Summary of Benefits and Rate Guide

For plans effective January 1, 2016

Product Overview

2–4 Plan Benefits & Program Guidelines

5–50 Plan Benefits & Program Guidelines

Supplemental Life

Rates

Limitations and Exclusions

Enrollment Checklist

2-5

6

7-10

11

12

13-19

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CoPower SUITE TM

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CoPower SUITE TM

Unique Packaged Products through CoPowerCoPower has relationships with MetLife, and VSP to deliver employee benefits solutions for your clients. By leveraging our strengths and expertise, we are able to offer competitive group rates and plan designs to help meet and exceed your clients’ needs.

Different Fits for Different Sizes

No matter the group size, CoPower SUITE has the ancillary benefits solutions for your clients. There are three SUITEs with two additional choices to choose from.

Plus, CoPower SUITE comes with so much more!

• Travel Assistance• Identity Theft Solutions• HR Resources

• Discount Prescription Program• Will Preparation and Estate Resolution Services6

About MetLifeWith more than 140 years of experience in the insurance business and 90 years in the group benefits business, MetLife is positioned to meet its obligations to your clients and their employees both today and in the future.

MetLife has years of experience serving 100 million customers, including 90 of the Fortune 100

®.

About VSPVSP provides affordable, high-quality eyecare plans that promote visual wellness and improve members’ quality of life. Their plans even cover advanced vision correction procedures, including surgery.

With more than 29,000 VSP doctors in over 21,000 offices across the country—that’s 50,000 points of access for members—a doctor is an average of only four miles from where members live and work.

Please Note: Vision Service Plan, VSP, Rancho Cordova, CA, is not affiliated with Metropolitan Life Insurance Company or its affiliates.

MiniSUITEPPO 2–4 + SUITEVision

Choice Plan B + $20,000 Life

Groups

2-4

Standard SUITEPPPO 1 or DHMO +

SUITEVision Choice Plan B + $25,000 Life

Groups

5-99

Preferred SUITEPPPO 2 or DHMO +

SUITEVision Choice Plan C + $25,000 Life

Groups

5-99

Standard SUITEDual Choice

PPO 1 and DHMO + SUITEVision Choice Plan B

+ $25,000 Life

Groups

10-99

Preferred SUITEDual Choice

PPO 2 and DHMO + SUITEVision Choice Plan C

+ $25,000 Life

Groups

10-99

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The MetLife Dental Difference A good dental benefits plan can be an important part of good oral health.

That’s why MetLife, through CoPower, is offering access to two great plan options—a Dental Health Maintenance Organization (DHMO)1 and a Dental Preferred Provider Organization (DPPO).2

DHMOThe DHMO plan offers a wide range of dental benefits through a network of participating dentists at a cost considerably lower than the fees typically charged.3 Members must preselect a participating dentist who is responsible for day-to-day care and members are only responsible for the copayments listed in the Benefit Grid. There are no annual maximums, deductibles, or claims.

DPPOThe MetLife Preferred Dentist Program provides both coverage for a broad range of services and the flexibility to visit any dentist, regardless of network status. Participating dentists have agreed to accept negotiated fees as payment in full, for covered services.4 This means out-of-pocket costs are 15–45% less than the average fees charged by dentists in the same community!

Additional Benefits• The DPPO dental network includes a broad national network, with greater access to thousands of general dentists and specialists

when you stay in the network.

• The DHMO dental network includes over 10,399 participating network dentist access points in California as of 1/1/15.

• The DHMO plan offers more than 400 covered services.5

• Employees can view and manage their dental benefits online.

SUITEVision Through VSP VSP’s vision plans are good for your clients’ eyes as well as their wallets! There’s no need to cut coupons or wait for retail chain sales—the savings and benefits are already built into the VSP plans.

Members get full-service vision plans that provide comprehensive coverage and value with competitive rates. VSP provides:

• Your clients what their employees want most—the lowest out-of-pocket costs. With competing vision plans, employees could pay hundreds more for the same glasses.

• Your clients’ employees with the widest selection of eyewear through the largest network of independent doctors and 1,000 retail chain locations such as Costco Optical.

• Early detection of chronic conditions like diabetes and high cholesterol. This means healthier, more productive employees, and lower healthcare costs for your clients.

1 Dental HMO plan benefits are provided by: SafeGuard Health Plans, Inc., a California corporation in CA. “DHMO” is used to refer to product designs that may differ by state of residence of the enrollee, including but not limited to: “Specialized Health Care Service Plans” in California.

2 Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166.3 Savings from enrolling in a dental benefits plan will depend on various factors, including how often participants visit the dentist and the cost of services received. 4 Negotiated fees for non-covered services may not apply in all states. Negotiated Fees refers to the fees that in-network dentists have agreed to accept as payment in full,

subject to any copayments, deductibles, cost sharing and benefits maximums.5 Copayments apply for many covered procedures and vary by procedure.6 Human Capital Management Services, Inc. (HCMS) study on behalf of VSP, 2010.

Health Management ProgramFor every initial $1 invested in VSP exam services, clients can expect an average two-year total return of $1.27 through avoided medical costs and improved human capital performance.6

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Term Life Benefits through MetLife MetLife can help employers provide a valuable solution to address a top concern of full-time employees—the impact of premature death on their family’s security.

Basic Term Life is a core employer-paid benefit that helps meet a portion of a family’s income needs in the event of premature death. Basic Term Life is solid protection that can meet the diverse needs of employees. Plus, employers with 10 or more employees have the option to allow their employees to purchase additional coverage for themselves and their dependents.1

Travel Assistance

As part of the Supplemental Life offering, the Travel Assistance Program offers enrolled employees and their families access to emergency services while travelling domestically or internationally.

Services include:

• A toll-free 800 number.

• Emergency medical services.

• Some non-emergency services such as help with visa and/or passport requirements.

Identity Theft Solutions

Another program offered in conjunction with MetLife’s Supplemental Life offering is their Identity Theft Solutions. This program educates employees on preventing an identity theft occurrence. In addition, it provides personal assistance and guidance to help alleviate the stress and time burden that victims often face.

Employees are provided with:

• Education regarding identity theft.

• A toll-free 800 number where service providers are available 24 hours a day, 365 days a year.

More for Your Loved Ones• Accelerated Benefits Option®: For access to funds during difficult times

• Conversion: For protection after coverage terminates

• Waiver of Premiums for Total Disability (Continued Protection): Offers continued coverage when it’s needed most

• Portability: So employees can keep their coverage even if they leave their employment

• Will Preparation Service: To help ensure decisions are fulfilled2

• MetLife Estate Resolution ServicesSM: Personal service and compassion to help beneficiaries and others manage an estate2

• Total Control Account®: For immediate access to death proceeds

• MetLife Advice® Program: Advice program to assist employees with various life transitions. Employees can view and manage their dental benefits online.

