Cleveland Clinic

Dental Benefit ProgramSummary Plan Description

Calendar Year 2015

Table of ContentsCLEVELAND CLINIC BENEFIT PROGRAMAbout the Benefit Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Dependents Eligible for Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Domestic Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Enrollment Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Newly Hired Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Current Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Employee Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Types of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Life Event Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Which Dental Benefit Program Is Primary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Provision Enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Facility of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Right of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Subrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Provider Status and Direction of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Dental Benefit Program Identification Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CLEVELAND CLINIC DENTAL BENEFIT PROGRAM SUMMARYThe Traditional Dental Benefit Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Annual Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Covered Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Covered Services Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Pretreatment Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Basic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Major Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Orthodontic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9The Preventive Dental Benefit Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Annual Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Covered Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Covered Services Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Pretreatment Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Basic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Major and Orthodontic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Continuation of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Leaves of Absence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Outplacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Termination of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Payment of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Claim Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Appeals Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Level One Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Level Two Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

CLEVELAND CLINICDENTAL BENEFIT PROGRAM TERMS AND DEFINITIONSDefinitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14A Statement of Your Rights Under ERISA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Receive Information About Your Plan and Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Continue Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Prudent Actions by Plan Fiduciaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Enforce Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Assistance with Your Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ERISA Required Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

About theCleveland Clinic

Dental Benefit ProgramThe Cleveland Clinic Dental Benefit Program has been developed to offeryou freedom of choice of three dental options: the Traditional DentalBenefit Program, the Preventive Dental Benefit Program and the CignaDental Care Benefit Program.

The Traditional Dental Benefit Program provides benefits for a wide varietyof dental services ranging from preventive cleanings to orthodontia (forcovered dependents under age 23). The amount the benefit program willpay depends on the type of covered service you receive. There is an annualmaximum for each covered person and a separate lifetime maximum fororthodontia services.

The Preventive Dental Benefit Program provides benefits for preventive andbasic dental services only. There is no coverage for major or orthodontiaservices under this benefit program. The amount the benefit programwill pay depends on the type of covered service you receive. There is anannual maximum for each covered person.

The Cigna Dental Care Benefit Program is a Dental HMO with no chargesfor most preventive services, no deductibles and no annual or lifetimemaximums. Orthodontia services are covered for both adults and dependentchildren. You must use providers who are part of the Cigna Dental CareHMO Network, and each family member is required to select a generaldentist. For additional information refer to the HRConnect Portal.

Since each benefit program has distinctive advantages, you should select thebenefit program that best meets the needs of you and your family members.

This booklet has been developed to guide you through the Traditional andPreventive Dental Benefit Program provisions. If you should have questionsabout the information provided in this summary, please contact the TotalRewards Department.

If you enroll in the Cigna Dental Care Benefit Program, you willreceive a complete description of the Program from Cigna Dental. Youcan also contact Cigna Dental toll-free at 800.Cigna24 (244.6224) orwww.cigna.com for additional information including a listing of generaldentists in your area.

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Eligibility You are eligible to participate in the dental benefit programs if you are a regular, full-time or part-timeemployee of Cleveland Clinic.

Note: 1. If both employees (spouses) work for Cleveland Clinic or a Cleveland Clinic hospital, they cannotcarry any family member twice.

2. If an employee has a child who is employed outside of Cleveland Clinic and is eligible for benefitsthrough his or her employer, he or she is not eligible to enroll in any of the Cleveland ClinicHealth, Dental or Vision Benefit Programs.

Dependents Eligible for CoverageDependents eligible for the Dental Benefit Program include:

1. Your lawful spouse (neither divorced nor legally separated).

2. Your children who are: your natural children, stepchildren, legally adopted children (or under placementfor adoption), or children under an officially court-appointed guardianship who are under age 23.Coverage for your children terminates on the last day of the month in which they reach age 23.

3. Your unmarried children age 23 or older who are disabled as determined by the Social SecurityAdministration. Proof of disability must be provided to Human Resources within 31 days after thedetermination of disability.

Ineligible members include the employee's parents, grandchildren, nieces, nephews, ex-spouses, common-law marriage partners (after the year 1991) and foster children who have not been legally adopted or whohave not been placed for adoption.

Domestic PartnersIf you are a participant, your same-gender domestic partner is eligible for coverage under the ClevelandClinic Dental Benefit Program. (Please note: Domestic Partner Benefits are not available to employees ofMarymount Hospital).

You and your domestic partner must meet all of the following criteria:

1. You are each of the same gender.

2. You are 18 years of age or older and mentally competent to enter into contracts.

3. You reside in the same household with each other.

4. You have been in a committed relationship with each other for at least six months, intend to remainin such relationship indefinitely and have no such relationship with anyone other than each other.

5. You have joint responsibility for each other’s welfare and financial obligations.

6. You are not related by blood to a degree that would prohibit marriage under the law of the state inwhich you reside.

7. You are not currently married to any other person under either statutory or common law.

In order to enroll your domestic partner in the Cleveland Clinic Dental Benefit Program, you and yourdomestic partner must sign an Affidavit of Domestic Partnership. Under current Federal and State law,the amount you pay towards the cost of domestic partner coverage must be made on an after-tax basis.Additionally, the full cost of benefits coverage for your domestic partner, less the amount of your after-taxcontribution, is added to your income and subject to ordinary Federal, FICA, State, local and any otherapplicable payroll taxes. This amount of additional taxable income will be shown on your paychecks andreported on your W-2 at the end of the year.

