oad Lions ssalun algei!ene lou aae saanpa0oad anoge agl aol sl!1aua8
aau!elu!ew aql 10 luewaOeid
10 alep aql wail pasdela
i aneq sgluow (9) )qs aalle
quo algel!eny) Jeu!elu!elnl
00'9 $ 00'9 $ 00'8 $ Hon aOed5 10 uo!leluawa3aH 0591.0
Anal wavy 4B!I.l
aoueMolld Apuulapul ejgeuoseaa pue einpaooid pop
to ainpay3S A.Jewo;sn3 'lensn
1 i panuijuo3) a3aIA0IId S1Id3N38 1V.N3a —A 3131111d
1
1 ARTICLE V—DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
1
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
07220 Extraction of Tooth—Soft UCR 29.00 $ 23.00 $ 18.00
1 Tissue Impaction (Tooth
Crown is encased in soft
tissue)
1 07230 Extraction of Tooth—Partial UCR 32.00 26.00 20.00
Bony Impaction (Tooth Crown
is partially encased in bone,
part in soft tissue)
07240 Extraction of Tooth— UCR 60.00 49.00 37.00
Complete Bony Impaction
1 Tooth is completely
encased in bone)
07241 Extraction of Tooth— UCR 72.00 58.00 45.00
Complete Bony Impaction
j Tooth is completely encased
in bone and presents unusual
difficulties and circumstances)
07250 Root Recovery—Surgical UCR 40.00 32.00 25.00
Removal of Residual Root
1 A retained root from previous
extraction or retained from
fractured tooth)
1 07260 Oral Antral Fistula Closure UCR 72.00 58.00 45.00
and/or Antral Root Recovery
Removal of a root or root tip
and/or the closing of a hole
1 in the maxillary sinus cavity)
07270 Tooth Replantation UCR 100.00 81.00 62.00
1 07280 Surgical Exposure of Impacted UCR 28.00 23.00 17.00
or Unerupted Tooth for
Orthodontic Reasons-
1 including wire attachment
when indicated (Causing a
tooth to erupt by removal of
bone and tissue)
07281 Surgical Exposure of UCR 19.00 16.00 12.00
Impacted or Unerupted
i
Tooth to aid eruption
07310 Alveoplasty, per Quadrant— UCR 61.00 49.00 38.00
In conjunction with extractions
i
Sometimes referred to as
Alveolectomy) (Surgical
preparation of ridge for
Jreceipt of dentures)
i - l', 1111111111MMEMINEIMEMERIK
Form No. 2809 2809.000-AL679
Meal wao;
dray ley1 senss!1 JO yloo;< e
wail 6u!leu!6!ao senss!1 o;
1 Saa;aa olua6o;uopo) aa}awe!p
u! you! ;!ey-auo oa dn
wse!doeN) aowni JO IsA0
1 000E 00'6£ 00'81 inn o!u860;uopp 40 !enoweu OSVLO
you! ;!ey-auo
JOAO Je;awe!p uo!sa-i —
00'9L 00'L6 00'0Zl don aownl lueu6!!eiN ;o u0!s!0x3 1-bbL0
gown;snoJeoueo ;o ienowaa
eo!6anS) qou! 1!ey-auo
o} dn Jo ewelp uo!se- —
00'LE 00'61 00'09 uon aownl1ueu6!iew ;o uo!slox3 OttLO
you! liey-auo
JOAO JOTawe!G uo!s81
00'Z9 00'1-8 00'001- a3fl aownl u6!ua8 ;o uo!s!ox3 L£tLO
I aowni snoaaoueouou
o ienowaa ieo!6ans) qou!
ey-auo o; dn aalawe!Q uo!sa1
1 00'0£ 00'6E 00'817 a3fl aownl u6lua8 ;o uo!s!ox3 OEVLO
00'8 00'01- 00'£1. a3fl enl6u!0 !euoaoolaad uo!slox3 SZtLO
1 you! ;!ey-auo JOAO aalawe!p
00'09 00'81 00'96 a fl uolsai —uo!s!ox3 !eo!Ped NVLO
suo!se! JO anss!1
I JBOS lo ienowaa !eo!6anS)
you! ;!ey-auo of dn aalaweia
00'0E 00'6£ 00.8V uon uo!sel —uo!s!ox3 !eo!Ped 01-VLO
I anss!l oRse!daadAq
pue pa!ydo.ipedAq
o luewa6euew pue `s;;ea6
I
enss!;;;os `uo!sue1Xe a pla
6u!pniou!—pa;eo!!dwoo
00'06 00'L 1-L 0017171- uon 110.1V Jed `Alse!doTewo;S 09CLO
sawn;uep;o ld!eoaa ao;
i(i!ensn 'wow NT lo Aae6ans
o!lseid JO uo!fona}suooaa)
peTeo!!dwoou f
j00'61 00'SZ 00'0£ doff yoay Jed `A;se!do;ewo;S OVCLO
seJn;uap ;o ;d!eoeJ
ao; e6pla ;o uo!eaedaad
1 eo!6anS) suo!loea}x3
1}!M uofounfuo3 u! ;oN
00'8C $ 00'617 $ 00'1.9 $ aofl 3ueapenp Jed `A;se!doeAlV OZELO
j Mol mew 461H
eoueMolly A;iuwapuI a geuoseau pue aJnpeocud epo3
o eppayos Liewo;sno yens fl
i penunuo3) a3a1A0ad S1133N38 1V1N30—A 3'1311x1'/
l
ARTICLE V-DENTAL BENEFITS PROVIDED (Continued)
iUsual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
1
High Medium Low
07451 Removal of Odontogentic Cyst UCR 100.00 $ 81.00 $ 62.00
or Tumor-over one-half
1 inch in diameter
I 07460 Removal of Non-Odontogentic UCR 48.00 39.00 30.00
Cyst or Tumor-up to
1 one-half inch in diameter
07461 Removal of Non-Odontogentic UCR 100.00 81.00 62.00
Cyst or Tumor-over
1
one-half inch in diameter
07470 Removal of Exostosis- UCR 44.00 36.00 27.00
Mandible or Maxilla (Surgical
removal of a spur or bony
outgrowth from a bone or
the root of a tooth)
1 07480 Partial Ostectomy-Guttering UCR 44.00 36.00 27.00
or Saucerization (Surgical
removal of bone resulting in
1 a gutter-like or saucer-like
depression)
07490 Radical Resection of Mandible UCR 320.00 260.00 200.00
with Bone Graft(Removal of
part of the lower jaw with a
bone graft replacement)
07510 Incision and Drainage of UCR 13.00 10.00 8.00
Abscess, Intraoral (Cutting or
lancing of an abscess inside
the mouth, to provide
drainage)
07520 Incision and Drainage of UCR 24.00 19.00 15.00
1j Abscess-Extraoral
Extraoral-outside the
mouth)
07530 Removal of Foreign Body UCR 20.00 16.00 12.00
Excludes Bone Spicule)
i 07540 Removal of Reaction- UCR 28.00 23.00 17.00
Producing Foreign Bodies-
Musculoskeletal System
1 07550 Sequestrectomy for UCR 52.00 42.00 32.00
Osteomyelitis (The surgical
removal of a fragment of dead
bone) Laboratory report
required.
J
i
l
Form No. 2810 ain (-Inn-el 674
ARTICLE V-DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
1 High Medium Low
07720 Fractured Maxilla- UCR 228.00 $185.00 $142.00
Compound-Closed
1 Reduction (See description
code 07620)
07730 Fractured Mandible-Open UCR 228.00 185.00 142.00
1 Reduction of Compound
Fracture
1
07740 Fractured Mandible-Closed UCR 228.00 185.00 142.00
Reduction of Compound
Fracture
07750 Fractured Malar and/or UCR 240.00 195.00 150.00
Zygomatic Arch-Compound
Open Reduction
07760 Fractured Malar and/or UCR 180.00 146.00 112.00
Zygomatic Arch-Compound
Closed Reduction
1 07770 Fractured Alveolus- UCR 180.00 146.00 112.00
Compound-Stabilization
of Teeth-Open Reduction
1 Splinting
j
07780 Facial Bones-Complicated UCR 360.00 292.00 225.00
Reduction with Fixation and
Multiple Surgical Approaches
07810 Open Reduction of Dislocation UCR 56.00 45.00 35.00
I
of the Mandible (Surgical
incision required for access to
the Temporomandibular Joint)
1 07820 Closed Reduction of UCR 20.00 16.00 12.00
Dislocation of the Mandible
Manipulation to position the
I mandible in its normal
position)
07830 Manipulation Under UCR 40.00 32.00 25.00
JAnesthesia
07840 Condylectomy (Removal of UCR 280.00 227.00 175.00
one of the condyles of the
mandible)
07850 Meniscectomy (Removal of UCR 240.00 195.00 150.00
J
the disc between the head
of the condyle and the base
of the temporal bone)
1
j
r: I IMIEMINIMMEMINEMIIIIIIIIIMMIE
Form No 2P11 n.I nnn .. c-,.
