A d d i t i o n a l i n f o r m a t i o n t o t h e b o o k l e t d a t e d J a n u a r y

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This plan is part of the contract of the CSQ and is governed by the terms and conditions mentioned in the booklet describing the group insurance plan offered to the CSQ members.

This booklet contains additionnal information on the provisions applying to the additional plan 1 - Dental care.

In this booklet, SSQ designates SSQ, Life Insurance Company Inc. This booklet is provided for information purposes only and in no way alters the stipulations and conditions of the group insurance contract.

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1- GENERAL INFORMATION

1.1 PUTTING INTO FORCE OF THE PLAN

For the additional plan 1 - Dental care to come into force in a union, the members must take a vote. When a same union has certifications in more than one employer, separate votes can be taken for each employer.

1.1.1 Vote in favour of the putting into force of the plan When the vote is in favour of the putting into force of additional plan 1 - Dental care, the plan comes into force on the day that follows “ the second end of a pay period” coinciding with or following the date of the vote, as long as the vote has been taken by June 30 of any year at the latest. If the vote is taken after June 30 of any year, the effective date of the plan is postponed to January 1 of the following year.

1.1.2 Vote against the putting into force of the plan

When members vote against additional plan 1 - Dental care, the plan does not come into force. A new vote cannot be taken within the next 12 months.

1.1.3 Vote to terminate the plan

When the vote is in favour of the termination of additional plan 1 - Dental care, the plan will terminate on the date corresponding to the “second end of a pay period” coinciding with or following the date of the vote. A new vote cannot be taken within the next12 months.

IMPORTANT

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1.2 ELIGIBILITY FOR THE PLAN

Are eligible for additional plan 1 - Dental care all individuals who are working for a same employer and are members of a same union when the union in question has voted in favour of the putting into force.

1.3 PARTICIPATION IN THE PLAN (INCLUDING THE RIGHT TO EXEMPTION)

1.3.1 Compulsory feature

Any individual eligible for additional plan 1 - Dental care must participate unless the individual takes advantage of the right to exemption described under the following item.

1.3.2 Right to exemption

a) Beginning of exemption

The individual can refuse or cease to participate in additional plan 1 - Dental care as long as there is evidence that the individual is covered by a group insurance plan with a similar coverage. To do so, the individual must complete the Application form or request

for change form and provide evidence of the existence

of the insurance allowing the exemption. Exemption comes into force on the first day of the pay period following the date SSQ receives the request.

b) Termination of exemption

The individual exempt from additional plan 1 - Dental care who ceases to be covered by the group plan that allowed exemption can reinstate participation in this plan. To do so, the individual must complete the

Application form or request for change form and indicate the

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i) If the employer receives the request for termination of exemption within the 30 days following the termination of the insurance that allowed the exemption

The coverage comes into force at the date of termination of the insurance that allowed the exemption.

ii) If the employer receives the request for termination of exemption more than 30 days after the termination of the insurance that allowed the exemption

The coverage comes into force on the first day of the pay period following the date SSQ receives the request and the applicable premium is payable as of that date.

However, no benefits are payable for expenses incurred by new dependent(s) during the three-month period following the effective date of the coverage.

1.4 EFFECTIVE DATE OF COVERAGE

For additional plan 1 - Dental care to come into force at one of the following dates, the employee must be at work or capable of performing the regular duties of the job. Otherwise, the coverage will come into force at the date of the effective return to work.

a) If the employer receives the Application form or request for change within 30 days following the date of eligibility*

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b) If the employer receives the Application from or request for change more than 30 days after the date of eligibility

Additional plan 1 - Dental care is automatically granted to the employee, with individual coverage, as of the date of eligibility.

If the employee requested to be exempt, the exemption is granted as of the first day of the pay period following the date SSQ receives the request.

If the employee chose a single-parent or family coverage status, this coverage is granted as of the first day of the pay period following the date SSQ receives the request and the premium is payable as of the same date. However, no benefits are payable for expenses incurred by dependents during the three-month period following the effective date of the coverage requested.