Children of your domestic partner are eligible for Domestic Partner Benefits as long as they meet thedefinition of eligible dependent children under Cleveland Clinic Employee Health Plan Total Care.

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Enrollment ProcessNewly Hired EmployeesWhen you begin working at a Cleveland Clinic facility, you are given an opportunity to sign up for dentalbenefits. You must elect a Dental Benefit Program within 31 days of your start date in order for yourcoverage to become effective.

If you DO NOT elect coverage for yourself and your dependents, you will not receive dental coverage. Youwill not be entitled to dental coverage until the next annual open enrollment period unless you experiencea Life Event Change, as described on page 4.

If an employee begins employment at Cleveland Clinic between October and December, near the openenrollment period, he/she will have the opportunity to elect benefits for the current year and will also begiven information about making benefit election changes for the new calendar year.

If you have further questions on how to apply for coverage, contact the Total Rewards Department.

Current EmployeesCurrent employees have the opportunity each year to enroll for dental coverage during the BeneFlex OpenEnrollment period. Through this process, you can choose to keep the same coverage you have or makechanges for the next calendar year. If you did not previously elect coverage through the Cleveland ClinicDental Benefit Program, you have the chance to do so at this time and your coverage will become effectiveon the first day of the new calendar year.

Employee ContributionsYou pay a percentage of the cost for coverage under the Cleveland Clinic Dental Benefit Program.Information on employee contributions is included with your BeneFlex materials.

Types of Coverage The choices are:• Employee Only — Only the employee is covered.• Employee + One — An employee along with one dependent (spouse or child) is covered.• Family — An employee along with two or more dependents.

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Life Event ChangesTo help Cleveland Clinic design a cost-effective benefit program each year, maintain costs, and to anticipatefuture needs, you are required to keep your selected BeneFlex elections unless you or your dependentsexperience a “Life Event Change.”

Under Internal Revenue Service guidelines, the following occurrences meet the definition of a qualifyinglife event and permit you to change certain elections:

1. Changes in legal marital status, including marriage, death of a spouse, divorce, legal separation orannulment.

2. Changes in the number of dependents for reasons that include birth, adoption, placement for adoption,the assumption of legal guardianship, or death.

3. Employment status changes, meaning an employee, spouse or dependent starts a new job or loses acurrent job.

4. Work schedule changes, meaning a reduction or increase in hours of employment for the employee,spouse, or dependent, including a switch between part-time and full-time, a strike or lockout, or thebeginning or end of an unpaid leave of absence.

5. Changes in work location, meaning a change in the place of residence or work of an employee, spouse,or dependent.

6. A dependent satisfies — or no longer satisfies — the eligibility requirements for unmarried dependentsbecause of age, job status or other circumstances.

7. A qualified medical child support court order (QMCSO), or other similar order, that requires healthcoverage for an employee’s child.

If you experience a qualifying life event and wish to change your coverage, you must contact the TotalRewards Department within 31 days of the event and provide the necessary supporting documentation.Any adjustment to coverage must be consistent with the changes resulting from the qualifying life event.

Employees/dependents covered under another dental program who lose that coverage as a result of oneof the life events listed above are eligible to participate in the Cleveland Clinic Dental Benefit Program.

Coordination of BenefitsCoordination of Benefits is the procedure used to pay dental expenses when you or an eligible dependentare covered by more than one dental program. The Cleveland Clinic Dental Benefit Program follows rulesestablished by Ohio law to decide which dental plan pays first and how much the other dental plan must pay.The objective is to make sure the combined payments of all dental plans are no more than your actualbills.

When you or your eligible dependents are covered by another dental program in addition to this one, theCleveland Clinic Dental Benefit Program Third-Party Administrator, Connecticut General Life InsuranceCompany (CG, and also referred to as Cigna Dental in this booklet) will follow Ohio coordination of benefitsrules to determine which dental program is primary and which is secondary. You must submit all billsfirst to the primary dental program. If the primary dental program denies the claim or does not pay thefull bill, you may then submit the balance to the secondary dental program. Generally, Coordination ofBenefits limits the total benefits payable from all sources to 100 percent of actual charges.

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Which Dental Benefit Program Is Primary?To decide which dental program is primary, Cigna Dental has to consider both the coordination of benefitprovisions of the other dental program and which member of your family is involved in a claim. The primarydental program will be determined by the first of the following which applies:• Non-coordinating Program — If you have another Group program which does not coordinate benefits,

it will always be primary.• Employee — The program which covers you as an active employee is always primary.• Children (Parents Divorced or Separated) — If the court decree makes one parent responsible for dental

care expenses, that parent’s program is primary.If the court decree gives joint custody and does not mention dental care, Cigna Dental follows the birthdayrule as discussed below.If neither of those rules applies, the order will be determined in accordance with the Ohio Departmentof Insurance rule on coordination of benefits.

• Children and the Birthday Rule — When your children’s dental care expenses are involved, Cigna Dentalfollows the “birthday rule.” The dental program of the parent with the first birthday in a calendar year isalways primary for the children. For example: If your birthday is in January and your spouse’s birthday isin March, your dental program will be primary for all of your children.However, if your spouse’s dental program has some other coordination of benefits rule (for example, a“gender rule” which says the father’s program is always primary), Cigna Dental will follow the rules ofthat dental program.