ARTICLE V—DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of1CodeProcedureandReasonableIndemnityAllowance
High Medium Low 1
07560 Maxillary Sinusotomy for UCR 72.00 $ 58.00 $ 45.00
removal of tooth fragment
or foreign body 1
07610 Fractured Maxilla—Simple UCR 280.00 227.00 175.00
Open Reduction—Teeth
Immobilized (if present) (Open
reduction requires cutting to
expose fractured sight)
07620 Fractured Maxilla—Simple UCR 200.00 162.00 125.00 I
Closed Reduction—
Teeth Immobilized (if present)
Closed reduction is a
manipulative reduction
without incision)
07630 Fractured Mandible—Simple UCR 280.00 227.00 175.00 1
Teeth Immobilized—
Open Reduction (See
description 07610)
07640 Fractured Mandible—Simple UCR 220.00 179.00 137.00
Teeth Immobilized— IClosedReduction
See description 07620)
07650 Fractured Malar and/or UCR 220.00 179.00 137.00 r
Zygomatic Arch—Simple— L
Open Reduction (Cheek
bone region)
07660 Fractured Malar and/or UCR 80.00 65.00 50.00
Zygomatic Arch —Simple—
Closed Reduction
07670 Fractured Alveolus—Simple UCR 80.00 65.00 50.00
Stabilization of Teeth—
Open Reduction—Splinting
A fracture of the bony
process surrounding the teeth)
07680 Fractured Facial Bones— UCR 320.00 260.00 200.00
Complicated Reduction with
Fixation and Multiple
Surgical Approaches
07710 Fractured Maxilla— UCR 300.00 244.00 187.00
Compound—Open Reduction
See description code 07610)
I
I
ARTICLE V-DENTAL BENEFITS PROVIDED (Continued)
1 Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
07970 Excision of Hyperplastic UCR 32.00 $ 26.00 $ 20.00
Tissue-Per Arch (Removal
1 of excessive tissue, usually
for receipt of dentures or
due to excessive growth)
1
07980 Sialolithotomy (Parotid) UCR 68.00 55.00 42.00
Incision of the parotid gland
or duct for the removal of
a calculus)
1 07981 Excision of Salivary Gland UCR 96.00 78.00 60.00
07982 Sialodochoplasty (A plastic UCR 80.00 65.00 50.00
1 operation on the salivary duct)
07983 Closure of Salivary Fistula UCR 68.00 55.00 42.00
Closing of an abnormal
1 passage which involves the
salivary duct)
07990 Emergency Tracheotomy UCR 64.00 52.00 40.00
1 Benefits for oral surgical procedures shall include routine preoperative and postoperative
care, sutures, suture and/or arch wire removal and local anesthetics; benefits for alveoplasty
shall not include extractions; benefits for stomatoplasty shall include revision of the soft tissue
Iof the ridges, muscle reattachment, tongue, palate and other oral soft tissues.
b. PERIAPICAL SERVICES, as follows:
1
03410 Apicoectomy-Performed as UCR 48.00 $ 39.00 $ 30.00
a Separate Surgical
Procedure (Amputation of the
apex of the root of a tooth)
1 03420 Apicoectomy-Performed in UCR 72.00 58.00 45.00
Conjunction with Endodontic
Manipulation
03430 Retrograde Filling (Filling of UCR 48.00 39.00 30.00
the apex of a root including
surgical procedures)
c. ENDODONTIC PROCEDURE, as follows:
03920 Hemisection (The removal of UCR 40.00 32.00 25.00
i a root of a multi-rooted tooth
and its related crown portion)
1
3. PROSTHETIC BENEFITS
If item 11 of the Schedule is indicated "Applied For," the following Covered Dental Expenses
will be paid up to the Dentist's charge, not to exceed: (a) If item 12 of the Schedule is indi-
cated, the percentage of the Dentist's Usual, Customary and Reasonable charge (UCR) as
indicated in item 13 of the Schedule, or (b) If item 14 of the Schedule is indicated, the
indemnity allowance of either High, Medium, or Low as indicated in item 15 of the Schedule.
J
1
Form No. 2812 2812.000-AL679
i
1 Awolouaad
JO Awo;oauaad) aanpeoOad
00'0t 00'Z9 00'b9 JOfl eleaedes—(woloalnuaad 096L0
1 sloe;ao enssl1 paeH pue
00'09 00'08 00'001- aOfl ll0S le!ae1011!xew to a!edaa 996L0
a!q!pUeW ail to llaa0 abe1!lae0
1 00.01.Z 00'08Z 00'09E Ofl ao lealsoped `lealso!aadoalsO 096L0
sa!l!wao;aa o!ileuboyla0
1
00'92 007E 00'0b u0f1 and—Alseldoals0 0176L0
anaau ayl;o lenowaa au)
00'Z9 00'1-8 00'001- aOfl anaaN leu!wab!al;o uo!slnny L£6L0
l! Awlsep of sloe yo!ynn
anaau mil lo eaae ail u!
uo!loafu! uv) uo!lonalsaa ao;
1 00'9Z 00'n 00'0•17 doff anaaN leu!wob!al;o uO!loafUI 0£6L0
1
el!S Jouoa—
1;ea0 ;o ads j pue uo!leoo1
1 paaano0 papa Amuep!
00'06 00'Zl 00'091- ion spunoM) slIea0 1-1!)1S OZ6L0
1 sayou! OM
JGAO aalawe!p—aansolo
snolnollaw Jo; bu!u!waapun
ap!M—senss!l ;o
1 6u!lpuey aleo!lap 6u!a!nbaa
uo!lonalsuooaa — punoM
00'0t7 0079 00179 u9fl o 6uunln5 paleo!ldwoO Z1.6L0
IJe;awe!p u! sayou! ov,;of do
aansolo snolno!law Jo;
bu!u!waapun eon—senss!l
1 o bu!lpueq eleo!lap bu!a!nbaa
uo!lonalsuooaa — punoM
00'0E 00'6E 00'817 NOl to 6u!anlns paleo!IdWOO L L6L0
aalawe!p u! saiou!
ow.o;do—spunoM IIeWS
00'Z I- 00'91- 00'02 inn lueoaa ;oaanlnseldw!S 01-6L0
i lu!of a ;o
6u!lea!dse pue bu!anlound
00'91. 00'61- 0017Z 1-:1-08 et-II) s!seluaooaylay OL8L0
lu!of e uo!s!ou!
00'0E $ 00'6£ $ 00'8i $ Ofl leo!6ans au) AwoloaylJV 098L0
j Amyl wnrpew y6fH
aouemolly ai}iuwapui ameuoseeu pue aJnpaooad epo0
jo ampayos i iewolsn0 leusn
I panusjuoO) 0301AO1:1d S1113N38 1V.N30—A 31011/IV
J
ARTICLE V- DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
1 High Medium Low
05250 Upper-with gold palatal bar UCR 280.00 $227.00 $175.00
and two clasps, acrylic base
1 05251 Upper-with chrome palatal UCR 280.00 227.00 175.00
bar and two clasps,
1
acrylic base
05260 Upper-with gold palatal UCR 240.00 195.00 150.00
bar and two clasps, cast base
1 05261 Upper-with chrome palatal UCR 240.00 195.00 150.00
bar and two clasps, cast base
05280 Removable unilateral partial UCR 100.00 81.00 62.00
1 denture one-piece gold
casting, clasp attachments,
per unit including pontics
1 05281 Removable unilateral partial UCR 100.00 81.00 62.00
denture one-piece chrome
casting, clasp attachments,
1 per unit including pontics
05291 Full-cast partial -with two UCR 240.00 195.00 150.00
gold clasps (upper)
1 05292 Full-cast partial-with two UCR 240.00 195.00 150.00
chrome clasps (upper)
1 05293 Full-cast partial-with two UCR 240.00 195.00 150.00
gold clasps (lower)
05294 Full-cast partial-with two UCR 240.00 195.00 150.00
1 chrome clasps (lower)
05310 Each additional clasp with UCR 20.00 16.00 12.00
rest (added at time of
1 construction of dentures)
05320 Each tooth (applies to codes UCR 10.00 8.00 6.00
05291 and 05294 only)
05830 Obturator-for surgically UCR 144.00 117.00 90.00
excised palatal tissue
J
a prosthesis used to close
an opening in the palate)
05840 Obturator-for deficient UCR 200.00 162.00 125.00
1 velopharyngeal function
cleft palate)
i The above procedures shall include base adjustments, clasp and rest adjustments, framework
adjustments, relief of sore spots, rebalancing occlusion, and six (6) months post-delivery
care.
1
H .
Form No. 2813 2813.000-AL679
i
aseq lseo `sdselo oMl pue aeq
00'OS 1.00'961.00'O Z on len6ull awoayo yllM—aam0l 1.17Z90
aseq lseo `sdselo oMl pue
1 00'091.00'961.00'0bZ uan aeq len6ull pl06 tow—aaMo1 ObZ90
slelaalew llegoa-awoayo ol
saajaa aanlelouewou oil u!