*Note: For a newly hired individual signing a contract of employment after the date the individual becomes eligible (contract with retroactive effect), the 30-day period begins on the date the contract of employment is signed.

1.5 COVERAGE STATUS AVAILABLE

At the time of application, the individual can choose one of the following coverage status:

• individual coverage which insures the employee only; • single-parent coverage which insures the employee and the

dependent children;

• family coverage which insures the employee, the spouse and the dependent children, if any.

IMPORTANT

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1.6 CHANGE IN COVERAGE STATUS 1.6.1 Increase of coverage status

The participant can increase the coverage status in the following ways:

• change the individual coverage for a single-parent or family coverage;

• change the single-parent coverage for a family coverage.

Increase of the coverage status can only be granted on acknowledgement of new dependents following one of the events listed below:

• marriage;

• cohabitation since more than one (1) year (without a minimum period if a child is born of the union or legal procedures of adoption have been undertaken); • birth or adoption of a child;

• termination of the insurance of the spouse or the dependent children.

To request an increase, the participant must complete a new Application form or request for change form and return it to the employer.

a) If the employer receives the Application form or request

for change within the 30 days following the date of

acknowledgement of new dependents

The new coverage status requested comes into force at the date of the event.

b) If the employer receives the Application form or request for change more than 30 days after the date of acknowledgement of new dependents

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the request, and the new premium is payable as of the same date.

However, no benefits are payable for expenses incurred by the participant and the dependents, if any, during a three-month period following the effective date of the new coverage status.

1.6.2 Decrease of coverage status

The participant can decrease the coverage status in the following ways:

• change a family coverage for a single-parent or individual coverage;

• change a single-parent coverage for an individual coverage.

To do so, the participant must complete a new Application

form or request for change form and return it to the

employer.

The new coverage status comes into force on the first day of the pay period following the date the employer receives the request.

IMPORTANT

Please make sure to inform your employer of any change regarding your dependents so SSQ can be notified. The coverage held in the dental care plan (individual, single-parent or family) must correspond to your current family status to avoid paying unnecessary premiums.

1.7 WAIVER OF PREMIUMS IN THE EVENT OF TOTAL DISABILITY

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the first working day of the pay period following the 52th_consecutive

week of total disability. The waiver of premiums terminates at the first of the following dates:

a) the last day of a period of 36 months of waiver for a same period of total disability;

b) June 30 coinciding with or following the 65th_{birthday. If the}

participant still receives remuneration from the employer at this date, waiver then terminates at the last day the participant received remuneration from the employer;

c) the date at which the period of total disability ends.

However, any participant who is totally disabled and who takes a pre-retirement leave with pay cannot benefit from the waiver of premiums during this pre-retirement leave.

1.8 CONVERSION PRIVILEGE

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2 - ELIGIBLE EXPENSES

Eligible expenses are those related to care or treatments administered by a dental surgeon , a specialist or a denturist legally licensed. Eligible expenses are those incurred for the procedures defined hereinafter up to the amounts and procedures provided for in the current edition of the fee guide of the Association des chirurgiens dentistes du Québec (ACDQ)

DENTAIDE SYSTEM

Electronic transmission of your claims through the Dentaide system is available. Details related to its use are found under chapter 3. 2.1 PREVENTIVE DENTAL CARE

Eligible expenses are reimbursable at 80%, without deductible. The following expenses are eligible for reimbursement:

2.1.1 Clinical oral examination

• examination not reimbursed by the RAMQ in children less than 10 years old: procedure 01250;

• recall or periodic examination: procedure 01200; • complete examination: procedures 01110, 01120 and

01130;

• emergency examination: procedure 01300; • specific oral examination: procedure 01400;

• complete periodontal examination: procedure 01500. 2.1.2 X-rays

Procedures 02110 to 02910.

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2.1.3 Other procedures (laboratory tests and examinations, biopsy and diagnosis casts)

Procedures 04100 to 04730.

2.1.4 Preventive care (cleaning, polishing, fluoride treatments, etc.)

Procedures 11100 to 13404, 13700 and 13710.