• Other Situations — For all other situations not described above, the order of benefits will be determinedin accordance with the Ohio Department of Insurance rule on coordination of benefits.

Provision EnforcementCigna Dental will coordinate benefits to the extent that Cigna Dental is informed by you or some otherperson or organization of your coverage under any other dental program. Cigna Dental is not required todetermine if and to what extent you are covered under any other dental program.

In order to apply and enforce this provision or any provision of similar purpose of any other dental program,it is agreed that:• Any person claiming benefits described in this book will furnish Cigna Dental with any information

Cigna Dental needs; and • Cigna Dental may, without the consent of or notice to any person, release to or obtain from any source

any necessary information.

Facility of PaymentIf payment is made under any other dental program, which Cigna Dental should have made under thisprovision, then Cigna Dental has the right to pay whoever paid under the other dental program; CignaDental will determine the necessary amount under this provision. Amounts so paid are benefits underthis Program and Cigna Dental is discharged from liability to the extent of such amounts paid for CoveredExpenses.

Right of RecoveryIf an overpayment is made by Cigna Dental, Cigna Dental has the right to (a) recover that overpaymentfrom the person to whom or on whose behalf it was made; or (b) offset the amount of that overpaymentfrom a future claim payment.

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SubrogationIf Cigna Dental provides benefits for Covered Expenses and you have the right to recover from anotherperson, organization or insurer as a result of a negligent or wrongful act, Cigna Dental assumes your legalrights to any recovery of incurred expenses. For the purposes of this section, “insurer” shall include, but isnot limited to, (1) any insurer of any third party, (2) any insurer providing uninsured or under-insuredmotorist coverage, and (3) your own insurer other than Cigna Dental.

To the extent Cigna Dental provides benefits for Covered Expenses, you must repay Cigna Dental amountsrecovered by suit, settlement or otherwise from any person, organization or insurer.

You have the legal obligation to help Cigna Dental in all possible ways when Cigna Dental tries to recoverthese amounts.

You must give Cigna Dental information and assistance and sign the necessary documents to help enforceCigna Dental’s rights. You must not do anything that might limit Cigna Dental’s rights.

Provider Status and Direction of PaymentCigna Dental has agreed to make payment directly to Providers. You and your eligible covered dependentscan choose any dental provider for your services. You are not required to use a network of dental providers.However, if you use a Cigna Dental network provider, you may experience lower out-of-pocket costsbecause of the discounted rates the providers have agreed to accept.

You authorize Cigna Dental to make payments directly to certain Providers who have performed servicesfor you. Cigna Dental also reserves the right to make payment directly to you. When this occurs, you mustpay the Provider and Cigna Dental is not legally obligated to pay any additional amounts. You cannotassign your right to receive payment to anyone else, nor can you authorize someone else to receive yourpayments for you.

If Cigna Dental has incorrectly paid for services or it is later discovered that payment was made for servicesthat are not considered Covered Expenses, then Cigna Dental has the right to recover payment, and youmust repay this amount when requested.

Claims A claim must be filed with Cigna Dental in order for you to receive dental benefits under either theTraditional Dental Benefit program or the Preventive Dental Benefit program. A separate claim must befiled for each person who receives services under the Benefit program. All claims for services (regardlessof provider) should be directed to:

Cigna DentalP.O. Box 188037Chattanooga, TN 37422-8037

If you or your dentist have any questions about the claim filing procedure, or about how a claim was paid,you can contact the Cigna Healthcare Service Center toll-free at 800.Cigna24 (244.6224).

For both Benefit Programs, claims must be submitted no later than one year from the original date whenthe services are incurred.

Dental Benefit Program Identification CardsDental Benefit Program ID cards will be issued to Cleveland Clinic Dental Benefit Program participants.

If your Dental Benefit Program card should be lost or stolen, you may contact Cigna Dental toll-freeat 800.Cigna24 (244.6224) for a replacement.

The Traditional Dental Benefit ProgramAnnual DeductibleThe annual deductible is the amount you pay before the dental benefit program pays for diagnostic,therapeutic, restorative, or major services. The annual deductible does not apply to preventive services.All of these services are explained in the section called “Covered Expenses.”

The annual deductible is $50 per person. If you elect the Employee + One level of coverage, each covered personmust meet a $50 annual deductible before the benefit program begins to pay for certain services. If you electthe Employee + Family level of coverage, the maximum deductible is $150 for the calendar year. Once thefamily maximum deductible is satisfied during a given calendar year, the annual deductibles for all coveredpersons will be met for the rest of that year. This deductible applies only once during the calendar year,even though you or another covered person may have several different courses of treatment during the year.

Covered ExpensesCovered Expenses are the expenses that are eligible for reimbursement under the Traditional Dental BenefitProgram. The benefit program reimbursements are based on either the Contracted Fee or the Reasonable andCustomary (R&C) Charges, depending on the provider. If you use Cigna network providers, your co-paymentsmay be less due to the discounted rates the Cigna network providers have agreed to accept. The Reasonableand Customary Charge is the amount that is most often charged by dentists in your area.