1 pasn „awoayo„ waal ayl) aseq
all/aae `sdselo oMl pue aeq
00'Z91.00'I.LZ 00'09Z Elan len6ull awoayo gum—aaMo1 L£Z90
1 aseq oll(JOB `sdsela OMl pue
00'29 L 00'L LZ 00'092 a n aeq len6ull PI06 yl1M—JOMO1 0£290
aseq ollkoe `sisal won sdselo
1 00'091-00'961 00'Ot'Z a9n awoayo OMT illM—aaMoi 91290
aseq ollitaoe `slsaa il1M
00'091.00'961.00'0t7Z uon sdsep plo6 oMl gTIM—JOMO1 L LZ90
1 aseq ollkJOe 'slsaa iTIM sdselo
00'091.00'961-00'O17Z uon awoayo 0Ml yllM—aaddn 9 290
1 aseq o!!/(Joe 'slsaa gum
00'09 00'961.00'017Z a n sdselo plo6 ow Law—aaddn 91-Z90
aseq o!IAJOe
1 00'9L 0016 00'021. ion sdselo lnoyl!M—aaMO1 Z290
aaddlll•a se of paaaalaa
Alluanbaal) aseq 011AaOe
1 00'9L 0016 00'0Z1. aon sdselo lnoyllM—aaddn 1.1290
S3bn1N3a 1VI1}:1Vd
I 9.1E0 Aaan11ap-lsod syluow (9) xls pue 'uolsnIOOo
6ulouelegaa `slods aaos jo 1a11aa `sluawlsnfpe aseq apnjoul !leis saanpeooad anoge ail
aaddn
alelpawwl JOl uo!ldlaosap
001£1-00'6Ll 00'0ZZ uon eaS) aaMO] alelpawwl 0171-90
Meal 6ululewaa ail
Ile to lenowaa ail 6u!M011ol
clalelpawwl palaasu! Si leyl
auo s! aanluep alelpawwl
001£1.00'6L1.00'0ZZ lion uv) aaddn alelpawwl 0£1.90
00'921.00'291.00'00Z Ion aOMO1 eialdwo0 OZ L90
I00'sZ1.$ 00'291.$ 00'002$ don aaddn alaidwoa 01.190
S3si111N3a 1-1n3
sM011o1 se `1Vl11:1Vd aNV -nnJ `S3£1111N3a 'e
1 i Mot wnipe J 461H
aoueMo11d A;luwepu, aigeuoseaa pue ainpeooid 01303
jo apnpagog ewo;sno `ensni
panu!;uoO) a34IA01:id S1I33N38 11/1N30 —A 3131.LUV
1
ARTICLE V- DENTAL BENEFITS PROVIDED (Continued)
I- Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
06251 Plastic processed to UCR 109.00 $ 88.00 $ 68.00
non-precious metal pontic
r 06252 Plastic processed to UCR 112.00 91.00 70.00
semiprecious metal pontic
06520 Gold inlay-two surfaces UCR 104.00 87.00 65.00
f retainer part of bridge)
06530 Gold inlay-three or more UCR 112.00 91.00 70.00
surfaces (retainer part
of bridge)
1
06540 Gold inlay-(Onlaying cusps) UCR 12.00 10.00 7.00
I
Retainer part of bridge)
06710 Plastic (acrylic) crowns UCR 80.00 65.00 50.00
06720 Plastic processed to gold UCR 116.00 94.00 72.00
Icrowns
06721 Plastic processed to UCR 109.00 88.00 68.00
non-precious metal crown
1 06722 Plastic processed to UCR 112.00 91.00 70.00
semiprecious metal crown
l
06740 Porcelain Crown UCR 120.00 97.00 75.00
06750 Porcelain fused to gold crown UCR 160.00 130.00 100.00
06751 Porcelain fused to UCR 136.00 110.00 85.00
Lnon-precious metal crown
06752 Porcelain fused to UCR 144.00 117.00 90.00
Isemiprecious metal crown
06780 Gold (3/4 cast) crown UCR 108.00 88.00 67.00
06790 Gold (full cast) crown UCR 120.00 97.00 75.00
L06791 Non-precious metal (full cast) UCR 83.00 68.00 52.00
06792 Semiprecious metal (full cast) UCR 80.00 78.00 60.00
L06960 Dowel pin-metal UCR 19.00 16.00 12.00
d. FIXED PROSTHODONTIC REPAIRS-Procedure performed on a nonremovable bridge
Lto restore it to its previous functional state, as follows:
06610 Replace broken pin facing UCR 18.00 $ 15.00 $ 11.00
with slotted or other facing
L06620 Replace broken facing where UCR 16.00 13.00 10.00
post is intact
L
06630 Replace broken facing where UCR 24.00 19.00 15.00
post backing is broken
L
I_ VII
Form No. 2814 2814.000-A L 679
ARTICLE V- DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low I
b. DENTURE ADJUSTMENTS AND RELINING are those procedures required to attain a
satisfactory prosthetic appliance, as follows:
05410 Complete Denture UCR 11.00 $ 9.00 $ 7.00 r
Adjustment)
05421 Partial Denture (Upper) UCR 11.00 9.00 7.00
Adjustment)
05422 Partial Denture (Lower) UCR 11.00 9.00 7.00
Adjustment)
05730 Relining upper or lower UCR 40.00 32.00 25.00
complete denture
office reline)
05740 Relining upper or lower UCR 52.00 42.00 32.00
t
partial denture (office reline)
05750 Relining upper or lower UCR 64.00 52.00 40.00 I
complete denture (laboratory)
05760 Relining upper or lower UCR 60.00 49.00 37.00 r
partial denture (laboratory)
Benefits for the above procedures are not payable within the first six (6) months following
the initial installation of the appliance. Denture adjustments are limited to three (3) adjust-
ments in any one consecutive twelve (12) months period and are limited to dentists other
than the one who provided or repaired the initial appliance. The above procedures include
base adjustments, clasp and rest adjustments, framework adjustments, relief of sore spots,
and base occlusions. 1_
c. BRIDGES, fixed and removable (Each pontic [false or replacement tooth] and each abut-
ment [crown or inlay] is referred to as a unit [e.g., a six-unit bridge could be #6 crown,
7, 8, 9, 10-pontics, #11 crown]), as follows:
06210 Cast gold pontics UCR 120.00 $ 97.00 $ 75.00
06211 Cast non-precious pontics UCR 80.00 65.00 50.00
L
06212 Cast semiprecious pontics UCR 96.00 78.00 60.00
06220 Slotted facing pontics UCR 96.00 78.00 60.00
06230 Slotted pontic UCR 100.00 81.00 62.00
06240 Porcelain fused to gold pontic UCR 160.00 130.00 100.00
06241 Porcelain fused to UCR 136.00 110.00 85.00
non-precious metal pontic L06242PorcelainfusedtoUCR144.00 117.00 90.00
semiprecious metal pontic
06250 Plastic processed to UCR 120.00 97.00 75.00 L
gold pontic
I-
ARTICLE V— DENTAL BENEFITS PROVIDED (Continued)
Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance r
High Medium Low I(
06640 Replace broken facing UCR 48.00 $ 39.00 $ 30.00
with acrylic
06650 Replace broken pontic UCR 18.00 15.00 11.00
The above procedures include relief of sore spots and rebalancing of occlusion. F
4. PERIODONTIC BENEFITS
If item 16 of the Schedule is indicated "Applied For," the following Covered Dental Expenses f:=
will be paid up to the Dentist's charge, not to exceed: (a) If item 17 of the Schedule is indi-i
cated, the percentage of the Dentist's Usual, Customary and Reasonable charge (UCR) as
indicated in item 18 of the Schedule, or (b) If item 19 of the Schedule is indicated, the
indemnity allowance of either High, Medium, or Low as indicated in item 20 of the Schedule.
Periodontal procedures shall consist of: Surgical periodontic examination; Gingival Curet-
tage; Gingivectomy and Gingivoplasty; Osseous Surgery, including flap entry and closure;
Mucogingivoplastic surgery; Management of acute infection and oral lesions, as follows:
04210 Gingivectomy or Gingivoplasty UCR 48.00 $ 39.00 $ 30.00
Per Quadrant
Gingivectomy is the removal
of the gingival tissue from
about the necks of the teeth
thus eliminating subgingival
pockets.) (Gingivoplasty is
defined as the recontouring
of the gingival tissue.)
04220 Gingival Curettage and root UCR 24.00 20.00 15.00
planing (removal of diseased
tissue and smoothing of root
surface—Per quadrant)
04240 Gingival Flap Procedure (Per UCR 64.00 52.00 40.00 L
Quadrant) (A procedure in
which the bone is recontoured
and the gingival tissue is
reattached at a lower site
on the neck of the tooth.)