Expenses related to procedures 12400, 13401 to 13404 and 13700 are eligible for reimbursement only for children who are less than 14 years old.

Pit and fissure sealants (procedures 13401 and 13404) are eligible only on occlusal surfaces of permanent premolars and molars.

2.1.5 Scaling

Procedures 43411 to 43414 and 43417.

2.1.6 Control of oral habits and space maintainers Procedures 14045 to 14300 and 15108 to 15420.

Expenses related to procedures 14045 to 15420 are eligible for reimbursement only for children who are less than 14 years old.

2.1.7 General services (anaesthesia)

Procedures 91110, 91200, 92110, 92120 and 92201. 2.2 BASIC DENTAL CARE

Eligible expenses are reimbursable at 80% and subject to the common deductible mentioned in section 2.4.

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2.2.1 Minor restoration (amalgam or composite filling) Procedures 20111 to 23118 (except 21501), 23122 and 23211 to 23415.

Note: A same surface or class on the same tooth is eligible for reimbursement once per 12-month period.

The equivalent of a bonded amalgam is reimbursed when composite restoration on molars is claimed.

2.2.2 Endodontics (root canal treatment, root amputation, etc.)

Procedures 32201 to 39230 and 39901 to 39985.

2.2.3 Periodontal treatments (infection treatment, surgery, splinting, etc.)

Procedures 41200 to 42611, 42711 to 43310, 43611 to 43631 and 49211.

Procedures 42003 and 42100 are eligible subject to a maximum of six (6) different sextants per calendar year. 2.2.4 Oral surgery (removal, alveolectomy, alveoplasty, etc.)

Procedures 71101 to 72411, 73020 and 73110 to 79602. Procedures 73020, 73110 and 73140 are eligible subject to a maximum of six (6) different sextants per calendar year.

Limitations to sections 2.1 and 2.2

a) Some of the eligible orodental procedures listed under sections

2.1. and 2.2 are subject to a waiting-period before a new request

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3 times per calendar year Once per calendar year 2 times per calendar year 5 times per calendar year Once per lifetime 5 times per lifetime Frequency

treatment when expenses were eligible and the applicable waiting-period are indicated in the following schedule:

Number of months

9 months 12 months 24 months 36 months 60 months

01200 01250(2) ₁₄₀₄₅(1) ₀₁₁₁₀(6) ₄₃₂₇₀ 11100(4) ₄₂₀₀₀(3) ₁₄₁₀₀(1)_to ₀₁₁₂₀(6) ₄₃₆₁₁ 11200(4) ₄₂₀₀₁(3) ₁₄₁₀₂(1) ₀₁₁₃₀(6) ₄₃₆₁₂ 11300(4) ₁₄₂₀₁(1) ₀₁₅₀₀ 12400(1) ₁₄₂₀₂(1) ₀₂₆₀₀ 43411(5)_to ₁₅₁₀₈(1)_{to 13401}(1)(3) 43417 (5) ₁₅₄₂₀(1) ₁₃₄₀₄(1)(3)

(1) _{child less than 14 years old only} (2) _{child less than 10 years old only} (3) _{for a same tooth}

(4) _{only one of these codes during the period} (5) _{only one of these codes during the period} (6) _{only one of these codes during the period}

b) Some of the eligible orodental procedures listed under sections 2.1 and 2.2 are subject to limitations per calendar year or per lifetime of the insured. The orodental procedures and the applicable period are indicated in the following schedule:

02800 01300 43300 13220 13100 14300(1) 43310 01400 13200 43622 02910 13210 13700(1) ₁₄₀₅₀(1)

(1) _{child less than 14 years old}

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The following expenses are eligible for reimbursement: 2.3.1 Removable prosthesis

Procedures 51100 to 51713, 52120 to 57202, 21501 and 23701.

Note: Any fixed bridge will be covered up to the cost and limitations of an equivalent removable denture.