The following chart summarizes the covered services and benefits provided by the Traditional DentalBenefit Program:

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Cleveland Clinic Dental Benefit ProgramSUMMARY

Traditional Plan

Cigna DPPO Cigna DPPOCovered Services Advantage Network Network Out-of-Network

Class 1: Preventive & diagnostic 100% 100% 100% ofcare — oral exams, cleanings, Reasonable & Customary

x-rays, etc.Class 2: Basic/restorative 80% 70% 70% of

care — fillings, oral surgery, (after deductible) (after deductible) Reasonable & Customaryextractions, etc. (after deductible)

Class 3: Major restorative 50% 50% 50% ofcare — dentures, crowns, etc. (after deductible) (after deductible) Reasonable & Customary

(after deductible)Class 4: Orthodontia 50% 50% 50% of

(lifetime maximum benefit of (after deductible) (after deductible) Reasonable & Customary$1,250 per eligible covered (after deductible)dependent under age 23)

Annual Deductible: Individual 1$50 1$50 1$50Family $150 $150 $150

Annual Benefit Maximum $1,250 $1,000 $1,000Class 1, 2 & 3 expenses per person per person per person

Dentist Reimbursement Levels Based on contrated fees Based on contrated fees 80% ofReasonable & Customary

Balance Billing by Dentist No No Yesin excess of co-insurance

Pretreatment ReviewIf your dentist proposes a course of treatment that will cost more than $500, you should get a writtenestimate from the dentist before treatment begins. While not mandatory, this predetermination ofbenefits is strongly recommended so you can be sure you understand what the Benefit Program pays andwhat your costs will be.

You can obtain a pretreatment review of benefits by asking your dentist for an estimate of expenses. Youshould then forward this estimate to Cigna Dental. Upon review, Cigna Dental will provide a writtenestimate of what the Benefit Program will pay based on the estimate submitted by the dentist.

Preventive ServicesThe annual deductible does not apply to preventive dental services. The benefit program covers 100%of either the Contracted Fee or Reasonable and Customary Charges (depending on the provider) for thefollowing preventive services for each covered person:• Oral exams (two per calendar year).• Cleanings (two per calendar year).• Full mouth x-rays (one complete set every three calendar years).• Bitewing x-ray (two per calendar year).• Panoramic x-ray (one every three calendar years).• Fluoride application (two per calendar year).• Prophylaxis (two per calendar year).• Sealants (one treatment per tooth every three calendar years).• Space maintainers (limited to non-orthodontic treatment).• Emergency care to relieve pain.

Basic ServicesAfter you pay the annual deductible, the benefit program pays 80% of the Contracted Fee for in-networkproviders and 70% of the Reasonable and Customary Charges for out-of-network providers for the followingbasic services for each covered person:• Fillings.• Root canal therapy.• Osseous surgery.• Periodontal scaling and root planing.• Denture adjustments and repairs.• Extractions.• Anesthetics.• Oral surgery.• General anesthesia (when medically necessary and administered in conjunction with oral surgery).• Injection of antibiotic drugs by the attending dentist.

Major ServicesAfter you pay the annual deductible, the benefit program pays 50% of either the Contracted Fee or theReasonable and Customary Charges (depending on the provider) for the following major services for eachcovered person:• Crowns.• Dentures.• Bridges.• Implants.

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The benefit program has a “missing tooth provision” which means that benefits are not payable until thecovered person has been covered under the benefit program for 24 months.

Orthodontic ServicesThe Benefit Program pays 50% of either the Contracted Fee or the Reasonable and Customary Charges,depending on the provider (subject to a lifetime maximum benefit of $1,250 per eligible covered dependentunder age 23) for orthodontia.

The Preventive Dental Benefit ProgramAnnual DeductibleThe annual deductible is the amount you pay before the dental benefit program pays for diagnostic,therapeutic, restorative, or major services. The annual deductible does not apply to preventive services.All of these services are explained in the section called “Covered Expenses.”

The annual deductible is $50 per person. If you elect the Employee + One level of coverage, each coveredperson must meet a $50 annual deductible before the benefit program begins to pay for certain services.If you elect the Employee + Family level of coverage, the maximum deductible is $150 for the calendar year.Once the family maximum deductible is satisfied during a given calendar year, the annual deductibles for allcovered persons will be met for the rest of that year. This deductible applies only once during the calendaryear, even though you or another covered person may have several different courses of treatment duringthe year.

Covered ExpensesCovered Expenses are the expenses that are eligible for reimbursement under the Preventive DentalBenefit Program. The benefit program reimbursements are based on the Reasonable and CustomaryCharges. The Reasonable and Customary Charge for a given dental service, supply, or procedure is theamount that is most often charged by dentists in your area.

The following chart summarizes the covered services and benefits provided by the Preventive DentalBenefit Program:

Covered Services Preventive Benefit Program

*Preventive Care 100% R&C, no deductible oral exams, cleanings, x-rays, etc.)

*Basic Services 80% R&C, after deductible(fillings, oral surgery, extractions, etc.)*

*Major Services Not Covered(dentures, crowns, dental implants, etc.)*

*Orthodontia Not Covered

*Annual Deductible $50 per person/$150 per family

*Annual Benefit Maximum $500 per covered person

Pretreatment ReviewIf your dentist proposes a course of treatment that will cost more than $500, you should get a writtenestimate from the dentist before treatment begins. While not mandatory, this predetermination ofbenefits is strongly recommended so you can be sure you understand what the Plan pays and whatyour costs will be.