04250 Muco-Gingival Surgery per UCR 56.00 45.00 35.00
Quadrant
04260 Osseous Surgery (Including UCR 60.00 49.00 37.00
flap entry and closure) —
per quadrant (Surgery
performed on the alveolar
bone)
I 1_
6L91d-O00'S 1-82 9192 'ON wiod
4t h .k3.-i',at.4W' *** .?.'.r . :"t!Ff Le,'di A.;,5 .r.'',-°+
i'--L*••.,`' s,--,3L
1
F
1
r
1
quaw;eaal ;o asano0 awes ay4 6uunp ;ueapenb awes ail uo pawaoped uagm
Aaa6ans snoasso—O9 f7O pus `aanpaooad del; lenl6u!6—OiZVO saanpaooad ao; algeilens
IOU aas s;l;aua8 •ol;ay;saue leoo! pus lenowaa pus luawaoeld ){oed Is;uopopad `lenowaa
aan;ns `saan}ns `also and;eaado;sod pus aad aul;noa apniou! saanpaooad le4uopoped anoge eq j
Meal Z1. mil
00'6 00'Zl 00'171- aOfl canned) 6ulleoS le;uopopad lt,CIO
sninolso i
len!6u!6gns ;o IBAOWOJ ay;
ao; „6ulleos deep„ y) q now
00'91- 00'61- 00'bZ Hon aailu3—6ulleoS le;uopoiaad O17Et70 1-
00'9p 00'89 00'ZL lion A;seldoingl;saA ZLZt70
paq s3! woa;
paaa;Ala;aldwoo enssu ;o
ea6 y) (ails aouop bulpnloul)
00'09 00'99 00'08 UOfl s;;ea0 anssll 110S eaad LLZ10
ails aouop
ay; 04 p91435445 su!swaa
Iyo!unn Lied a)lll-;oo;e q
pagoe;;s anssl; snoauelnogns
ay; pus u!){s ay;;o ssauilom
lin;9144 JO 6ulls!suoo t;ea6 y)
00'ZE 00'Zt7 OOHS uon s;;ea0 enssll I;oS elo!Ped OLZVO
ails aouop pus aansolo pus
Aa;ua del; 6u!pnioul) sails
0019 00'88 00'801. on eldltlnw—s;;ea9 snoasso 39ZPO
oa;ap Auoq a J!sdaa o;
JO auoq penowaa a;o aoeld
ay;axle;04 pasn pus ;ua!led
ay;;o auoq lay;o awos
woa;ueme}auoq lo eoald y) f
ails aouop pus aansolo
pus Aa;ue del; 6ulpnloul)
001E $ 00'6t7 $ 00'09 $ uon ails elbuls—s;;ea9 snoasso 1-9Zt0 f
Mol wnlpal y 46lH L
aouemopd Alluwapul algeuossaa pus aanpeooId apo0
jo alnpayog Aiswol sn9 lensn
panufluoo) Q3QIAOad S1Id3N38 1V1N30 —A 31OIUIV
ARTICLE V— DENTAL BENEFITS PROVIDED (Continued)
filling material. Transitional or temporary crowns are not covered.
The above procedures shall be deemed to include all necessary bases (excluding pulp
1 capping), buildups, liners, local anesthetics, and required postoperative care (e.g., equilibra-
tion).
1 b. INLAYS (not part of a bridge)—A restoration formed to fit a tooth cavity which is then
cemented into place,as follows:
1 Usual, Customary Schedule of
Code Procedure and Reasonable Indemnity Allowance
High Medium Low
l 02510 Inlay Gold—one surface UCR 88.00 $ 71.00 $ 55.00
02520 Inlay Gold—two surfaces UCR 104.00 84.00 65.00
1 02530 Inlay Gold—three surfaces UCR 112.00 91.00 70.00
02540 Onlay—Per Tooth (in UCR 12.00 10.00 7.00
1
addition to above) Onlay is
an inlay which fits over the
biting or grinding surface
of a tooth
02610 Inlay—Porcelain UCR 45.00 36.00 28.00
The above procedures for inlays and onlays shall be deemed to include all necessary bases
J except pulp cap), buildups, liners, local anesthetics, and postoperative care.
1 6. ORTHODONTIC BENEFITS
a. If item 26 of the Schedule is indicated "Applied For," subject to the maximums, exclu-
I
sions, limitations and all other terms as set forth herein, when any Participant, while
under 19 years of age and while covered hereunder shall incur Orthodontic Expenses,
the Carrier will pay an amount determined by multiplying the Usual, Customary and
Reasonable charge (UCR) for such Orthodontic Expenses by the percentage indicated
Iin item 27 of the Schedule up to the applicable maximums.
b. The maximum benefit payable for any Participant during his lifetime shall be that indi-
1 cated in item 28 of the Schedule.
c. Orthodontic benefit payments will be of two types: (1) The initial payment, which will con-
1
sist of all services performed prior to and including the placement of the orthodontic
appliance, and such payment shall not exceed 50% of the orthodontic lifetime maximum
benefit; (2) Active treatment which includes all adjustment charges to be paid on a
iquarterly basis following proof of continuation of treatment during contract eligibility.
d. Orthodontic Expense means those Covered Dental Expenses normally and usually con-
sidered to fall within the Orthodontic field and which require the placement of an
1 Orthodontic appliance for the movement of and subsequent retention of the teeth after
repositioning.
i
1
y
Form No. 2816.1 2816.000-AL560
6491V-000'S in SLBZ 'oN wioj
1
1
1
ivawleeoi to asonoo awes NI 6u!onp lueopenb awes aql uo pawooload uegm 1
kio6ons snoesso—09Z70 pue 'aanpa000d dell lenl6ul6—07370 seonpa000d aol algeilene
iou aoe slllaue •ollaglsaue pool pue `lenowaa pue luawaoeld Toed leluopolaad `lenowaa
aims 'seonlns 'WED anlleoado;sod pue and aullnoa apnloul seonpaooad leluopolaad anoge ail
I
yleel Z1. Ueyl
00'6 00'31. 00171. uon JeMed) 6ulleoS leluopolaad 1.7£70
snlnoleo
lenl6ul6gns to lenowaa ay'
ool „6ulleos daap„ v) wow
00'91. 00'61. 0017Z boll aallu3—6ulleoS leluopolaad 07£70
00'97 00'85 00'ZL loll AiseldoinglisaA ZLZ70
Paq sit wool
pawl (l a a l dwoo anssq jo
lleo6 v) (ells oouop 6ulpnloul)
00'09 00'99 00'08 UOfl sUeo0 anss!11 0S eaad 1-LZ7O
ells oouop
NI of pagoelle sulewao
go!14M 4 ed a II-loo}e Aq
pegoelle anssll snoeuelnogns
ail pue upls ail to sseu>lolil
Ilnl 041 10 6ugslsuoo lleo6 V)
00'3£ 00'37 00'39 E Ofl sileo0 anssll lloS elolPed OLZ70
alts oouop pue aonsolo pus
Aolue dell 6ulpnloul) salts
00'19 00'88 00'801. don eld!linw—slleoo snoesso Z9Z70
loalap Auoq a oledao 04
0o auoq panowao e jo aoeld
014 a){el 01 pasn pus walled
ail to auoq aaylo awos
wool um{el auoq to 3001d v) r
alts oouop pus aonsolo
pue Aolua dell 6ulpnloul)
00'L£ $ 00'67 $ 00'09 $ aon ails al6uls—slleo0 snoesso 1.9370
nnoi wnipew g6IH
eoueMoipi Ai!uwepui a geuoseeu pue aanpaooad epo0
jo ampayos Laewolsn0 `Iensn
panunuo3) 03alAOUd SiId3N38 1V1N3a —A 313I111V
I
ARTICLE V- DENTAL BENEFITS PROVIDED (Continued)
Section B
INCENTIVE-USUAL, CUSTOMARY AND REASONABLE CHARGE
Subject to the maximums, deductibles, exclusions, limitations and all other terms and provisions
set forth herein, when any Participant while covered hereunder shall receive any of the services
of a Dentist for which benefits are paid under Section A, Subsections 1, 2, 3, 4, or 5, of this
Article V, if item 29 of the Schedule is indicated "Applied For,"the Carrier will provide additional
benefits for Covered Dental Expenses incurred during successive Contract Years, commencing
with the second of such successive Contract Years,as detailed below.
1. For the second successive Contract Year, the Carrier will provide benefits in the amount of
the percentage specified in item 30 of the Schedule, to be applied to the Covered Dental
Expenses for which benefits are payable under the preceding Section A, Subsections
1, 2, 3, 4, or 5, provided payment was made in such Section A, Subsections 1, 2, 3, 4, or 5,
for the first Contract Year.
2. For the third successive Contract Year,the Carrier will provide benefits in the amount of the
percentage specified in item 31 of the Schedule, to be applied to the Covered Dental Ex-
penses for which benefits are payable under the preceding Section A, Subsections 1, 2,
3, 4, or 5 , provided payment was made under item 1, above, for the second successive
Contract Year.
3. For the fourth successive Contract Year, the Carrier will provide benefits in the amount of the
percentage specified in item 32 of the Schedule to be applied to the Covered Dental Expenses
for which benefits are payable under the preceding Section A, Subsections 1, 2, 3, 4, or 5,
provided payment was made under item 2, above, for the third successive Contract Year.
Section C
DEDUCTIBLE
If item 33 of the Schedule is indicated "Applied For," a deductible amount as indicated in item
36 of the Schedule shall apply and must be satisfied before any benefits become payable; pro-
vided, however, if item 34 of the Schedule has been indicated, no deductible shall apply to
Orthodontic Benefits, or if item 35 of the Schedule has been indicated, no deductible shall apply 1.
to Basic Benefits.
The Deductible shall apply to each Participant for each Benefit Period. If benefits are payable L
on an indemnity basis, the deductible shall be satisfied on the basis of the first Covered Dental
Expenses incurred by a Participant in a Benefit Period and shall be subtracted from amounts of
benefits otherwise payable under Section A, Subsections 1, 2, 3, 4, or 5 of this Article V. If
benefits are payable on the basis of Usual, Customary and Reasonable charges, the deductible
shall be satisfied on the basis of the first Covered Dental Expenses incurred by a Participant
in a Benefit Period which would be payable otherwise under Section A, Subsections 1, 2, 3, 4,
or 5 of this Article V, and notwithstanding the wording of such subsections, benefits shall be
based on the Covered Dental Expenses incurred in a Benefit Period in excess of the Deductible.