1 Travel Assistance and Identity Theft Solutions services are administered by AXA Assistance USA, Inc. Certain benefits provided under the Travel Assistance program are underwritten by the United States Fire Insurance Company, a member of the Crum & Forster group of insurers. AXA Assistance and the Crum & Forster group are not affiliated with MetLife and its affiliates, and the services and benefits they provide are separate and apart from the insurance provided by MetLife.

2 Will Preparation and Estate Resolution Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. Please refer to pages 16 and 17 of this brochure for additional information.

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Valuable BenefitsDental implants and composite fillings are covered benefits under the MiniSUITE PPO!

MiniSUITE Plan

For groups of 2-4 eligible employees

Even the smallest group can get quality ancillary benefits.

MiniSUITE—a dental, vision, and life package—includes a $1,000 Calendar Year Maximum and 100/80/50 in-network dental benefit, paired with a $20,000 Basic Term Life with AD&D policy from MetLife, and a Choice B Vision plan through VSP.

DENTAL COVERAGEMiniSUITE PPO 2-4

In-network Out-of-network

Dental Provider Reimbursement Basis Negotiated Fee Schedule Negotiated Fee Schedule - MAC

Calendar Year Max $1,000 $750

Deductible $50 Individual$150 Family

$75 Individual$225 Family

Deductible Waived for Preventive Services Yes No

Diagnostic and Preventive ServicesCleaning, exam, bite-wing x-rays, etc. 100% 80%

Basic ServicesComposite fillings, sealants, space maintainers, etc. 80% 60%

Major ServicesCrowns, bridges, dentures, implants, etc. 50% 50%

Endodontics, Periodontics, & Oral Surgery Endodontics & Periodontics - Basic ServicesOral Surgery - Major Services

Orthodontics Not Covered

VISION COVERAGESUITEVision Choice Plan B $25

In-network Out-of-network

Annual Copayment $25

Eye Exam Covered in full Reimbursed up to $45

Lenses by Type (Glass or Plastic)

Single-vison Covered in full Reimbursed up to $30

Bifocal Covered in full Reimbursed up to $50

Trifocal Covered in full Reimbursed up to $65

Lenticular Covered in full Reimbursed up to $100

Frames $150 Allowance Reimbursed up to $70

Contact Lenses (in lieu of all other eyewear benefits) $150 Allowance Reimbursed up to $105

Frequency of Services

Eye Exam 12 months

Lenses 12 months

Frames 24 months

Contact Lenses (in lieu of lenses and frames) 12 months

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Plan Benefits & Program GuidelinesFor groups with 2-4 eligible employees

BASIC TERM LIFE PLUS AD&D COVERAGE $20,000 Basic Term Life with AD&D

Coverage Amount* $20,000 (dependent upon Risk Assessment Summary)

Employee Class Schedule Classes not allowed

Disability Provision—Basic Life Only Waiver of premium: Disabled prior to age 60, coverage continues to age 65

Age Reduction Schedule • 35% at age 65• 50% at age 70

Employee Assistance Program Not available

Accelerated Benefit Option 12 months or less to live, up to 80% of coverage amount to a maximum of $500,000

PROGRAM GUIDELINES Dental, Vision, and Basic Term Life with AD&D

Group Size and Eligibility

• Groups with 2–4 employees• Minimum of 2 enrolled employees• To maintain enrollment in the 2–4 program, member must enroll in all three lines of

coverage (dental, vision, and basic term life)• COBRA participants not to exceed 15% of enrolled employees

Employer Contribution • DPPO and Vision: Minimum 50% of employee-only premium• Basic Term Life: 99% of employee premium

Participation• 75% of total eligible employees, not including waivers• No more than 75% of a group can be members of the same family (husband, wife, siblings,

children, and parents)

Product Combinations DPPO must be sold with Vision and Basic Term Life

Ineligible Industries SIC Codes: 8020–8021, 8070, 8072, 8200–8299

Waiting Period for Services None, except for dental late entrants

Dependents DPPO and Vision: Dependent children are eligible until age 26

Ineligible Employees Retirees, part-time, temporary, seasonal, 1099, pilots, and elected officials

Voluntary No

Rate Guarantee • DPPO and Vision: 12 months• Basic Term Life: 24 months

Industry Loads None

Out-of-State • No more than 25% of primary enrollees may reside outside of California• PPO coverage is not available in the following states: LA, MS, MT, TX

Carve-outs Union/Non-union and Management

Basic Life Age Restriction Schedule • 35% at age 65• 50% at age 70

Open Enrollment Not allowed

* Subject to MetLife acceptance of group for coverage based on information provided in the Risk Assessment Summary in the Employer Enrollment Packet.

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Additional SUITE Benefits• Dual Choice dental is available

for groups of 10 or more.

• Supplemental voluntary life is available for groups with at least 10 eligible employees and 5 or more enrolled.

Finding a MetLife Participating DentistVisit www.metlife.com and click on “Find a Dentist” on the right side of the home page. Enter your zip code and select your plan.

For DPPO dentists, choose PDP Plus network.

For DHMO dentists, choose “Dental HMO/Managed Care”, then select Plan Name MET185A.

SUITE Plan BenefitsFor groups of 5-99 eligible employees

Choose the SUITE that Best Fits Your Clients’ Needs.

Standard SUITE includes a $1,500 Calendar Year Maximum PPO plan or DHMO from MetLife.

Preferred SUITE includes a $1,500 Calendar Year Maximum PPO plan with Ortho or DHMO from MetLife.

Both SUITE packages come with a $25,000 Basic Term Life and AD&D policy from MetLife and rich vision coverage through VSP.

The SUITE Dental Coverage

DPPO• Negotiated fees accepted by participating network dentists generally range from

15–45% below the average charges in a dentist’s community.

• MetLife’s negotiated fees apply to all covered services provided by MetLife participating.1

DHMO• Covered procedures include copays for services such as implants, veneers, white

fillings, IV sedation, general anesthesia and nitrous oxide, plus orthodontic treatment in progress at initial group enrollment.2 In California, orthodontic and pedodontic specialty services require pre-approval. Your selected participating dentist will contact SafeGuard for pre-approval. Once approved, your dentist will contact you with the name of a participating specialist.

• Defined fees for materials and procedures requiring multiple services (e.g., root canals, crowns, and bridges) to minimize fee confusion.