You can obtain a pretreatment review of benefits by asking your dentist for an estimate of expenses. Youshould then forward this estimate to Cigna Dental. Upon review, Cigna Dental will provide a writtenestimate of what the Benefit Program will pay based on the estimate submitted by the dentist.

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Preventive ServicesThe annual deductible does not apply to preventive dental services. The benefit program covers 100% ofthe Reasonable and Customary Charges for the following preventive services for each covered person:• Oral exams (two per calendar year).• Cleanings (two per calendar year).• Full mouth x-rays (one complete set every three calendar years).• Bitewing x-ray (two per calendar year).• Panoramic x-ray (one every three calendar years).• Fluoride application (two per calendar year).• Prophylaxis (two per calendar year).• Sealants (one treatment per tooth every three calendar years).• Space maintainers (limited to non-orthodontic treatment).• Emergency care to relieve pain.

Basic ServicesAfter you pay the annual deductible, the benefit program covers 80% of the Reasonable and CustomaryCharges for the following basic services for each covered person:• Fillings.• Root canal therapy.• Osseous surgery.• Periodontal scaling and root planing.• Denture adjustments and repairs.• Extractions.• Anesthetics.• Oral surgery.• General anesthesia (when medically necessary and administered in conjunction with oral surgery).• Injection of antibiotic drugs by the attending dentist.

Major and Orthodontic ServicesThe Preventive Dental Benefit Program does not provide coverage for these services.

Exclusions The Dental Benefit Programs do not provide benefits for (by way of example, but not limited to):• Services performed solely for cosmetic reasons.• Replacement of a lost or stolen appliance.• Replacement of a bridge or denture within five years following the date of its original installation.• Replacement of a bridge or denture which can be made useable according to accepted dental standards.• Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical

dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion.• Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first,

second and third molars.• Bite registrations; precision or semi-precision attachments; splinting.• Instruction for plaque control, oral hygiene and diet.• Dental services that do not meet common dental standards.• Services that are deemed to be medical services.• Hospital facility charges received from a hospital.

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• Charges which the person is not legally required to pay.• Charges made by a hospital which performs services for the U.S. Government if the charges are directly

related to a condition connected to a military service.• Experimental or investigational procedures and treatments.• Any injury resulting from, or in the course of, any employment for wage or profit.• Any sickness covered under any Workers’ Compensation or similar law.• Charges in excess of the Reasonable and Customary allowances.• Athletic mouth guards.• Prescription drugs and medications not dispensed while receiving treatment in a dental facility.• Reasonable and Customary other than the 80th percentile under the Traditional Plan and the 90th

percentile under the Preventive Plan.• Procedures performed by a Dentist who is a member of the covered person’s family. A covered person’s

family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings andparents.

Continuation of CoverageLeaves of Absence If you go on an approved leave of absence, your coverage may continue. You must make arrangementsfor continuation of coverage directly with the Total Rewards Department.

OutplacementIf you are outplaced, dental coverage and deductions continue at the active employee rate during yourseverance benefit period.

RetirementDental benefits in which you are currently enrolled will continue through the end of the month in whichyou retire (unless you elect to continue coverage under COBRA — see below).

Termination of CoverageYour coverage under the Cleveland Clinic Dental Benefit Program terminates the last day of the monthin which:• You transfer to a non-benefits eligible position;• You terminate employment; or• You or your dependents are no longer eligible participants.

However, you may elect to extend coverage if Dental Benefit Program coverage is lost due to one of theCOBRA-related provisions listed below.

COBRA CoverageConsolidated Omnibus Budget Reconciliation Act (COBRA) CoverageThe Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) may require that you and/or yourdependents be provided with the opportunity to continue your group healthcare coverage on a contributorybasis under the following circumstances. The extension of coverage applies to almost all employee healthplans providing medical, dental, prescription drug, vision, or hearing benefits. You will be able to continuecoverage through COBRA by paying all of the costs of the Dental Benefit Program you choose, includingany portion formerly paid for by the Cleveland Clinic facility that employed you.

Qualifying Events: Who, When, and for How LongIf your Cleveland Clinic Dental Benefit Program coverage terminates, you and your covered dependentsmay continue dental care coverage for up to 18 months:1. If your employment terminates for any reason, including retirement, other than gross misconduct; or2. If you lose your Cleveland Clinic Dental Benefit Program coverage due to a reduction in your hours of

employment; or3. If you or a dependent become disabled within the first 60 days of COBRA continuation, coverage may

be continued for an additional 11 months (29 months total).

Your covered dependents may continue such coverage under the Cleveland Clinic Dental Benefit Programfor up to 36 months: 1. If you die while covered by the benefit program; or2. If you and your spouse are divorced, your marriage is annulled or you are legally separated from your

spouse; or3. If you become eligible for Medicare; or4. If your dependent child is no longer eligible for coverage under the Cleveland Clinic Dental Benefit

Program.

If you are entitled to Medicare benefits at the time coverage terminates due to your termination ofemployment or reduction in hours, the continuation period for covered dependents will be the longer of:1. 18 months from the date coverage terminates due to your termination of employment or reduction of

hours; or2. 36 months from the date you became entitled to Medicare.