The Deductible for,an Employee and all of his Dependents shall be deemed to be satisfied for the
remainder of the Benefit Period when the Employee and two or more Dependents, or three
Dependents, have satisfied their Deductibles. The Usual, Customary and Reasonable charge for
any Covered Dental Expenses
ARTICLE V— DENTAL BENEFITS PROVIDED (Continued)
incurred during the last three (3) months of a Benefit Period, and applied toward satisfaction
of the Deductible for such Benefit Period, may be applied toward satisfaction of the Deductible
for the next succeeding Benefit Period.
Section D
PREDETERMINATION
If a Course of Treatment can reasonably be expected to involve Covered Dental Expenses of
more than $100.00, and the payment is based on Usual, Customary and Reasonable charges, a
description of the procedures to be performed and an estimate of the Dentist's charge must be
filed with and predetermined by the Carrier prior to the commencement of treatment. If Predeter-
mination is not obtained in advance of treatment, the Carrier will unilaterally determine benefits
applying alternate plans of treatment when applicable.
Section E
MAXIMUM BENEFITS PAYABLE
If item 37 of the Schedule is indicated "Applied For," the maximum amount payable under this
contract for any one Participant during any one Benefit Period shall be indicated in item 38
of the Schedule. The provision of this section shall not apply to Section A, Subsection 6,
Orthodontic Benefits.
L
L
L
L
L
Form No.2817 2817.000-AL679
r .
ARTICLE VI - LIMITATIONS AND EXCLUSIONS
The benefits of this contract are not available for any Covered Dental Expenses:
A. Received or rendered through or in Veterans Administration facilities; any dental proce-
I dures for which benefits are or could upon proper claim be provided under the Workers'
Compensation law, or any other present or future laws enacted by the Legislature of any
state, or by the Congress of the United States, or the laws, regulations or established proce-
dures of any county or municipality; provided, however, that the provisions of this Section A
shall not be applicable to any coverage held by the Participant for Dental expenses which
is written as a part of or in conjunction with any automobile insurance policy;
I B. Resulting from disease contracted or injuries sustained as a result of war, declared or
undeclared, or any act of war;
C. Rendered primarily for cosmetic purposes, except for services rendered for correction of
11 defects incurred through traumatic injuries sustained by the Participant while covered
hereunder and excepting Orthodontics; nor for procedures not dentally necessary;
D. For which a benefit is not specifically listed in Article V and indicated as "Applied For" in
ji
the Schedule, or for procedures for which the American Dental Association has not approved
a specific procedure code;
1
E. Received or rendered for consultation purposes;
F. For replacement of dentures, removable or fixed prosthesis, and dental restorations con-
taining gold or platinum due to theft, misplacement or loss;
G. For replacement of dentures, removable or fixed prosthesis, and dental restorations con-
taining gold or platinum within five (5) years after receiving such dentures, prosthesis or
restorations;
I(
H. For any full-mouth x-ray rendered within three (3) years from the date of the Participant's
last full-mouth x-ray. Any bitewing x-ray or prophylaxis rendered within six (6) months
of the previous bitewing x-ray or prophylaxis.
L I. For which an optional technique of treatment or procedure carrying a lesser fee is payable
under this contract;
I J. For personalized complete or partial dentures, overdentures and their related procedures,
or other specialized techniques not normally taught in regular dental school classes;
K. Rendered before the effective date of a Participant's coverage or after termination of
I-- coverage;
L. For appliances, restorations, or special equipment used to increase vertical dimension,
L
correct or determine proper occlusion except as provided for in Article V, Section A, Sub-
section 6; or to correct temporomandibular joint dysfunction or pain syndromes;
M. For the administration or cost of drugs and/or gases used for sedation or as an analgesia;
i N. For which benefits are otherwise provided under Hospitalization, Medical-Surgical, or
L Prescription Drug Expense Coverages;
L
O. For treatment by other than a Dentist, except that x-rays, scaling or cleaning of teeth and
topical application of fluoride may be performed by a licensed dental hygienist if the
treatment is rendered under the supervision and guidance of the Dentist;
L
P. For veneers or similar properties of crowns and pontics placed on or replacing second and
third molar teeth;
Q. For prosthetic devices (including bridges), crowns, inlays, onlays, and the fitting thereof,
I.
which began before the effective date of the Participant's coverage hereunder;
Form No. 2819 2819.000-AL679
i
1
r
I
i
f '
l
1
1
1
L
i .sWJo;aoueJnsui Aue;o uogaIdwoo Jo;Jo;sguaa a y4!M us!n painpayos
e daa)i o; ainue; ay} woa; 6umnsaa e6Jeyo a Jo; ;oe.quoo sly; aapun ;i;auaq ou s! aaagj
y;aai;o 6ui;ulids and •A
s;uejdwi god 'X
L
weJ6oad iauuoo anbejd a Jo `suoi;onJ;su!Aae;aip `s;ueleas Joj •M
uoi;eJo;saJ Ie;uap a;eo!Idnp Jo saoueudde a;eoiIdnp Jaywo `aoinap oRay;soad a;eo!ldnp a JOA •n
uoi;eioossd le;uaa ued!Jawy 844 lo Hounoo e
1 Aq panoidde Alin; jou JO aan;eu u! Ie;uaw!Jadxa aae goigM sauddns JO saoinaas Jo; 886Jeyo
6uipnjoui 'aoi;oead ie;uap ;o spiepue}s pa;daooe ;aaw ;ou op yoiyM sa!Iddns Jo seoinaes and .n
a6eaanoa le;uaa s!ql ;o aouasge ay; in apew aq pinoM a6Jeyo ou yoigM Jo;
JO Aed o; pa}e6ugo Alle6a! }ou Si aaAoidwa ay; yoigM Jo; Jo apew Si abieyo ou go!gM JoJ •1
aaAoidwa sjuai;ed ay;Aq
pau!e;view Jo papinoad A;ilioe; JeIiw!s Jo `oiuipo ';uaw oedap Ieoipew e g6no.iy; paaapuaa •S
1 aoue!Idde oi;uopoy;Jo ue;o nedaJ Jo;uawaoelda,aoj •a
panul;uoo) SNOISf 13X3 GNb SNOIlt/llWil — IA 37O1l1:Ib
i
ARTICLE VII - TERMINATION OF COVERAGE
A. The coverage of all Participants hereunder shall automatically terminate when this contract is
terminated in any manner, as follows:
1. By cancellation on any premium due date, at the request in writing of the Employer
furnished to the Carrier at its Home Office, not less than thirty (30) days in advance;
2. By default in premium payment, subject to the grace period provided in Article III;
3. By failure of the Employer to maintain enrollment of its Employees hereunder at a level of
at least seventy-five percent(75%) of the total eligible number, with a minimum enrollment
of twenty-five (25) Employees provided that the Carrier shall first notify the Employer of
such enrollment deficiency, and provided further that the contract shall not terminate if,
within the thirty (30) days following such notification, the deficiency is remedied. In the
event of failure to remedy the enrollment deficiency in such case, the date of termination
of this contract shall be the last day of the contract month following the month in which
the deficiency notification is furnished.
B. The coverage of any Employee and his Dependents included hereunder shall automatically
terminate upon:
1, The last day of the last period for which his portion of the group premium is paid to the
Carrier;
2. The effective date of an amendment to this contract which terminates the coverage of any
class of Employees to which he belongs.
C. The coverage of any Dependent of an Employee included hereunder shall automatically termi-
nate at the end of the contract month in which such Dependent ceases to be a Dependent as
defined in Article I,Section C, of this contract.
11
D. The Carrier will refund to the Employer the portion of the premium theretofore paid in advance
for coverage of a Dependent whose coverage terminates in accordance with the provisions of
Section C, above; provided, however, that in case of termination on account of marriage, the
refund will not be made as to any period before the Carrier is actually notified of the marriage.
E. Under no circumstances shall the Carrier be obligated to notify any Participant of the termina-
1 tion of this contract or of his coverage hereunder.
F. Notwithstanding the above provisions of this Article VII, if the Employer is paying an
Employee's premiums in whole or in part pursuant to the terms of a collective bargaining
agreement and in the event of cessation of work as the result of a labor dispute by its
Employees who are members of the bargaining unit, coverage under this contract for such
Employees and their Dependents hereunder shall terminate on the last day of the Contract
Month in which such cessation of work began; except that coverage under this contract may
be continued for such Employees and Dependents for a period of up to six (6) additional
Contract Months, provided that for each such additional Contract Month:
1. Coverage of at least seventy-five percent (75%) of the Employees, who are members of
the bargaining unit and who cease working due to the labor dispute, is maintained; and
2. A single payment for the premiums due from such Employees is remitted within the grace
period for such premium payment.
The Carrier reserves the right to adjust premium rates for such Employees which shall be
payable for such additional Contract Months.