DPPO COVERAGEStandard SUITE PPO Option 1 Preferred SUITE PPO Option 2

In-network Out-of-network In-network Out-of-network

Dental Provider Reimbursement Basis Negotiated Fee Schedule

Negotiated Fee Schedule - MAC

Negotiated Fee Schedule

R&C80th percentile3

Calendar Year Max $1,500 $1,000 $1,500 $1,500

Deductible $50 Individual$150 Family

$75 Individual$225 Family

$50 Individual$150 Family

$50 Individual$150 Family

Deductible Waived for Preventive Services Yes No Yes Yes

Diagnostic and Preventive ServicesCleaning, exam, bite-wing x-rays, etc. 100% 80% 100% 100%

Basic ServicesComposite fillings, sealants, space maintainers, etc. 80% 80%

Major ServicesCrowns, bridges, dentures, implants, etc. 50% 50%

Endodontics, Periodontics, & Oral Surgery Each split between Basic and Major Services

Endodontics & Periodontics - Basic Services

Oral Surgery - Major Services

Orthodontics (Lifetime maximum) Not Covered Child only to age 19, no deductible, 50% to max of $1,000

1 Negotiated Fees refers to the fees that in-network dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums.

2 Continuing orthodontic treatment applies to groups with 5 or more eligible lives.3 R&C refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or

similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.

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Plan BenefitsFor groups with 5-99 eligible employeesDHMO COVERAGE Standard and Preferred SUITEs, and Dual Choice DHMO

Code Services Copay

Office Visit — Per visit (including all fees for sterilization and/or infection control) $0

Diagnostic Treatment

D0120 Periodic oral evaluation — established patient $0

D0150 Comprehensive oral evaluation — new or established patient $0

D0210 Intra-oral — complete series (including bite-wings) $0

D0274 Bite-wings — four films $0

Preventive Services

D1110/D1120 Prophylaxis — adult and child $0

D1351 Sealant — per tooth $0

Restorative Services

D02140 Amalgam — one surface, primary or permanent $0

D2330 Resin-based composite —one surface, anterior $0

D2391 Resin-based composite — one surface, posterior $30

Crowns (Additional fees for metal upgrades and/or porcelain apply)

D2750 Crown — porcelain fused to high noble metal $185

D2751 Crown — porcelain fused to predominantly base metal $185

Endodontics

D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to dentinocemental junction and application of medicament $10

D3330 Endodontic therapy, molar tooth (excluding final restoration) $200

Periodontics

D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth or tooth-bounded spaces per quadrant $295

D4341 Periodontal scaling and root planing — four or more teeth per quadrant $40

D4910 Periodontal maintenance $30

Prosthodontics

D5110/D5120 Complete denture — maxillary/mandibular $210

D5211/D5212 Partial denture — resin base ,  maxillary/mandibular $240

Crowns/Fixed Bridges (Additional fees for metal upgrades and/or porcelain apply)

D6241 Pontic — porcelain fused to predominantly base metal $185

D6750 Crown — porcelain fused to predominantly base metal $185

Oral Surgery

D7140 Extraction — erupted tooth or exposed root (elevation and/or forceps removal) $0

D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated $30

D7220 Removal of impacted tooth — soft tissue $45

D7240 Removal of impacted tooth — completely bony $80

Orthodontics

D8070/D8080/D8090 Comprehensive orthodontic treatment of transitional dentition, adolescent dentition or adult dentition $1695

Adjunctive General Services

D9110 Palliative (emergency) treatment of dental pain — minor procedure $0

D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician $0

The DHMO Plan Benefits description is only a summary of the DHMO plan being offered. A complete copy of all the terms and conditions of the DHMO plan being offered is set forth in the DHMO Schedule of Benefits and Evidence of Coverage and Disclosure Statement available from CoPower upon request.

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Finding a VSP ProviderSimply go to www.vsp.com and look for the “Find A VSP Doctor” box. Enter your zip code, and click “Choice” to see a list of participating providers.

MetLife Customer Service for LifeMembers can call MetLife’s Customer Service Hotline at 1-800-ASK-4MET or 1-800-275-4638. Press Option 2, then Option 4 for Life inquiries.

Plan BenefitsFor groups of 5-99 eligible employees

The SUITEVision Coverage.

Through VSP, members receive:

• Complete eyecare and wellness solution

• Reduced healthcare costs over time

• Lowest out-of-pocket costs

• Employee satisfaction and loyalty

VSP also offers additional eyecare services specifically to members with Type 1 Diabetes. The benefits in their Diabetic Eyecare Program include medical follow-up exams, specialized screenings and tests, medically necessary retinal imaging, and diabetic retinopathy.Members never need a referral and pay only a copay for services.

The SUITE Life Coverage

MetLife sets itself apart by offering a comprehensive Group Life portfolio that uniquely addresses the needs of three key audiences—Group Customer, Participant, and Beneficiary—with services including Will Preparation and Estate Resolution, Portability, and so much more.

To finish off the package, MetLife offers $25,000 Basic Term Life as an employer-paid benefit. All policies include MetLife’s Basic AD&D coverage. In addition, there is an employee-paid Supplemental Life with AD&D option for groups with 10 or more eligible employees.

VISION COVERAGEStandard SUITE and Dual Choice

SUITEVision Choice Plan B $25Preferred SUITE and Dual Choice

SUITEVision Choice Plan C $25

In-network Out-of-network In-nework Out-of-network

Annual Copayment $25 $25

Eye Exam Covered in full Reimbursed up to $45 Covered in full Reimbursed up to $45

Lenses by Type (Glass or Plastic)

Single-vision Covered in full Reimbursed up to $30 Covered in full Reimbursed up to $30

Bifocal Covered in full Reimbursed up to $50 Covered in full Reimbursed up to $50

Trifocal Covered in full Reimbursed up to $65 Covered in full Reimbursed up to $65

Lenticular Covered in full Reimbursed up to $100 Covered in full Reimbursed up to $100

Frames $150 in allowance Reimbursed up to $70 $150 in allowance Reimbursed up to $70

Contact Lenses (available in lieu of all other eyewear benefits) $150 in allowance Reimbursed up to $105 $150 in allowance Reimbursed up to $105

Frequency of Services

Eye Exam 12 months 12 months

Lenses 12 months 12 months

Frames 24 months 12 months

Contact Lenses (available in lieu of all other eyewear benefits) 12 months 12 months

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Plan Benefits & Program GuidelinesFor groups with 5-99 eligible employees

BASIC LIFE PLUS AD&D COVERAGE Standard and Preferred SUITEs, and Dual Choice Basic Term Life with AD&D

Coverage Amount* $25,000

Employee Class Schedule Classes not allowed

Disability Provision - Basic Life Only Waiver of premium: Disabled prior to age 60, coverage continues to age 65

Age Reduction Schedule • 35% at age 65• 50% at age 70

Employee Assistance Program Not available

Accelerated Benefit Option 12 months or less to live, up to 80% of coverage amount to a maximum of $500,000

PROGRAM GUIDELINES Dental, Vision, Basic Term Life with AD&D, and Supplemental Life with AD&D