When Continued Coverage EndsThe continued coverage will end for any qualified person when:1. The cost of continued coverage is not paid on or before the date it is due; or2. That person becomes eligible for Medicare, if later than the date of the COBRA election; or3. That person becomes covered under another group health plan unless that other plan contains an

exclusion or limitation with respect to any pre-existing health condition; or4. The Cleveland Clinic Dental Benefit Program terminates for all Employees; or5. You or your dependent are no longer deemed disabled during the additional 11-month extended

period; or6. The last day of the applicable 18, 29 or 36 month time limit.

How to Obtain CoverageWhen your coverage terminates, the Total Rewards Department will notify the COBRA Administrator(Ceridian). Ceridian then notifies you of your election rights. You will need to make your election within60 days of the event in order to be eligible for continuation of coverage. For questions regarding COBRA,Ceridian can be reached toll-free at 800.877.7994 or you can contact the Total Rewards Department.There is generally a 1-2 week lag time between the time Ceridian processes the first paid premium andthe time Cigna Dental is updated. You will be able to receive covered care during this lag time. However,be prepared to provide proof of insurance or be prepared to resubmit the claim if denied the first time.

If you elect to continue any benefits under COBRA, the first payment must be made within 45 days of yourelection to continue coverage. The first payment covers the period beginning with the date the qualifyingevent occurred through the date the continuation coverage was elected. Thereafter, monthly payments aredue on the first of the month and must be paid within the 31 day grace period following the due date.

COBRA regulations may change from time to time. The extension of coverage will be provided in accordancewith current law.

Because COBRA rules are complicated, if you have any questions about eligibility, contact the TotalRewards Department.

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Veteran ReemploymentCleveland Clinic will also comply with the provisions of the Uniformed Services Employment andReemployment Rights Act of 1994 (USERRA).

Payment of BenefitsNormally, when a dental claim is approved, the benefit payment will be paid to your dentist or otherprovider. You assign benefit payments by signing the “Authorization to Pay Benefits” portion of yourclaim form. Then payment will be made directly to your dentist or other provider for the dental servicesyou received.

Claim Appeals If you have a concern regarding a person, a service, the quality of care, or contractual benefits, you cancall the toll-free number on your Dental Identification card, explanation of benefits, or claim form andexplain your concern to one of Cigna Dental’s Member Services representatives. You can also express thatconcern in writing.

Cigna Dental will do its’ best to resolve the matter on your initial contact. If more time is needed to reviewor investigate your concern, Cigna Dental will get back to you as soon as possible, but in any case within30 days.

If you are not satisfied with the results of a coverage decision, you can start the appeals procedure.

Appeals ProcedureThe Cleveland Clinic Dental Benefit Program has a two-step appeals procedure for coverage decisions. Toinitiate an appeal, you must submit a request for an appeal in writing to Cigna Dental within 365 days ofreceipt of a denial notice. You should state the reason why you feel your appeal should be approved andinclude any information supporting your appeal. If you are unable or choose not to write, you may askCigna Dental to register your appeal by telephone. Call or write at the toll-free number or address on yourDental Identification card, explanation of benefits, or claim form.

Level One AppealYour appeal will be reviewed and the decision made by someone not involved in the initial decision. Appealsinvolving Medical Necessity or clinical appropriateness will be considered by a healthcare professional.

For level one appeals, Cigna Dental will respond in writing with a decision within 30 calendar days afterreceiving an appeal for a post-service coverage determination. If more time or information is needed tomake the determination, Cigna Dental will notify you in writing to request an extension of up to 15 calendardays and to specify any additional information needed to complete the review.

Level Two AppealIf you are dissatisfied with the level one appeal decision, you may request a second review. To initiatea level two appeal, send a written appeal to the address below:

Cleveland Clinic Total Rewards Department / AC341Appeal Review Committee3050 Science Park DriveBeachwood, OH 44122

The appeal must be resolved within 45 days of the request if the required documents to conduct theappeal are submitted.

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Cleveland Clinic Dental Benefit ProgramTERMS AND DEFINITIONS

DefinitionsAlternate Benefit Provision — When more than one covered Dental Service could provide suitable treatmentbased on common dental standards, Cigna Dental will determine the covered Dental Service on whichpayment will be based and the expenses that will be included as Covered Expenses. Benefits will be providedfor treatment rendered in accordance with accepted dental standards for adequate and appropriate care.You and your Dentist are free to apply this benefit payment to the treatment of your choice; however, youare responsible for the expenses incurred which exceed Covered Expenses. For this reason, Cigna Dentalstrongly recommends the use of predetermination of benefits when major dental services are needed, sothat you and your Dentist know in advance what the benefit plan will cover before any treatment begins.

Cleveland Clinic — Cleveland Clinic consists of the following group of hospitals: Cleveland Clinic,Ashtabula County Medical Center, Cleveland Clinic Hospital for Children’s Rehabilitation, Euclid Hospital,Fairview Hospital, Hillcrest Hospital, Lakewood Hospital, Lutheran Hospital, Marymount Hospital, MedinaHospital, South Pointe Hospital, Cleveland Clinic Florida and Cleveland Clinic Nevada.

Contracted Fee (Cigna Dental Preferred Provider) — The term Contracted Fee refers to the totalcompensation level that a provider has agreed to accept as payment for dental procedures and servicesperformed on an employee or dependent, according to the employee’s dental benefit program.