Form No. 2820 2820.000-AL679
TARTICLE VIII - GENERAL PROVISIONS
A. CONTRACT; AMENDMENTS:
1. This contract and the Application of the Employer hereof, a copy of which is attached
hereto, and the applications of Employees shall constitute the entire contract. All state-
ments made by the Employer or by the Employees covered shall be deemed representa-
tions and not warranties, and no statement made by any Employee covered shall be used
in any contest or in defense of a claim hereunder unless a copy of the instrument contain-
ing the statement is or has been furnished to such person or to his beneficiary.
2. This contract may be amended or changed at any time, subject to the laws of the jurisdic-
tion in which it is delivered, without the consent of the Employees covered hereunder or
of their beneficiaries, by written agreement between the Employer and the Carrier. Only
i :: the President, a Vice-President, the Secretary, or an Assistant Secretary of the Carrier
I has the power to change, modify, or waive the provisions of this contract, and then only in
writing done at the Home Office. The Carrier shall not be bound by any promise or repre-
sentation heretofore or hereafter made by or to any agent other than specified above.
B. INCONTESTABILITY: This contract shall be incontestable after two years from date of issue
for nonpayment ofexceptfo premiums.p
C. TIME LIMIT ON CERTAIN DEFENSES: After one year from the effective date of coverage for
any Employee no misstatements, except fraudulent misstatements, made in his application for
1 coverage shall be used to void his coverage or to deny a claim for benefits on account of
Dental services rendered after the expiration of such one-year period.
l
D. REINSTATEMENT: If default be made in the premium payments for this contract, the subse-
quent acceptance of such premium by the Carrier or any of its duly authorized agents shall
fully reinstate the contract.
f E. NOTICE OF CLAIM:The Employee shall give or cause to be given written notice to the Home
l Office of the Carrier at Dallas, Texas or its duly authorized agent within thirty (30) days or as
soon as reasonably possible after any Participant receives any of the services for which
Lbenefits are provided herein.
F. CLAIM FORMS: The Carrier will furnish to the Employee and/or the Participant's Dentist,
upon receipt of a notice of claim or prior thereto, such forms as are usually furnished by
it for filing proof of loss. If such forms are not furnished within fifteen (15) days after the giving
of such notice, the Participant shall be deemed to have complied with the requirements of
this contract as to proof of loss upon submitting, within the time fixed in the contract for filing
L proofs of loss, written proof covering the occurrence, the character and the extent of the
loss for which claim is made.
L G. PROOFS OF LOSS: Written proof of loss must be furnished to the Home Office of the Carrier
at Dallas, Texas, by the Employee within ninety (90) days after any Participant hereunder
receives services for which benefits are provided herein. Failure to give notice or furnish
proof within the time specified shall not invalidate any rights if it shall be shown not to have
L been reasonably possible to give such notice or furnish such proof, and that it was done as
soon as was reasonably possible, and in no event, except in the absence of legal capacity,
later than one year from the time proof is otherwise required.
LH. TIME OF PAYMENT OF CLAIMS: Benefits payable under this contract for any loss will be
paid immediately upon receipt of due written proof of such loss.
L
I V 111111111111111111111111111111111111111.11111111111111111M
0.
Form No. 2821 2821.000—AL 679
I
I
1
j_aolnJaS Jelnol;Jed e y;Inn uol;aauuoa u1 aoua!Jadxa pue Alois `awl; Ieuol;lppe
6uulnbai suol;eo11dwoo 'mac] Jo SaOUe;swnOJlo lensnun pue `aouauedxa pue 6uiuiei;aellwls
y;IM A;lieooi ay; ul s;sl;uaa Aq apew AHJewo;snO saolnaas JBHwls JO; sa6aeyo ay; `aolnaas
ay; 6uiJapuei ;sl;uaa ay; Aq apew i(Ilensn saolnaas aellwls Jo; sa6aeyo ay; Japlsuoo days
JalJJeo ay; `;sl;uaa a Aq paaapuaa aolnaas e Jo; a6Jeyo ameuoseeld pue Aaewo;sn0 lensn ay;
6ululwJa;ap uI :30EIVH0 318VNOSV3a pUe A8iVWIO.SflO `1Vflsfl dO NOIIVNIINa313a '0
alnpayog Mau Lions ul pa;elndl;s amp and;oa;;a ay;as;;e
pue uo ;oeJ;uoo sly; Japun ;uedlol;Jed yoea o; paaapuaa saolnaas He o; AIdde IHM alnpayog
Mau ay; ul SJO;oed a6eaano0 ay; 'alnpayog Mau a y;IM paoeidaJ s! ;oeJ;uoo ao; uol;e311ddy
ay; ul alnpayog ay; ;vane ay; in :SNOIjV3Id103dS JO 31fla3HOS AO 1N3W3OV1d3a 'd
saaded a;egad
oxide Ile ;o uol;noaxa 6ulpnioul `AJanooaJ ay; aanoas o; kessaoau aq stew Jan94e1M op
04 paaJ6e aney 04 pue JOIJJBO ay; 04 Aaan008J ;o s;y61J Lions paublsse aney 04 pawaap aq
Heys 'aseo Lions ul Japunaaay s;I;auaq 6ulnlaoaJ Aq `;uedlol;Jed Auy •papinoad os s;l;auaq ay;
c o ;ua;xe ay; 01 Aiuo ;nq `Japunaaaq papinoJd aae s;I;auaq Lio14M Jo; Aanful Jo ssaull! ul 6u!
InsaJ ;Oe in;iilM Aue JO aoue6116au Jo; uol;ezlue6JO Jo uosJad Aue ;sule6e aalnboe Amu wed
O!;Jed Aue 143114M i(aanooai JO s 41461J Ile 04 pa;e6oagns aq Heys Ja!JJBO ayl :NOIIVOO1:18f1S '0
1 JelJJe3 8144 04 ;uawAed Lions pun;ei `puewap uodn 'Heys Agaaay; 6u1;I;auaq
uedlol;Jed Jay;o Jo eaAoidw3 ay; 'pai;I;ue Alie681 ;ou seM waged ay; yo14M o; JapunaJay
pled uaaq aney s;I;auaq ;e(; paulwJalep aq Heys ;l ua(M pue ;I :S11d3N38 JO aNfld3H 'N
I—spaooaw pue uol;ewJO;ul Lions ;o aJnsoioslp all 6ulpplgJo; Mel ;o suolslnoJd He panleM
aney o; pawaap aq 'Japunaaaq s;l;auaq JO; wleio 6u1;Jasse Aq `Keys s;uedlol;Jed Lions pue
i
a6eJanoo sly; Japun papnloul ;uedlol;Jed Aue ;o aae° JO `;uaw;eaJ; `slsou6elp ay; 04 6ul;eiaJ
spJooaJ ;o saldoo Jo spiopeJ pue uol;ew.io;ul He lepieo ay; yslu.in; o4 ;spuaa 6ulpua;;e
Cue pezuoq;ne aney o; pawaap eq Heys `s;uepuedea paaanOO sly pue }laswly ;o >.ieyaq
uo `aaAoldw3 ay1 `JapunaJay ebBJanoo Jo; uol;eotidde ay; y;IM uol;oauuoo u1 uol;eulwexe
l
IeolsAyd panleM 61.11ney S,JaIJJeO ay; ;o uol;eJaplsuoo u1 :NOIIVZI1:IOHif1V 3unsolosia 'W
saolnaas Aue ;o Iesn;aJ a Jo i(;IHgeul Jo; JepunaJa1 sayoe;;e A;IllglsuodsaJ
f ou pue `;oeJ;uoo sly;aapun saolnaas 6u!ApoeJ ;uedlol;Jed a Jo; 6u!Jeo Li! `seeAoidw3 Jo s;ua6e
L Jlay; `;sl;uaa Aue Aq uolsslwo Jo ;Oe ,cue ao; algell aq ;ou Heys Ja!JJe3 ayl :1131AiIy10Sla 1
1 ` AJBJ;uoo ay;sa;eolpul (JJealo;xa;uoo ay;ssalun aululwa;ay;apnloul
Lo; pawaap aq !legs Japua6 aulinOSew ay; u1 unouoad IeuosJad a ;o ulaJay asn :1:13GN3D
aigeAed OJE s;I;auaq ay;woIM 04 pue pai;l;ueLslayyo1gMo; s;I;auaq le;uaa ay; o; se ;uawa;e;s a y;JO; 6u1;;as a;eo1;I;Jao Ienpinlpul ue
eeAoidw3 pOJanOO yoea Jo;JaAoldw3 ay;04 anss! IIIM aaIJJeQ eyl :31VOIdlla30 1V110iAIONl 'P
apewL - sl wleio yo!LiM Jo; saolnaas ay; ;o uol;IpUeJ ,o amp ay;Jelle SJeec aaay; my;IM ;y6nOJq ssaiun
OBJ;uoo sly;Jepun JOA038J 0;416noaq eq Heys A)!nba uI JO Mel ;e uol;Oe oN :SNOIIOV 1V031 1
panui;uoo) SNOISIAOlid 1Vii3N3O — IIIA 310111:Id
AMENDMENT
to any
Group Hospitalization, Medical-Surgical, and/or Dental Contract, including any supple-
1 ments thereto, issued by the Carrier or Carriers named below, as follows:
This contract is hereby amended to provide that benefits for services or
supplies shall not be excluded solely because benefits are paid or pay-
able for such services or supplies under the Medical Assistance Act of
1967, as amended, and to further provide that benefits shall be payable
to the Texas State Department of Human Resources to the extent required
1 by the provisions of Chapter 783, Acts of the 66th Legislature, 1979.