Group Size and Eligibility

• Groups with 5–99 employees• Minimum of 5 enrolled employees• To maintain enrollment in the 5–99 program, member must enroll in all three lines of

coverage (dental, vision, and basic term life)• COBRA participants not to exceed 15% of enrolled employees

Employer Contribution• Dental and Vision: Minimum 50% of employee-only premium• Basic Term Life: 99% of employee premium• Supplemental Life: 0%

Participation

• Minimum 75% of total eligible employees, not including waivers• For groups with under 10 members, no more than 75% of a group can be members of the

same family (husband, wife, siblings, children, and parents)• Supplemental Life: Greater of 25% or 5 enrolled employees

Product Combinations • Dental Dual Option: Available for groups of 10–99 eligible employees• Minimum of three enrolled in a plan (PPO/HMO)

Ineligible Industries SIC Codes: 8020–8021, 8070, 8072, 8200–8299

Waiting Period for Services None, except for dental late entrants

Dependents • Dental, Vision, and Supplemental Life: Dependent children are eligible until age 26

Eligible Employees Permanent, full-time employees working 30 or more hours per week

Ineligible Employees Retirees, part-time, temporary, seasonal, 1099, pilots, and elected officials

Voluntary No

Rate Guarantee• Dental and Vision: 12 months• Basic Term Life: 24 months• Supplemental Life: 24 months

Industry Loads None

Out-of-state

• Dental PPO SUITEs: No more than 25% of primary enrollees may reside outside of California. PPO coverage is not available in the following states: LA, MS, MT, TX.

• Dental HMO SUITEs: None allowed• Supplemental Life: No restrictions on number of employees residing outside of California

Carve-outs Union/Non-union and Management

Basic Life Age Restriction Schedule• 35% at age 65• 50% at age 70• No age restriction for Supplemental Life

Open Enrollment Available for Package Dental, Vision, and Basic Life/AD&D

* Subject to MetLife acceptance of group for coverage based on information provided in the Risk Assessment Summary in the Employer Enrollment Packet.

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Note: All rates are effective from January 1, 2016 through December 31, 2016.

Supplement Life Plans:Program Guidelines & RatesFor groups with 10-99 eligible employees

SUPPLEMENTAL LIFE COVERAGE Employee

Dependent

Spouse Child

Group Size and Eligibility • 10–99 eligible employees• 25% must participate with a minimum of 5 enrolled

Available Amounts $10,000 increments $5,000 increments Amounts of $1,000/$2,000/$4,000/$5,000/$10,000

Plan Maximum Lesser of 5x pay or $500,000 50% of the employee amount up to $100,000

50% of the employee amount up to $10,000

Guaranteed Issue Amount $50,000 $25,000 $10,000

Age Reduction Schedule None None None

Will Preparation and Estate Resolution Services Included Included Included

Travel Assistance and Identity Theft Included Included Included

SUPPLEMENTAL TERM AD&D COVERAGE

Coverage 100% of Supplement Term Life benefit

100% of Dependent Supplement Term Life benefit

• Under 15 days: $0• 15 days–6 months old: $100• 6+ months old: $1,000, $2,000,

$4,000, $5,000 or $10,000, not to exceed spouse’s benefit amount

SUPPLEMENTAL LIFE AD&D RATES

AgeEmployee and Spouse(Per $1,000 of covered

volume)

Less than 30 $0.118

30–34 $0.145

35–39 $0.170

40–44 $0.209

45–49 $0.308

50–54 $0.491

55–59 $0.813

60–64 $1.208

65–69 $2.166

70+ $4.007

SUPPLEMENTAL LIFE AD&D RATESAge Child

Birth to 26 $0.311

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RatesMiniSUITE: For groups with 2-4 eligible employees

Standard and Preferred SUITE: For groups with 5-99 eligible employees

DPPOMiniSUITE PPO 2-4

Employee EE + 1 EE + 2 or more

Region 1 $41.46 $82.43 $137.15

Region 2 $42.54 $84.58 $140.72

Region 3 $45.19 $89.84 $149.48

Region 4 $46.99 $93.42 $155.44

Region 5 $48.53 $96.49 $160.54

Region 6 $52.96 $105.30 $175.21

DENTAL Standard SUITEPPO Option 1

Preferred SUITEPPO Option 2

Standard and Preferred SUITEs, and Dual Choice DHMO

5 - 50 Employees Employee EE+1 EE + 2

or more Employee EE+1 EE + 2 or more Employee EE+1 EE + 2

or more

Region 1 $37.48 $74.21 $122.68 $44.15 $88.35 $152.59 $15.79 $29.99 $41.85

Region 2 $38.57 $76.37 $126.25 $47.27 $94.60 $163.40 $15.79 $29.99 $41.85

Region 3 $41.42 $82.01 $135.57 $51.92 $103.90 $179.45 $15.79 $29.99 $41.85

Region 4 $43.37 $85.87 $141.96 $56.03 $112.13 $193.67 $15.79 $29.99 $41.85

Region 5 $44.95 $89.00 $147.14 $59.71 $119.50 $206.40 $15.79 $29.99 $41.85

Region 6 $49.64 $98.29 $162.49 $68.28 $136.66 $236.03 $15.79 $29.99 $41.85

51-99 Employees Employee EE+1 EE + 2

or more Employee EE+1 EE + 2 or more Employee EE+1 EE + 2

or more

Region 1 $32.98 $65.30 $107.96 $38.85 $77.75 $134.28 $14.90 $28.33 $39.50

Region 2 $33.94 $67.21 $111.10 $41.60 $83.25 $143.79 $14.90 $28.33 $39.50

Region 3 $36.45 $72.17 $119.30 $45.69 $91.43 $157.92 $14.90 $28.33 $39.50

Region 4 $38.17 $75.57 $124.92 $49.31 $98.67 $170.43 $14.90 $28.33 $39.50

Region 5 $39.56 $78.32 $129.48 $52.54 $105.16 $181.63 $14.90 $28.33 $39.50

Region 6 $43.68 $86.50 $142.99 $60.09 $120.26 $207.71 $14.90 $28.33 $39.50

VISIONSUITE Vision Choice Plan B

Employee EE + 1 EE + 2 or more

Statewide $7.30 $10.70 $19.10

VISION

Standard SUITE & Dual Choice SUITEVision Choice Plan B

Employee EE + 1 EE + 2 or more

Statewide

$7.30 $10.70 $19.10

Preferred SUITE & Dual Choice SUITEVision Choice Plan C

$9.00 $13.00 $23.30

DENTAL ZIP CODE REGIONSRegion 1 932-934, 936, 937

Region 2 919-925, 956-958

Region 3 917, 930, 931, 935, 952, 953, 959

Region 4902, 905, 907, 908, 910-912, 916, 926-928, 939-941, 946, 947, 949, 954, 960, 961

Region 5 900, 901, 903, 904, 906, 913-915, 918, 945, 948, 950, 951, 955

Region 6 942-944

BASIC TERM LIFE PLUS AD&D

$20,000 Life with AD&DPer $1,000 of Covered Volume

Per Employee Per Month $0.415

Note: All rates are effective from January 1, 2016 through December 31, 2016.