Co-payment — A dollar amount that you are required to pay for Covered Expenses.

Covered Expenses — Billed charges for dental services or procedures that are covered by the Benefit Program.

Deductible — An amount, usually stated in dollars, for which you are responsible each calendar yearbefore the Cleveland Clinic Dental Benefit Program will start to provide benefits.

Dentist — The term Dentist means a person practicing dentistry or oral surgery within the scope of hislicense. It will also include a physician operating within the scope of his license when he performs any ofthe dental services described in this booklet.

Hospital — An institution which meets the specifications of Chapter 3727 of the Ohio Revised Code,except for the requirement that such institution be operated within the State of Ohio.

Non-Covered Expenses — Billed charges for services and supplies which are not covered services.

Participating Provider (Cigna Dental Preferred Provider) — The term Participating Provider means adentist, or a professional corporation, professional association, partnership, or other entity which hasentered into a contract with Cigna Dental to provide dental services at predetermined fees.

The providers qualifying as Participating Providers may change from time to time. A list of the currentParticipating Providers is available through www.cigna.com.

Predetermination of Benefits — The term Predetermination of Benefits means a review by Cigna Dentalof a Dentist’s description of planned treatment and expected charges, including those for diagnostic x-rays.This review should be made whenever extensive dental work is proposed. The information should be sentto Cigna Dental before the dental work is started. If there is a major change in the treatment plan, arevised plan should be sent to Cigna Dental.

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The expenses that will be included as Covered Expenses will be determined by Cigna Dental and are subjectto the Alternate Benefit Provision. When there has not been a Predetermination of Benefits, Cigna Dentalwill determine the expenses that will be included as Covered Expenses at the time the claim is received.Predetermination of Benefits does not guarantee payment. The estimate of benefits payable may changebased on the benefits, if any, for which a person qualifies at the time services are completed.

Reasonable and Customary Charge — A charge will be considered Reasonable and Customary if:• It is the normal charge made by the provider for a similar service or supply; and• It does not exceed the normal charge made by most providers of such service or supply in the geographic

area where the service is received, as determined by Cigna Dental.

To determine if a charge is Reasonable and Customary, the nature and severity of the Injury or Sicknessbeing treated will be considered.

A Statement of Your Rights Under ERISAAs a participant in the Cleveland Clinic Welfare Benefits Plan, you are entitled to certain rights and protectionsunder the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participantsshall be entitled to:

Receive Information about Your Plan and BenefitsExamine, without charge, at the Plan Administrator’s office and at other specified locations, such asworksites, all documents governing the Plan and/or this Benefit Program including insurance contractsand a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department ofLabor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the operationof the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) andupdated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies.

Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law tofurnish each participant with a copy of this summary annual report.

Continue Group Health Plan CoverageContinue dental care coverage for yourself, spouse or dependents if there is a loss of coverage under thePlan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Reviewthis Summary Plan Description and the documents governing the plan on the rules governing your COBRAcontinuation coverage rights.

Prudent Actions by Plan FiduciariesIn addition to creating rights for plan participants ERISA imposes duties upon the people who are responsiblefor the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of theplan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries.No one, including your employer, or any other person, may fire you or otherwise discriminate against youin any way to prevent you from obtaining a benefit or exercising your rights under ERISA.

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Enforce Your RightsIf your claim for benefits is denied or ignored, in whole or in part, you have a right to know why this wasdone, to obtain copies of documents relating to the decision without charge, and to appeal any denial, allwithin certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copyof Plan Documents or the latest annual report from the plan and do not receive them within thirty (30) days,you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to providethe materials and pay you up to $110 a day until you receive the materials, unless the materials were not sentbecause of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state orFederal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualifiedstatus of a domestic relations order or a medical child support order, you may file suit in Federal court.

If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against forasserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in aFederal court. The court will decide who should pay court costs and legal fees. If you are successful the courtmay order the person you have sued to pay these costs and fees. If you lose, the court may order you to paythese costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your QuestionsIf you have any questions about your plan, you should contact the Plan Administrator. If you have anyquestions about this statement or about your rights under ERISA, or if you need assistance in obtainingdocuments from the Plan Administrator, you should contact the nearest office of the Employee BenefitsSecurity Administration, U.S. Department of Labor, listed in your telephone directory or the Division ofTechnical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor,200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications aboutyour rights and responsibilities under ERISA by calling the publications hotline of the Employee BenefitsSecurity Administration.

ERISA Required InformationThis information is provided in compliance with the Employee Retirement Income Security Act of 1974(ERISA), as amended. While you should not need these details on a regular basis, the information may beuseful if you have specific questions about the Plan. This following provides information specific to theCleveland Clinic Welfare Benefit Plan (the “Plan”), and the Dental Benefit Program (the “Benefit Program”)which is a component of the Plan and is a welfare plan that provides benefits to certain employees..

Official Plan Name . . . . . . . . . . . . . . Cleveland Clinic Welfare Benefits Plan

Official Benefit Program Name . . . Cleveland Clinic Dental Benefit Program

Plan Number . . . . . . . . . . . . . . . . . . . 530

Type of Administration . . . . . . . . . . . Benefits are provided solely under the terms and conditions of a contractbetween Cleveland Clinic and Cigna Dental. The Insurer acts on behalfof Cleveland Clinic or the Plan Administrator of the Plan.

