City Care Benefit Dental Plan Summary

2006 Renewal

Golden West PPO Dental Plan RC1500 (High Option)

· $50 Calendar Year Deductible (waived for Preventive)

· $1500 Calendar Year Maximum Benefit per Member

· Type I Preventive Services Covered at 100%

· Type II Basic Services Covered at 80%

· Type III Major Services Covered at 50%

· No Waiting Period for Major Services for New Employees & Dependents. (There is a 12 month waiting period for late enrollees).

Monthly Premiums: Employee Only $ 52.06

Employee & Spouse $105.26

Employee & Child(ren) $102.49

Employee & Family $155.69

Golden West PPO Dental Plan RC1000 (Low Option)

· $50 Calendar Year Deductible (waived for Preventive/PPO Provider only)

· $1000 Calendar Year Maximum Benefit per Member

· Type I Preventive Services

o 100% PPO Providers Only

o 80% Non-Participating Providers

· Type II Basic Services Covered at 80%

· Type III Major Services Covered at 50%

· No Waiting Period for Major Services. (There is a 12 month waiting period for late enrollees.)

Monthly Premiums: Employee Only $ 40.19

Employee & Spouse $ 81.05

Employee & Child(ren) $ 78.94

Employee & Family $119.80

NOTE:

1. PPO Dental Plan Rates are Guaranteed to August 1, 2007.

2. PPO Dental Plans will require 5 or more enrolled employees in an employer group.

3. PPO Dental Plans ARE available as a dual-choice option with HMO Dental Plans (Still require 5 or more to enroll in the PPO program).

Golden West HMO Dental Plan 89L3 (High Option)

· No Deductibles

· No Charge for Diagnostic Exams and Routine Cleanings Every Six Months

· Additional Cleanings Covered with Copayment

· LOWER Member Copayments for All Covered Services

o Preventive

o Prosthetics

o Prosthodontics

o Oral Surgery

o Orthodontics

o Adjunctive General Services

o Material Upgrades

o Cosmetic Dentistry (Elective Services)

Monthly Premiums: Employee Only $14.58

Employee & Spouse $26.39

Employee & Child(ren) $28.27

Employee & Family $40.89

Golden West HMO Dental Plan PCP (Low Option)

· No Deductibles

· No Charge for Diagnostic Exams and Routine Cleanings Every Six Months

· Additional Cleanings Covered with Copayment

· HIGHER Member Copayments for All Covered Services

o Preventive

o Prosthetics

o Prosthodontics

o Oral Surgery

o Orthodontics

o Adjunctive General Services

o Material Upgrades

o Cosmetic Dentistry (Elective Services)

Monthly Premiums: Employee Only $10.46

Employee & Spouse $16.80

Employee & Child(ren) $15.90

Employee & Family $24.36

NOTE:

1. HMO Dental Plan Rates are Guaranteed to August 1, 2007.

2. HMO Dental Plans Will Cover 2+ Eligible Employee Groups.

3. HMO Dental Plans ARE available as a dual-choice option with PPO Dental Plans.

NOTE: City Care Benefits plan descriptions provide a brief summary of the benefits only and are not complete regarding all the provisions of the plans, including limitations and exclusions.