BASIC TERM LIFE PLUS AD&D

$25,000 Life with AD&D Per $1,000 of Covered Volume

5-50 employees 51-99 employees

Per Employee Per Month $0.276 $0.245

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Dental Plan Limitations & ExclusionsFor Groups with 5-99 Eligible EmployeesDental Exclusions for DHMO PlanGeneralGeneral anesthesia is a covered benefit only when administered by the treating dentist, in conjunction with oral and periodontal surgical procedures.

Preventative• Routine Cleanings (prophylaxis), periodontal maintenance services, and

fluoride treatments are limited to twice a year • Two (2) additional cleanings (routine and periodontal) are available at

the copayment listed on this Plan’s Schedule of Benefits. Additional prophylaxis is available, if medically necessary.

• Sealants and/or preventive resin restorations: Plan benefit applies to primary and permanent molar teeth, within four (4) years of eruption, unless medically necessary.

Diagnostic• Panoramic or full-mouth X-rays: Once every three (3) years, unless

medically necessary.

Restorative Treatment• An additional charge, not to exceed $150 per unit, will be applied for

any procedure using noble, high noble, or titanium metal.• Replacement of any crowns or fixed bridges (per unit) are limited to

once every five (5) years.• Cases involving seven (7) or more crowns and/or fixed bridge units in

the same treatment plan require an additional $125 copayment per unit in addition to the specified copayment for each crown/bridge unit.

• There is a $75 copayment per crown/bridge unit in addition to the specified copayment for porcelain on molars.

• Provisional crowns/restorations are to be used for an interim of at least six (6) months duration. Interim crowns/restorations are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations.

Prosthodontics• Relines are limited to one (1) every twelve (12) months.• Dentures (full or partial): Replacement only after five (5) years have

elapsed following any prior provision of such dentures under a SafeGuard Plan, unless due to the loss of a natural functioning tooth. Replacements will be a benefit under this Plan only if the existing denture is unsatisfactory and cannot be made satisfactory as determined by the treating SafeGuard selected general dentist.

• Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service.

• Provisional prostheses are to be used for an interim of at least six (6) months duration. Interim prostheses are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations.

EndodonticsThe copayments listed for endodontic procedures do not include the cost of the final restoration.

Oral Surgery The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists.

Dental Exclusions for DHMO Plan• Any procedures not specifically listed as a covered benefit in this Plan’s

Schedule of Benefits are not covered.

• Services performed by any dentist not contracted with SafeGuard, without prior approval by SafeGuard (except for out-of-area emergency services). This includes services performed by a general dentist or specialty care dentist.

• Dental procedures started prior to the member’s eligibility under this Plan or started after the member’s termination from the Plan. Examples include teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken.

• Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or improving the member’s dental health, as determined by the SafeGuard selected general dentist.

• Orthognathic surgery.• In-patient/out-patient hospital charges of any kind including dentist

and/or physician charges, prescriptions or medications.• Replacement of dentures, crowns, appliances or bridgework that have

been lost, stolen or damaged due to abuse, misuse, or neglect.• Treatment of malignancies, cysts, or neoplasms, unless specifically

listed as a covered benefit on this Plan’s Schedule of Benefits. Any services related to pathology laboratory fees.

• Procedures, appliances, or restorations whose primary main purpose is to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits.

• Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services.

• Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare.

• Dental services required while serving in the Armed Forces of any country or international authority.

• Dental services considered experimental in nature.• Any dental procedure or treatment unable to be performed in the

dental office due to the general health or physical limitations of the member.

Orthodontics • If you require the services of an orthodontist, a referral must first be

obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment. If you terminate coverage from the SafeGuard Plan after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment.

• Orthodontic treatment must be provided by a SafeGuard selected general dentist or SafeGuard contracted orthodontist in order for the copayments listed in this Plan’s Schedule of Benefits to apply.

• Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a charge of $25 per visit.

• The following are not included as orthodontic benefits: repair or replacement of lost or broken appliances; retreatment of orthodontic cases; treatment involving maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; hormonal imbalances or other factors affecting growth or developmental abnormalities; treatment related to temporomandibular joint disorders; composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.

• The retention phase of treatment shall include the construction, placement, and adjustment of retainers.

• Active orthodontic treatment in progress on your effective date of coverage is not covered. Active orthodontic treatment means tooth movement has begun.

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Dental Plan Limitations & Exclusions (cont.)For Groups with 2-4 Eligible EmployeesDental Frequency & Allocations for DPPO Plan Benefits are payable immediately from the start date of an individual’s benefits.

TYPE A:• Examinations: 1 time in 6 months • Examinations—Problem Focused: Combined with Examinations Limit• Prophylaxis—Cleanings: 1 time in 6 months• Fluoride: 1 time in 12 months for a child under age 14• Full Mouth X-Rays: Once in 60 months• Bitewing X-Rays—Child under 14: 2 times in 1 calendar year• Bitewing X-Rays—Adult: 1 time in 1 calendar year

TYPE B: • Sealants: 1 per molar in lifetime for a child under age 14• Space Maintainers: No limit for a child under age 14• Amalgam Fillings: 1 replacement per surface in 24 months• Root Canal: 1 in 24 months• Periodontal Maintenance: 2 treatments in 1 calendar year, includes 2

cleanings (total combination: 2)• Periodontal Surgery: 1 per quadrant in any 36 month period• Scaling and Root Planing: 1 per quadrant in any 24 month period• Labs and Other Tests• Emergency Palliative Treatment• Periapical X-Rays • Other X-Rays• Resin Composite Fillings: Includes coverage for composite fillings on

molars• Pulpotomy• Pulp Capping• Pulp Therapy• Apexification and Recalcification• Periodontal Surgery—Soft and Connective Tissue Grafts• Periodontics—Non-Surgical• General Services

TYPE C: • Consultations: 1 in 12 months• Prefabricated Crowns: 1 per tooth in 24 months• Crown Buildups/Post Core: 1 per tooth in 60 months• Repairs: 1 in 12 months• Recementations: 1 in 12 months• Dentures: 1 in 10 calendar years• Immediate Temporary Dentures—Complete/Partial: 1 replacement in

12 months• Dentures—Rebases/Relines: 1 in 36 months• Denture Adjustments: 1 in 12 months• Fixed Bridges: 1 in 10 calendar years• Inlays/Onlays/Crowns: 1 replacement per tooth in 60 months• Implant Services: 1 per tooth position in 10 calendar years• Implant Repairs: 1 per tooth in 12 months• Implant Supported Prosthetic: 1 per tooth in 10 calendar years• Tissue Conditioning: 1 in 36 months• Occlusal Adjustments: 1 in 12 months• General Anesthesia• Oral Surgery—Simple Extractions• Oral Surgery—Surgical Extractions• Other Oral Surgery

For Groups with 5–99 Eligible EmployeeDental Frequency & Allocations for Standard PPO Option 1All of the benefits above, with the following adjustments:

TYPE B: • Oral Surgery - Simple Extractions

TYPE C: • Root Canal: 1 in 24 months• Periodontal Surgery: 1 per quadrant in any 36 month period• Periodontal Surgery—Soft & Connective Tissue Grafts• Pulpotomy• Apexification and Recalcification

For Groups with 5-99 Eligible EmployeesDental Frequency & Allocations Preferred PPO Option 2Benefits are payable immediately from the start date of an individual’s benefits.

