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TABLE OF CONTENTS <br />Data Section 1 <br />Section 1 Definitions 2 <br />Section 2 Eligibility and Enrollment 4 <br />2.1 Eligible Employees 4 <br />2.2 Eligible Family Members 4 <br />2.3 Initial Enrollment Period. 4 <br />2 4 Open Enrollment Period 4 <br />2.5 Special Enrollment Period 4 <br />Section 3 Premium Provisions 6 <br />3.1 Payment of Premium 6 <br />3 2 Premium and Contract Revisions 6 <br />3 3 Payment of Premium when Coverage is Continued 6 <br />3 4 Return of Advance Payment of Premium 6 <br />Section 4 Dental Coverage 7 <br />4.1 Agreement to Provide Covered Services. 7 <br />4.2 Referrals 7 <br />4.3 Dental Emergency 7 <br />4.4 Dual Coverage 7 <br />4.5 Coordination of Benefits 7 <br />Section 5 Exclusions and Limitations 13 <br />5.1 Exclusions. 13 <br />5.2 Limitations. 14 <br />Section 6 Termination Provisions 16 <br />6.1 Termination of Contract 16 <br />6.2 Termination of Coverage 16 <br />6.3 False Statements. 16 <br />6.4 Cessation of Benefits 17 <br />6.5 Continuation Rights 17 <br />6.6 Reinstatement. 18 <br />6.7 Extension of Benefits 18 <br />Section 7 General Provisions 19 <br />7 1 Policyholder Duties. 19 <br />7.2 Subrogation. 19 <br />7.3 Complaints, Grievances, and Appeals. 20 <br />7.4 Rights Not Transferable 21 <br />7.5 Modification of Contract. 21 <br />7.6 Force Majeure 21 <br />7 7 State Law and Forum 21 <br />7.8 Notice of Suit and Indemnification 22 <br />7 9 Waiver and Severability 22 <br />7.10 Notices 22 <br />711 Certificates. 22 <br />7 12 Clerical Error 22 <br />7.13 Statements 22 <br />Appendix A - Schedule of Covered Services and Copayments 23 <br />Appendix B - Orthodontic Treatment 29 <br />Appendix C - Temporomandibular Joint Disorder Treatment 30 <br />Appendix D - Dental Implants 31 <br />001 L-WA811(5/20) <br />