1
I
GROUP HOSPITAL SERVICE, INC.
GROUP LIFE & HEALTH INSURANCE COMPANY
W. F. Hachmeister, President
w
Re i str r
STOex No. 9460.000-AL1279
This Application Is Hereby Made to
1 GROUP HOSPITAL SERVICE, INC.
Dallas, Texas
1 by the Employer named below for an Experience Rated Group Dental Contract, Form No. GDC-2, in
accordance with the stipulations set out herein. The Contract Number shall be 65816
ISCHEDULE OF SPECIFICATIONS
1
XXX in any space means Coverage factor applicable
COVERAGE FACTORS
BASIC BENEFITS: ADDITIONAL BASIC BENEFITS:
Item Item
Number Number
1. j Applied For f Not Applied For 6. mc Applied For Not Applied For
i 2. XX1i Basis of Payment — Usual, 7. [c Basis of Payment— Usual,
Customary and Reasonable Customary and Reasonable
3. [ 100% 90%X 80% 8. 100% 90% XI 80%
i
70% 60% % 50% 70% 60% 50%
Other Specify _ Other Specify _%
4. Basis of Payment — Schedule of 9. Basis of Payment— Schedule of
Indemnity Allowance Indemnity Allowance
5. High Medium 1 Low 10. High Medium Low
PROSTHETIC BENEFITS: PERIODONTIC BENEFITS:
i Item Item
Number Number
11. Applied For —]Not Applied For 16. [X]Applied For 1 Not Applied For
12. Basis of Payment— Usual,17. [ Basis of Payment — Usual,
Customary and Reasonable Customary and Reasonable
13. 100% 90% 80% 18. 100% 90%MP 80%
70% 60% 50% 70% 60% 50%
IOther Specify Other Specify
14. Basis of Payment — Schedule of 19. Basis of Payment — Schedule of
lIndemnity Allowance Indemnity Allowance
15. High Medium Low 20. High Medium Low
1
1 Form No. GDC-2-App Page 1 Stock No. 2822.000-N679
r
CROWNS, INLAYS AND ONLAYS BENEFITS: ORTHODONTIC BENEFITS:
1
Item Item
Number Number
21. Applied For ® Not Applied For 26. taxi Applied For Not Applied For
1 22. Basis of Payment — Usual, 27. Usual, Customary and Reasonable
Customary and Reasonable
Eail 50% 60%
1
23. 100% 90% 80%
Other Specify
70% 60% 50%
28. Lifetime Maximum Benefit
Other Specify
500 600 I1CXX $700
24. [ Basis of Payment — Schedule of
Indemnity Allowance Other Specify $
25. High j Medium Low
IINCENTIVE—USUAL, CUSTOMARY AND DEDUCTIBLE:
REASONABLE
Item
1 Item
Number
Number 33. Applied ForXX Not Applied For
29. Applied For g Not Applied For
34. XXX Does not apply to Orthodontic Benefits
1 30. Percentage for second Contract Year 35. Does not apply to Basic Benefits
10% Other 36. 25 50 1$75
lSpecify__ %Other Specify $-
31. Percentage for third Contract Year
1 20% Other
MAXIMUMS: Per Benefit Period
Item
Specify Number
37. XXX Applied For Not Applied For
1 32. Percentage for fourth Contract Year 38. 500 750 1000
30% Other
Other Specify $
Specify
I
f
f.
i
Form No. GDC-2-App Page 2 Stock No.2823.000-N679
4,
ELIGIBILITY REGULATIONS: Persons eligible to apply for coverage under the contract shall be the
Employees of the Employer named below
who have been continuously employed for not less than _60 days. No period of continuous
1
employment shall be required for Employees otherwise eligible on the Contract Date 0 Yes No.
EFFECTIVE DATES: The effective dates of individual applications are to be handled under the terms of:
E Standard Option Eil Option I [_ Option II Other (See Special Provisions)
END OF SCHEDULE OF SPECIFICATIONS
1 CONTRACT DATES:The Contract Date is December 1 19 80 The first contract
anniversary shall be November 1 19 81 , whether or not the two dates are separated
by twelve months.
l
MINIMUM ENROLLMENT REQUIREMENTS: The Employer certifies that 932 _ Employees are
eligible to make application for coverage at the date of this group application, and agrees that at least
75% of that number (25 minimum) must make application for coverage before the contract date, otherwise
this application shall be deemed to have been withdrawn.
PREMIUMS: The Employer will provide payroll deduction facilities for the Employee's portion of the
premium and make consolidated g rou p p remium remittances. The following shall be the initial monthly
premium rates:
i
Employee, spouse
Employee Employee Employee and Employee and and dependent child•
Only and Spouse Dependent child Dependent children or children
1.95 4.10 5.96 5.96 8.10
lThe above monthly premium rates shall be subject to change on the first contract
anniversary. As of the Contract Date, the amount of Employer contribution is: total employee rate
with no contribution toward dependents.
i SPECIAL PROVISIONS: The following stipulations shall be considered a part of this application:
1 !
The contract and the coverage provided thereunder shall become effective on the Contract Date stipu-
lated above under Contract Dates, provided that (1) this application is executed in duplicate; (2) payment
of the first month's premium is received by Group Hospital Service, Inc.; and (3) in the event of any
1
alteration of this application, such alteration is accepted in writing by Group Hospital Service, Inc.
Employer: City of Wichita Falls
Wichita Falls, Texas
t City and State)
by
uarts 8 h;t1tt' Manager
Signed at Witness:
On 19 ' 1 1— --
Representative of the Carer
i Form No. GDC-2-App Page 3 Stock No.2824.000-N679
MINIMUM FUNDING COST-PLUS AGREEMENT
This Agreement is entered into by and between
GROUP HOSPITAL SERVICE, INCORPORATED
and
GROUP LIFE & HEALTH INSURANCE COMPANY
Dallas, Texas
hereinafter jointly called Blue Cross and Blue Shield of Texas)
and
CITY OF WICHITA FALLS
Wichita Falls, Texas
hereinafter called the Employer)
EFFECTIVE: November 1, 1980
for the purpose of determining the ultimate consideration to be paid by the
Employer for the coverage provided by Blue Cross and Blue Shield Health
Contract numbered 5448, hereinafter called "Health Contract."
ARTICLE 1 - DEFINITIONS
As used in this Agreement:
A. Exhibit means the attached specifications setting out certain particulars
of this Agreement or any other subse-quent set of specifications supplied
by Blue Cross and Blue Shield of Texas as a replacement exhibit. The
specifi-cations or items of the Exhibit may be changed at any time
by notifying the Employer of such change and the reasons therefore
except that Item III of the Exhibit, Adminis-tration Charge, may be
changed only one time in any Contract Year.
B. Deposit Premium means the amount of money required by Blue Cross and
Blue Shield of Texas for payment of anticipated Paid Claims and anticipated
Administration Charge thereon for a period of one (1) month, such amount
to be due and payable to Blue Cross and Blue Shield of Texas on or
before the fifteenth of each month, the first such month being the
month during which this Agreement becomes effective. Deposit Premium
will be considered received on the date the money is received in the
Dallas,. Texas home office. A daily charge equal to .05% of the amount
due may be charged for late receipt of Deposit Premium. Each monthly
Deposit Premium shall equal an :,mount calculated in accordance with
the formula indicated in Item I (‘f the Exhibit.
C. Contract Year means each consecutive twelve (12) month
period, the first period commencing with the effective date
of this Agreement.
D. Quarter means each consecutive three (3) month period, the first period
commencing with the effective date of this Agreement.
E. Stop-Loss Premium means the monthly consideration required by Blue Cross
and Blue Shield of Texas for the risk assumed for the Stop-Loss Claims
which are indicated "Applied for" in Item V of the Exhibit. Each
Stop-Loss Premium is calculated and payable monthly in accordance with
the formula indicated in Item II of the Exhibit. A daily charge equal
to .05% of the amount due may be charged for late receipt of Stop-Loss
Premium.
F. Paid Claims means the total of all benefits paid under the benefit-
provision of the Health Contract.
G. Expected Paid Claims means the total claims that are actuarially expected
to be paid each Contract Year under the benefit clause of the Health
Contract by Blue Cross and Blue Shield of Texas. Expected Paid Claims
will be calculated for each Contract Year in accordance with the formula
indicated in Item IV of the Exhibit, provided Item V B is indicated
Applied for."
H. Stop-Loss Claims means those Paid Claims for which Blue Cross and Blue
Shield of Texas assumes responsibility and risk for payment which is the
sum of individual Stop-Loss Claims if indicated "Applied for" in Item V
A of the Exhibit and Aggregate Stop-Loss Claims if indicated "Applied
for" in Item V B of the Exhibit.
1. If, during any Contract Year, claims paid for an individual certificate
exceed the amount indicated in Item V A of the Exhibit, such excess
shall be referred to in this Agreement as Individual Stop-Loss
Claims.
2. If, during any Contract Year, Paid Claims for that Contract Year
less individual Stop-Loss Claims, if any, exceed the results
obtained by multiplying Expected Paid Claims for that Contract Year
by the percentage indicated in Item V B of the Exhibit, such
excess, if any, will be referred to in this Agreement as Aggregate
Stop-Loss Claims.