TYPE A:• Examinations: 1 time in 6 months • Examinations—Problem Focused: Combined with Examinations Limit• Prophylaxis—Cleanings: 1 time in 6 months• Sealants: 1 per molar in 60 months for children under age 14• Space Maintainers: No limit for a child under age 14• Fluoride: 1 time in 12 months for a child under age 14• Full Mouth X-Rays: Once in 60 months• Bitewing X-Rays—For a child under 14: 2 times in 1 calendar year• Bitewing X-Rays—Adult: 1 time in 1 calendar year• Emergency Palliative Treatment• Periapical X-Rays • Other X-Rays

TYPE B: • Amalgam Fillings: 1 replacement per surface in 24 months• Root Canal: 1 in 24 months• Periodontal Maintenance: 2 periodontal treatments in 1 calendar year,

includes 2 cleanings (total combination: 2)• Periodontal Surgery: 1 per quadrant in any 36 month period• Scaling and Root Planing: 1 per quadrant in any 24 month period• Labs and Other Tests• Resin Composite Fillings (includes coverage for composite fillings or

molars)• Pulpotomy• Pulp Capping• Pulp Therapy• Apexification and Recalcification• Periodontal Surgery—Soft and Connective Tissue Grafts• Periodontics—Non-Surgical • General Services

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Dental Plan Limitations & Exclusions (cont.)TYPE C: • Consultations: 1 in 12 months• Prefabricated Crowns: 1 per tooth in 24 months• Crown Buildups/Post Core: 1 per tooth in 60 months• Repairs: 1 in 12 months• Recementations: 1 in 12 months• Dentures: 1 in 10 calendar years• Immediate Temporary Dentures—Complete/Partial: 1 Replacement in

12 months• Dentures—Rebases/Relines: 1 in 36 months• Denture Adjustments: 1 in 12 months• Fixed Bridges: 1 in 10 calendar years• Inlays/Onlays/Crowns: 1 replacement per tooth in 60 months• Implant Services: 1 per tooth position in 10 calendar years• Implant Repairs: 1 per tooth in 12 months• Implant Supported Prosthetic: 1 per tooth in 10 calendar years• Tissue Conditioning: 1 in 36 months• Occlusal Adjustments: 1 in 12 months• General Anesthesia• Other Oral Surgery• Oral Surgery—Simple Extractions• Oral Surgery—Surgical Extractions

ORTHODONTICS: • Orthodontics diagnostics• Orthodontic treatment

For Groups with 5-99 Eligible EmployeeDental Exclusions for PPO Options 1 and 2Late Entrants Employees who do not elect coverage during their 31-day application period may still elect coverage later. Dental coverage would be subject to the following waiting periods:

• Type A Services: No waiting period • Type B Services—Fillings: 6-month waiting period • Type B Services—All Other Services: 12-month waiting period • Type C Services: 12-month waiting period • Orthodontic Services (if applicable): 12-month waiting period

• Services which are not dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which MetLife deems experimental in nature.

• Services for which a covered person would not be required to pay in the absence of dental insurance.

• Services or supplies received by a covered person before the insurance starts for that person.

• Services which are neither performed nor prescribed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling or polishing of teeth or fluoride treatment.

• Services which are primarily cosmetic. (For residents of Texas: Services which are primarily cosmetic unless required for the treatment or correction of a congenital defect of a newborn child).

• Services or appliances which restore or alter occlusion or vertical dimension.

• Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease.

• Restorations or appliances used for the purpose of periodontal splinting.

• Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.

• Personal supplies or devices including, but not limited to water picks, toothbrushes, or dental floss.

• Initial installation of a denture to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.

• Decoration or inscription of any tooth, device, appliance, crown or

other dental work.• Missed appointments.• Services covered under any workers’ compensation or occupational

disease law.• Services covered under any employer liability law.• Services for which the employer of the person receiving such services

is not required to pay.• Services received at a facility maintained by the Policyholder, labor

union, mutual benefit association, or VA hospital.• Services covered under other coverage provided by the Policyholder.• Temporary or provisional restorations.• Temporary or provisional appliances.• Prescription drugs.• Services for which the submitted documentation indicates a poor

prognosis.• Services, to the extent such services, or benefits for such services, are

available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. MetLife will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first.

• The following when charged by the dentist on a separate basis—Claim form completion; infection control such as gloves, masks, and sterilization of supplies; or local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

• Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing and biting of food.

• Caries susceptibility tests.• Precision attachments associated with fixed and removable

prostheses.• Adjustment of a denture made within 6 months after installation by the

same dentist who installed it.• Duplicate prosthetic devices or appliances.• Replacement of a lost or stolen appliance, cast restoration or denture.• Intra- and extra-oral photographic images.• Fixed and removable appliances for correction of harmful habits.• Appliances or treatment for bruxism (grinding teeth), including but not

limited to occlusal guards and night guards.• Treatment of temporomandibular joint disorder. This exclusion does

not apply to residents of Minnesota.

Dental Exclusions for DPPO (2–4) and PPO Option 1 (5–99)• All of the exclusions above, plus:• Orthodontia services or appliances.• Repair or a replacement of an orthodontic appliance.

16

Basic Term Life Features & LimitationsFor Groups with 2-4 Eligible EmployeesCoverage—Flat $20,000

MetLife Advice® ProgramAn advice program to assist employees with various life transitions.