Limitations to section 2.3

When a benefit claim has been made for a removable prosthesis and that eligible expenses were acknowledged, a replacement prosthesis will not be eligible for reimbursement if it is installed within the 60 months following the installation of the previous one. However, a permanent removable prosthesis, partial or full, is eligible for reimbursement if it replaces a transitional removable prosthesis (partial or full) and is installed within six (6) months of the installation date of the transitional prosthesis.

2.4 DEDUCTIBLE COMMON TO SECTIONS 2.2. AND 2.3

Basic dental care and major restorative care are subject to a common deductible of $50 per calendar year. This is a single deductible applying to expenses incurred by both the participant and the dependents (deductible per certificate).

2.5 PRE-AUTHORIZATION FOR TREATMENTS

When the total cost of the treatment is expected to exceed $800 or the scheduled services are major restorative care, SSQ must be provided with a treatment plan including an X-ray before the beginning of the treatment to determine the amount of expenses that will be covered.

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Maximum reimbursement per insured 2.6 MAXIMUM REIMBURSEMENT

All the care listed under sections 2.1, 2.2 and 2.3 are subject to a maximum reimbursement per insured, per calendar year, as indicated in the following table. The first calendar year corresponds to the year during which the additional plan 1 - Dental care becomes effective.

Calendar year

First $600

Second $800

Third and following years $1,000

* The maximum reimbursement of $600 provided for the first calendar year applies regardless of the effective date of the plan (no prorata).

2.7 EXCLUSIONS

No benefits are payable for expenses incurred: a) as a result of a war, insurrection or riot; b) as a result of participation in a criminal act;

c) while the insured is an active member of the armed forces; d) for services the insured is not required to pay;

e) for esthetic purposes, except if otherwise specified;

f) that are reimbursed or payable by a government plan or organization;

g) for medical examinations for work, insurance, control or verification purposes;

h) that are reimbursed or payable by any other private, individual or group plan;

i) for services or supplies, examinations, care, expenses, or their surplus, that are not in compliance with the reasonable standards of the common practice of the health professionals involved;

j) for products, devices or services used or offered for experimental purposes or in the medical research stage, or whose use does not comply with the indications approved by the proper authorities or, failing such authorities, with the indications

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Furthermore, any act, treatment, prosthesis, of any nature, related to a dental implant is not eligible.

NOTE

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3 - HOW TO SUBMIT A CLAIM

To have your claim electronically transmitted to SSQ, please present your Dentaide card to the participating dentist. You will only have to pay the portion of eligible expenses that is not reimbursable by SSQ.

If the dentist is not a member of Dentaide, you must ask the dentist to complete the Benefit claim for dental care form and you must sign and return this form to SSQ. The form can be obtained from the employer.

We recommend that you send in the original of your paid invoices every three (3) months. Please keep a copy of these invoices since they are not returned to you. Any invoices submitted more than 12 months after the date expenses were incurred are not eligible for reimbursement.

3.1 WHERE TO SEND CLAIMS

Please indicate your contract number on any claims or other correspondence sent to SSQ, at the following address:

SSQ, Life Insurance Company Inc. P.O. Box 10500, Sainte-Foy Station Sainte-Foy, Quebec

G1V 4H6

3.2 FILE AND PERSONAL INFORMATION

To insure the confidentiality of personal information that concerns you, SSQ opens an insurance file containing information on your insurance application as well as information relative to any claims for insurance benefits. Files are kept at the head office of SSQ in Sainte-Foy.

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Coverage status

4 - TABLE OF PREMIUMS

PER 14-DAY PERIOD

Premium per 14-day period*

2002 2003

Individual $7.47 $7.99

Single-parent $11.35 $12.14

Family $18.81 $20.13

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A d d i t i o n a l i n f o r m a t i o n t o t h e b o o k l e t d a t e d J a n u a r y

TABLE OF CONTENTS

1- GENERAL INFORMATION

2 - ELIGIBLE EXPENSES

3 - HOW TO SUBMIT A CLAIM

4 - TABLE OF PREMIUMS

PER 14-DAY PERIOD