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APPENDIX "C" ORTHODONTIC BENEFIT RIDER In consideration of the payments specified in paragraph 3.01 of the attached Contract, and subject to all of the terms and conditions thereof, except as herein otherwise specified, CDS agrees to provide Orthodontic Benefits to eligible dependent children, as follows. 1. Orthodontics are defined as the procedures performed by a licensed Dent[st, involving the use of an active orthodontic appli- ance and post-treatment retentive appliances for treatment of malalignment of teeth and/or jaws which significantly interferes with their function. 2. CDS will pay or otherwise discharge 6 0 % of the lesser of the Usual, Customary and Reasonable fees or the fees actually char~e(~ for Orthodontics, provided that the amount payable to a Dentist who is not a Participating Dentist shall not exceed % of the amounts for the corresponding services set forth in the Orthodontic Table of Allowances, a copy of which is attached hereto, marked Exhibit 1 and incorporated herein by reference. All payments shall be on a monthly or periodic basis, in accordance with the Dentist's normal billing practice. 3. The maximum amount payable by CDS for all Orthodontics rendered to each eligible dependent child shall be $ R CI (~ _ [') ~ , and the limitations on maximum amounts payable during a calendar year, if any, specified in the attached Agreement, shall not apply to Orthodontics. 4. EXCLUSIONS AND LIMITATIONS: In addition to the Exclusions and Limitations stated in Article IV to the attached Contract, the following exclusions and limitations shall apply to Orthodontic Benefits: (a) The obligation of CDS to make monthly or other periodic payments for an Orthodontic treatment plan begun prior to the eligibility date of the patient shall commence with the first payment due following the patient's eligibility date. The above-mentioned maximum amount payable will apply fully to this and subsequent payments. (b) The obligation of CDS to make monthly or other periodic payments for Orthodontics shall terminate on the payment due date next following the date the dependent child loses eligibility or the employee loses eligibility, or upon termina- tion of treatment for any reason prior to completion of the case, or on the termination of the Contract, whichever shall occur first. (c) COS will not make any payment for repair or replacement of an Orthodontic appliance furnished, in whole or in part, under this program. (d) X-rays and extraction procedures incident to Orthodontics are not covered by Orthodontic Benefits, but may be covered under the provisions of the attached Contract, subject to all of the terms and provisions thereof. (e} Surgical procedures for correct[on of malalignment of teeth and/or jaws are not covered. DATED: March 1, 1978 CALIFORNIA DENTAL SERVICE ~SS'T. VICE PRE~ENT/OPERATI$~ 11-77 O.R.