Total Control Account® (TCA) • Death claim proceeds paid via the TCA Settlement Option—an interest-

bearing account with draft-writing privileges• Relieves beneficiaries of the need to make immediate decisions about

what to do with a lump-sum check, while giving them the flexibility to access funds as needed and earn interest on the proceeds as they assess their financial situation

• Provides full and immediate access to the death proceeds• Principal and interest earned are guaranteed by the financial strength

and claims paying ability of the Metropolitan Life Insurance Company• Beneficiary receives a draft book, along with a Customer Agreement

and other materials describing the Account • Unlimited draft writing privileges• No charges for processing TCA drafts, no monthly maintenance fees,

and no charge for ordering additional TCA drafts• Account holders receive periodic statements itemizing account activity

and a free Life Advice newsletter • Information about the TCA is available electronically through MetLife’s

easy to use eSERVICE web site• Customer Service Representatives specially trained to provide service

to beneficiaries are available through a special toll-free number• At their convenience, Account holders are able to touch or speak their

requests into the phone such as, “hear account balance”, “get recent transactions”, and “order drafts.”

Subject to state law, and/or group policyholder direction, the TCA is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing the TCA are maintained in the Metropolitan Life Insurance Company (MetLife) general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA Accountholders and to provide a profit on the operation of the TCAs. Guarantees are subject to the financial strength and claims paying ability of MetLife.

Waiver of PremiumGroup life coverage is continued for an employee meeting the contractual definition of total disability. No further premium payment for that employee is required. The onset of the disability must occur prior to the age as defined in the Summary of Benefits, must last continuously for 9 months, and the employee must submit a request for the extension within 12 months of the onset of the total disability.

Enrolling in the PlanA statement of health will need to be submitted by employees who: • Request coverage amounts during their initial 31-day enrollment that

exceed the stated MEOI level.• Apply for coverage more than 31 days after they are first eligible (late

entrants).• Have indicated a medical condition on their enrollment form.

The coverage will be subject to a contestability clause in accordance with the law.No eligible individual may be covered more than once under this plan. If a person is covered as an employee, he/she cannot be covered as a spouse or dependent. If an employee and spouse are employed by the same employer, their eligible dependents may be insured as dependents of only one employee.

For Groups with 5-99 Eligible EmployeesCoverage - Flat $25,000

Supplemental LifeIncludes:

PortabilityOption to continue employee term life insurance under a different group policy, if included and eligible. The minimum benefit that can be continued is $20,000; maximums will apply.

MetLife Advice® ProgramAn advice program to assist employees with various life transitions.

Will Preparation ServiceAutomatically included with Supplemental Life. Face to Face meeting with a Hyatt attorney. Will Preparation Services are offered by Hyatt Legal Plans, Inc., a MetLife Company, Cleveland, Ohio. In certain states, Will Preparation Services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation. Tax Planning and preparation of Living Trusts are not covered by the Will Preparation Service.

Estate Resolution ServicesSM

Automatically included with Supplemental Life. Estate Resolution Services are offered by Hyatt Legal Plans, Inc., a MetLife Company, Cleveland, Ohio. In certain states, Estate Resolution Services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. The following are not covered by the Estate Resolution Service: Matters in which there is conflict of interest between the executor, administrator, any beneficiary or heir and the estate: any disputes with the Policyholder, Employer Plan Attorneys, MetLife and/or any of its affiliates, any disputes involving statutory benefits. Will contests or litigation outside Probate Court. Appeals; Court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines, and frivolous or unethical matters.

Benefit IncreasesSupplemental Term Life, Dependent Supplemental Term Life: Employees, actively at work, who are participating in the plan and want to increase their coverage by any amount will have to submit a statement of health.Except in Washington: Supplemental and Dependent Life Insurance will not be paid to the Beneficiary if an insured commits suicide within 2 years (1 year in Missouri if the insured intended to commit suicide when enrolling for such insurance, 1 year in North Dakota and Colorado) of the effective date of this certificate. Instead, we will pay the Beneficiary an amount equal to any contributions paid, without interest.

17

Basic Term Life Features & Limitations (cont.)

Maximum Amount payable for all cover Losses sustained in one accident is capped at 100% of the Full Amount.

Additional Covered Losses

Plan Limitations and Exclusions

LimitationsThe Accidental Death & Dismemberment (AD&D) loss must occur within 365 days after the date of the accident and be a direct result of bodily injury sustained from that accident, independent of other causes.

ExclusionsAD&D insurance does not include payment for any loss which in any way results from or is caused by or contributed to by:• physical or mental illness or infirmity, or the diagnosis or treatment of

such illness or infirmity;• infection, other than infection occurring in an external accidental

wound;• suicide or attempted suicide;• intentionally self-inflicted injury;• active duty service in the armed forces of any country or international

authority, except the United States National Guard;• any incident related to: (1) travel in an aircraft as a pilot, crew member,

flight student or while acting in any capacity other than as a passenger; (2) travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in flight; (3) parachuting or otherwise exiting from an aircraft while such aircraft is in flight except for self preservation; (4) travel in an aircraft or device used for testing or experimental purposes; by or for any military authority; or for travel or designed for travel beyond the earth’s atmosphere;

• committing or attempting to commit a felony;• the voluntary intake or use by any means of: (1) any drug, medication

or sedative, unless it is taken or used as prescribed by a Physician, or an “over the counter” drug, medication or sedative, taken as directed; (2) alcohol in combination with any drug, medication, or sedative; or (3) poison, gas, or fumes;

• war, whether declared or undeclared; or act of war, insurrection, rebellion, riot;

• driving a vehicle or other device while intoxicated as defined by the laws of the jurisdiction in which the vehicle or other device was being operated.

Covered Loss Basic AD&DLife 100%Hand 50%Foot 50%Arm 75%Leg 75%Sight of One Eye 50%Combination of a Hand, Foot, and/or Eye 100%Thumb and Index Finger on the Same Hand 25%Speech and HearingSpeechHearingParalysis of Both Arms and Both LegsParalysis of Both LegsParalysis of the Arm & Leg on Either Side of the BodyParalysis of One Arm or LegBrain DamageComa

100%50%50%100%50%50%

25%100%1% monthly up to 60 months

Covered Loss Basic AD&DAir Bag Use 5% up to $10,000Seat Belt Use 10% up to $25,000Common Carrier 100% of Full AmountChild Care Center $5,000 per year for 4 years up

to 12% of Full Amount

Except in Washington: If an insured commits suicide within 2 years (1 year in Missouri if the insured intended to commit suicide when enrolling for an increase in insurance, 1 year in North Dakota and Colorado) from the effective date of any increase in the amount of Supplemental and Dependent Life Insurance, such increased amount will not be paid to the Beneficiary. Instead MetLife will pay the Beneficiary an amount equal to all contributions paid for the increased amount, without interest, plus the amount of Supplemental Life Benefits that was in effect on the day before the effective date of such increased amount.The employee must be covered for benefits in order for dependents to be covered.Dependent Benefits Terminate: At the earlier of the employee’s retirement or when the employee’s coverage terminates.Dependent Eligibility Deferment: Dependent is not confined to hospital, confined to home or receiving disability income from any source.Dependent benefit cannot exceed the lesser of the amount for which the employee is insured or any applicable state law limit.