. . . . . . . . . . . . . . . . . . . . . . . . Cigna Dental P.O. Box 188037Chattanooga, TN 37422-9037

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Contributions to theBenefit Programs . . . . . . . . . . . . . . . . The Cleveland Clinic Dental Benefit Program is a Cigna Dental PPO Plan,

which is a self-insured benefit plan offering dental benefits. Benefitsfrom the Benefit Program are paid from employee contributions, asapplicable, and from the general assets of Cleveland Clinic, as needed.Cleveland Clinic has contracted with Cigna, a third-party administratorto administer the Benefit Program. The Plan Sponsor shall from time totime determine the amount of contributions payable by Participants

Funding Medium . . . . . . . . . . . . . . . . Benefits provided by this Benefit Program are provided solely throughCigna Dental. Cleveland Clinic does not directly provide any benefits.The Plan Sponsor shall from time to time determine the amount ofcontributions payable by Participants.

Plan Sponsor, PlanAdministrator andPlan Fiduciary . . . . . . . . . . . . . . . . . . Cleveland Clinic

3050 Science Park Drive / AC341Beachwood, OH 44122216.448.0600

. . . . . . . . . . . . . . . . . . . . . . . . The administration of the Plan, including the Benefit Program, will beunder the supervision of the Plan Administrator. To the fullest extentpermitted by law, the Plan Administrator will have the discretion todetermine all matters relating to eligibility, coverage and benefits underthe Plan. The Plan Administrator will also have the discretion to deter-mine all matters relating to the interpretation and operation of thePlan including any portion thereof. Any determination by the PlanAdministrator, or any authorized delegate, shall be final and binding.

Agent forService of Legal Process . . . . . . . . . Cleveland Clinic

Law Department / AC3213050 Science Park DriveBeachwood, OH 44122

. . . . . . . . . . . . . . . . . . . . . . . . Service of legal process may also be made on the Plan Administrator.

Employer IdentificationNumber of Plan Sponsor . . . . . . . . . 34-0714585

Plan Year . . . . . . . . . . . . . . . . . . . . . . January 1 – December 31 . . . . . . . . . . . . . . . . . . . . . . . . Records and reports for the Plan, including Benefit Programs contained

therein, are kept on a calendar year (January 1 – December 31). The PlanYear is also the Fiscal Year.

Employer IdentificationNumber of Plan Sponsor . . . . . . . . . 34-0714585

Dental Benefit ProgramEffective Date . . . . . . . . . . . . . . . . . . . The Benefit Program was originally effective on January 1, 2004 and is

part of the Plan. The Plan was effective January 1, 2013.

Plan Documentation . . . . . . . . . . . . . If there are any discrepancies between this summary plan descriptionand the provisions of the Plan Document, including the contract, the PlanDocument will prevail. No oral interpretations can change this Plan. ThePlan Sponsor also reserves the right to interpret the Plan’s coverage andmeaning in the exercise of its sole discretion.

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Future of the Plan: . . . . . . . . . . . . . . The Plan Sponsor reserves the right to amend, modify or terminatethe Plan, including this Benefit Program, in whole or in part, at anytime, without notice, in such manner as it shall determine regardlessof a participant’s health or treatment status, which may result in thetermination or modification of an empl0yee’s coverage. If the Plan isamended, modified, or terminated, the rights of employees are limitedto services and percentages of Allowed Amounts incurred prior to thePlan’s amendment, modification or termination. However, this will notaffect any claim for covered expenses incurred prior to the modificationor termination of the Plan.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Since premiums are paid on a monthly basis, if the Plan, or any of thecomponents are terminated, any premium paid but not applied toprovide coverage for a month, in whole or in part, will be returned tothe participant.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . This SPD does not create any contractual rights to employment nordoes it guarantee the right to receive benefits under the Plan. Benefitsare payable under the Plan only to individuals who have satisfied all ofthe conditions under the Plan Document for receiving benefits.

No Employment Contract . . . . . . . . This SPD does not create any contractual rights to employment nor doesit guarantee the right to receive benefits under the Plan or Benefit Program.Benefits are payable under the Plan or Benefit Program only to individualswho have satisfied all of the conditions under the Plan Document forreceiving benefits.

Delegation of Responsibility . . . . . . The Plan Administrator may delegate to other persons responsibilitiesfor performing certain duties of the Plan Administrator under theterms of the Plan. The Plan Administrator, Claims Administrator,and/or Appeals Administrator, as applicable, may seek such expertadvice as reasonably necessary with respect to the Plan or BenefitProgram. The Plan Administrator, Claims Administrator, and/orAppeals Administrator, as applicable, shall be entitled to rely uponthe information and advice furnished by such delegates and experts,unless actually knowing such information and advice to be inaccurateor unlawful. The Plan Administrator may adopt uniform rules for theadministration of the Plan from time to time, as it deems necessaryor appropriate.

2015

Every life deserves world class care.

9500 Euclid Avenue, Cleveland, OH 44195

Cleveland Clinic is a top-ranked nonprofit academic medicalcenter founded in 1921. With more than 1,300 staffed beds,as well as research and education institutes, the organizationis dedicated to providing expert inpatient and hospital carethrough innovation, quality, teamwork and service.

© The Cleveland Clinic Foundation 2015

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