I. Administration Charge means the consideration calculated quarterly, in
accordance with Item III of the Exhibit, which is required by Blue Cross
and Blue Shield of Texas for the administration of the Health Contract.
Such consideration will be automatically increased by the amount of
premium taxes whenever imposed by lawful authority over and above those
applicable on the effective date of this Agreement.
ARTICLE II - SETTLEMENTS
A. Quarterly Settlement. Within thirty (30) days following the end of each
quarter, Blue Cross and Blue Shield of Texas will furnish the Employer a
report for that quarter detailing Deposit Premium, Paid Claims, Administration
Charge and all other data required for a quarterly settlement. If the
report reflects that Deposit Premium exceeds Paid Claims plus Administration
Charge, the excess shall be due the Employer. If the report reflects
that Paid Claims plus Administration Charge exceeds Deposit Premium, the
excess shall he due Blue Cross and Blue Shield of Texas. Interest
calculated in accordance with Item VI of the Exhibit will be added to
each excess payment amount made either to the Employer or Blue Cross and
Blue Shield of Texas. No accounting will be made for Stop-Loss Premiums.
B. Remittance. Within ten (10) days of receipt of the Quarterly Settlement
provided for above, the Employer or Blue Cross and Blue Shield of Texas,
as the case may be, shall remit payment of such excess. A daily charge
equal to .05% of the amount of excess due may be charged for late remit-
tance.
C. Annual Stop-Loss Settlement. If Item V A of the Exhibit is indicated
Applied for", an Individual Stop-Loss Settlement will be made annually
within forty-five (45) days following the end of each Contract Year
during which this Agreement was in effect in accordance with paragraph
1, below; provided, however, if the Health Contract or this Agreement is
terminated on a date other than a contract anniversary, a settlement
will be made under paragraph 1, below, for that portion of any Contract
Year immediately preceding termination. If Item V B of the Exhibit is
indicated "Applied for", an Aggregate Stop-Loss Settlement will be made
annually within forty-five (45) days following ,the end of each Contract
Year during which this Agreement was in effect in accordance with
paragraph 2, below; provided, however, if the Health Contract or this
Agreement is terminated on a date other than a contract anniversary, in
no event will a settlement be made under paragraph 2, below, for that
portion of any Contract Year immediately preceding termination.
1. Individual Stop-Loss Settlement. Blue Cross and Blue Shield of
Texas will prepare a report listing Individual Stop-Loss Claims, if
any, by certificate. This report together with a payment for all
Individual Stop-Loss Claims, if any, will then be forwarded to the
Employer.
2. Aggregate Stop-Loss Settlement. If a settlement is required to be
made under paragraph 1, above, Paid Claims used for this settlement
shall not include individual Stop-Loss Claims, if any. If Paid
Claims for the Contract Year involved exceed Expected Paid Claims
for the
same Contract Year multiplied by the percentage indicated in Item V
B of the Exhibit, the amount of such excess shall be forwarded to
the Employer. If the reverse is true, the Aggregate Stop-Loss
shall not come into effect and no payment will be due under this
paragraph.
D. Termination. Upon termination of the Health Contract and/or this
Agreement, the time intervening between the end of the period covered by
the immediately preceding report required under Section A, above, and
the termination date regardless of the number of months involved, shall
be deemed a quarter and a settlement made as provided for in Article II,
Sections A and B, above. The Employer shall continue to remit Deposit
Premium for three (3) consecutive months subsequent to the effective
date of termination to provide for the remaining expected paid claim
liability and Administration Charge. For the purpose of this section,
the monthly Deposit Premium will be an amount equal to the Deposit
Premium payable for the month preceding termination; and the Administration
Charge will be an amount equal to the Administration Charge in effect
for the month preceding termination. At the end of the seventh (7th)
month following termination, Blue Cross and Blue Shield of Texas will
prepare a tentative settlement report for the six (6) month period
following termination, and will refund to the Employer any Deposit
Premium which is not considered by Blue Cross and Blue Shield of Texas
to be reasonably necessary to cover the cost of future Paid Claims plus
Administration Charge. Blue Cross and Blue Shield of Texas reserves the
right to bill the Employer for an additional amount at this time (an
Interim Billing) in the event any remaining Deposit Premium is considered
not adequate to cover the cost of future Paid Claims plus Administration
Charge. The Annual Stop-Loss Settlement does not apply to this section.
A final report will be furnished the Employer twenty-seven (27) months
after termination. This report will detail Deposit Premium, Paid
Claims, Administration Charge, Refunds and Interim Billings, if any,
applicable for the period commencing with the date of termination to the
date the report is rendered. If the report reflects that Deposit
Premium less Refunds plus Interim Billing Payments, if any, exceeds Paid
Claims plus Administration Charge, the excess shall be due the Employer.
If the report reflects that Paid Claims plus Administration Charge
exceeds the sum of Deposit Premium less Refunds plus Interim Billings,
if any, the excess shall be due Blue Cross and Blue Shield of Texas.
Blue Cross and Blue Shield of Texas reserves the right to bill the
Employer for Paid Claims plus Administration Charge for any claims
paid subsequent to the final settlement. Any amount due under this
section shall be paid in accordance with Article II, Section B, above.
ARTICLE III - GENERAL PROVISIONS
A. Contract Amendments. Article III of the Health Contract is hereby
amended, to provide that payment of the Deposit Premium as defined in
Article I, Section B of this Agreement and the quarterly payments as
provided in Article II, Sections A and B of this Agreement shall constitute
premiums" as used in such Article of the Contract.
B. Allocation. Blue Cross and Blue Shield of Texas have a reciprocal
agreement under which they will allocate monies received, and they agree
that the Employer shall have no responsibility for or interest in such
allocation.
C. Right to Terminate. This Minimum Funding Cost-Plus Agreement will termi-
nate if the Health Contract terminates and may be terminated by either
party pursuant to written notice given by either party to the other not
less than forty-five (45) days in advance of the termination date. Upon
such termination, subsequent settlement shall be effective in accordance
with the provisions of Article II hereof.
Witness our hands this /1 day of 19 5,n1:9 •
For Group Hospital Service, Incorporated
and Group Life & Health Insurance Company:
W. F. achmeister, President
For CITY OF WICHITA FALLS
Atillb Bach, City Manager
EXHIBIT
Specifications for Contract Year Beginning November 1 , 19 80
CITY OF WICHITA FALLS
GROUP NUMBER: 5448
Item I -- Deposit Premiums will be calculated monthly by multiplying the sum
of the figures shown in the columns headed "Paid Claims" and "Administration
Charge" for the month involved by the number of Certificates in force on the
first day of that month.
Item II -- Stop-Loss Premium will be calculated monthly by multiplying the
figures shown in the column headed "Stop-Loss Insurance" for the month
involved by the number of Certificates in force on the first day of that
month.
Monthly Payment Schedule Per Certificate
Deposit Premiums for Anticipated
Payment Administration Stop-Loss
Month Paid Claims Charge Insurance Total
11/80 2.00 0. 13 0.67 2.80
12/80 19.58 1.28 0.67 21.53
1/81 28.51 1.87 0.67 31.05
2/81 36.77 2.41 0.67 39.85
3/81 39.44 2.59 0.67 42.70
4/81 42.22 2.77 0.67 45.66
5/81 43.48 2.85 0.67 47.00
6/81 44.55 2.92 0.67 48. 14
7/81 45.39 2.98 0.67 49.04
8/81 46.35 3.04 0.67 50.06
9/81 47.09 3.09 0.67 50.85
10/81 47.32 3. 10 0.67 51.09
Item III -- Administration Charge for the indicated Contract Year shall be
6.56% of Paid Claims.
Item IV -- Expected Paid Claims for the Indicated Contract Year will be cal-
culated by completing the following schedule.
Risk A) B) C)
Exposure Monthly Expected Paid Total Expected Paid
Months Certificate Count Claims Per Certificate Claims For Contract Year (1 `
11/80 40.669
12/80 36.98
1/81 47.84
2/81 42. 56
3/81 46.26
4/81 43. 59
5/81 43. 12
6/81 41.82
7/81 39.85
8/81 34.86
9/81 22.80
10/81 2.43
Expected Paid Claims - Incurred During Contract Year $ 2 •
Expected Paid Claims - Incurred Prior to Contract Year $ -0-
Total Expected Paid Claims
Footnotes
1 ) Column (C) equals Column (A) times Column (B) .
2) Equals summation of Column (C) .
Item V -- Stop-Loss Options
A. individual Stop-Loss
Applied for. All claims paid per certificate during the indi-
cated Contract Year which are in excess of $
X Not applied for.•
R. Aggregate Stop-Loss
X Aupli.ed for. The amount of Paid Claims during the indicated
Contract Year which exceeds120 % of the Expected Paid Claims.
Not applied for.
Item VI -- Forty-five (45) days interest at the rate of 87 per annum will
be credited on all excess settlement •unounts payable under Article II,
Section A of this Agreement, while this Agreement is in effect.
gn,.iture of Croup Executive Date
Stuart Bach, City Manager
i 1 , '
SipnaLui , n1 Rine Cross Representative Date