Covered Losses for AD&D—Basic Term Life and Supplemental Life

18

Life Plan Limitations and Exclusions

Intermediary and Producer Compensation Notice

Additional Benefit OptionsThe Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances. The minimum that can be accelerated is $20,000. The definition of earnings used to define benefits will be Basic Monthly Earnings.Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the

MetLife enters into arrangements concerning the sale, servicing and/or renewal of MetLife group insurance and certain other group-related products (“Products”) with brokers, agents, consultants, thirdparty administrators, general agents, associations, and other parties that may participate in the sale, servicing and/or renewal of such Products (each an “Intermediary”). MetLife may pay your Intermediary compensation, which may include, among other things, base compensation, supplemental compensation and/or a service fee. MetLife may pay compensation for the sale, servicing and/or renewal of Products, or remit compensation to an Intermediary on your behalf. Your Intermediary may also be owned by, controlled by or affiliated with another person or party, which may also be an Intermediary and who may also perform marketing and/or administration services in connection with your Products and be paid compensation by MetLife. Base compensation, which may vary from case to case and may change if you renew your Products with MetLife, may be payable to your Intermediary as a percentage of premium or a fixed dollar amount.MetLife may also pay your Intermediary compensation that is based upon your Intermediary placing and/or retaining a certain volume of business (number of Products sold or dollar value of premium) with MetLife. In addition, supplemental compensation may be payable to your Intermediary. Under MetLife’s current supplemental compensation plan, the amount payable as supplemental compensation may range from 0% to 8% of premium. The supplemental compensation percentage may be based on: (1) the number of Products sold through your Intermediary during a prior one-year period; (2) the amount of premium or fees with respect to Products sold through your Intermediary during a prior one-year period; (3) the persistency percentage of Products inforce through your Intermediary during a prior one-year period; (4) premium growth during a prior one-year period; (5) a fixed percentage of the premium for Products as set by MetLife. The supplemental compensation percentage will be set by MetLife prior to the beginning of each calendar year and it may not be changed until the following calendar year. As such, the supplemental compensation percentage may vary from year to year, but will not exceed 8% under the current supplemental compensation plan.

effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family. Life and AD&D coverage are provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life and AD&D coverage under your employer’s plan terminates when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent or when a dependent (spouse/domestic partner) reaches age 70. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

The cost of supplemental compensation is not directly charged to the price of our Products except as an allocation of overhead expense, which is applied to all eligible group insurance products, whether or not supplemental compensation is paid in relation to a particular sale or renewal. As a result, your rates will not differ by whether or not your Intermediary receives supplemental compensation. If your Intermediary collects the premium from you in relation to your Products, your Intermediary may earn a return on such amounts. Additionally, MetLife may have a variety of other relationships with your Intermediary or its affiliates, or with other parties, that involve the payment of compensation and benefits that may or may not be related to your relationship with MetLife (e.g., insurance and employee benefits exchanges, enrollment firms and platforms, consulting agreements, or reinsurance arrangements). More information about the eligibility criteria, limitations, payment calculations and other terms and conditions under MetLife’s base compensation and supplemental compensation plans can be found on MetLife’s Web site at www.metlife.com/brokercompensation. Questions regarding Intermediary compensation can be directed to ask4met@metlifeservice.com, or if you would like to speak to someone about Intermediary compensation, please call (800) ASK 4MET. In addition to the compensation paid to an Intermediary, MetLife may also pay compensation to your MetLife sales representative. Compensation paid to your MetLife sales representative is for participating in the sale, servicing, and/or renewal of Products, and the compensation paid may vary based on a number of factors including the type of Product(s) and volume of business sold. If you are the person or entity to be charged under an insurance policy or annuity contract, you may request additional information about the compensation your MetLife sales representative expects to receive as a result of the sale or concerning compensation for any alternative quotes presented, by contacting your MetLife sales representative or calling (866) 796-1800.L0615427709[exp1016][All States]

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Alternate Benefits for Dental PPO PlansYour dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility.To avoid any misunderstandings, MetLife suggests you discuss treatment options with your dentist before services are rendered, and obtain a pre-treatment estimate of benefits prior to receiving certain high-cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Procedure charge schedules are subject to change each plan year. You can obtain an updated procedure charge schedule for your area via fax by calling 1-800-942-0854 and using the MetLife Dental Automated Information Service.

Dental PPO PlansPDP Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums.Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166

Information About MetLife Dental PlansCancellation/Termination of BenefitsCoverage is provided under a group insurance policy (Policy form GPNP99 issued by MetLife). Coverage terminates when your membership ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. The group policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: completion of a prosthetic device, crown or root canal therapy.

Dental HMO PlansDental HMO plan benefits are provided by SafeGuard Health Plans, Inc. a California corporation in CA; SafeGuard Health Plans, Inc. The Dental HMO companies are part of the MetLife family of companies.“DHMO” is used to refer to product designs that may differ by state of residence of the enrollee, including but not limited to: “Specialized Health Care Service Plans” in California.

Plan Administration:CoPower1600 W. Hillsdale Blvd.San Mateo, California 94402T: 888.920.2322E: sales@copower.comwww.copower.com

Carrier Contact Information:MetLife(800) 275-4638www.metlife.com

SafeGuard(800) 880-1800www.safeguard.net

VSP(800) 877-7195www.vsp.com

CPE-023 01/16

Enrollment Checklistn CoPower SUITE through MetLife Employer Application Packet

• Separate packet for groups 2–4 and 5–99• Packet combines all of the necessary employer applications for coverage

n Employee enrollment (choose one):• CoPower SUITE Census Enrollment form.• Enrolling employees may also complete the CoPower Employee Enrollment/Change Form - All Plans. DHMO enrollees must select a primary care dental facility.

n For Supplemental Life coverage, all applicants must fill out the top portion of the Health Statement. For amounts above Guaranteed Issue limits, all medical questions must be answered as well.

n Proof of employment for eligible employees age 70 and over, which can be submitted as W-2/Wage Report or letter on company letterhead.

n CoPower SUITE MetLife Broker Non-Standard Commission Agreement—completed and signed.n Brokers not yet appointed with MetLife will need to submit the CoPower SUITE Broker Appointment Inquiry Form.n Brokers not yet appointed with CoPower will need to submit a completed CoPower Producer Agreement with a copy of their

current insurance license, proof of E&O insurance, and W-9 form.

Part of the CoPower ALLIANCE portfolio of plans underwritten by Metlife and VSP, and available through CoPower, Inc.

While the information provided in this guide is believed to be accurate as of the print date, it is subject to change without notice. For the most up-to-date rates and information, contact CoPower.

This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and PA Multiple Employer Trust CoPower and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the booklet certificate. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or CoPower for costs and complete details.

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