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Dental Program Detailed Table of Contents
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Table of Contents
Detailed Table of Contents
Index

Introduction

Who Is Eligible

Glossary of Key Terms – Eligibility

General Information

Your Eligible Dependents

Extended Coverage for Full-Time Status Students Age 19 and Older

Extended Coverage for Disabled Children

Qualified Medical Child Support Order (QMCSO)

If You Are Reemployed

For Employees of New Participating Subsidiaries and/or Participating Employers

Enrolling for Coverage

General Information

Your Contributions

Enrolling Yourself and Your Eligible Dependents

When Coverage Begins

Adding Dependents

If You Are Not Actively at Work

If You Do Not Enroll by the Deadline

Qualified Status Changes

Special Enrollment Opportunities

Significant Cost or Coverage Change

Annual Enrollment

Your Rights and Responsibilities

General Information

Your Rights

Your Responsibilities

How the Program Works

Glossary of Key Terms – CIGNA Dental PPO Options

General Information

Key Features

Passive PPOs

Deductibles

Coinsurance

Annual Maximum

Orthodontic Lifetime Maximum

Pretreatment Review

A Summary Chart of the CIGNA Dental PPO Options

What Is Covered – CIGNA Dental PPO Options

Class I: Preventive and Diagnostic Services

Class II: Basic Services

Class III: Major Services

Class IV: Orthodontic Services

What Is Not Covered – CIGNA Dental PPO Options

How to File a Claim

General Information

Program Claims

When Coverage Ends

General Information

Extension of Benefits

If You Leave the Company, Retire, or Are No Longer Eligible for Coverage

If Your Employee Group Goes on Strike

Special Extensions of Coverage

General Information

During a Leave of Absence

Uniformed Services Employment and Reemployment Rights Act of 1994

If You Receive Disability Benefits

Your Legal Right to Continuation Coverage Under COBRA

General Information

Notification

Election Procedure

Disability Extension

Other Extension

Payment

When Continuation Coverage Ends

Trade Act Implications

Coordinating Benefits With Other Programs

General Information

How Coordination of Benefits Works

Claims and Appeals Procedures

General Information

Procedure for Filing a Claim

Defective Claims

Initial Claim Review

Initial Benefit Determination

Claim Involving Urgent Care

Concurrent Care Decision

Pre-Service Claim

Post-Service Claim

Manner and Content of Notification of Denied Claim

Review of Initial Benefit Denial

Procedure for Filing an Appeal of a Denial

Review Procedures for Denials

Timing of Notification of Benefit Determination on Review

Manner and Content of Notification of Benefit Determination on Review

Legal Action

Situations Affecting Your Benefits

General Information

Right of Recovery

Right to Reimbursement, Assignment of Rights, and Duty to Notify

Right to Reimbursement

Assignment of Rights

Duty to Notify

If the Group Benefits Plan Is Modified or Ended

Administrative and Contact Information

General Information

Type of Plan

Plan Sponsor

Employer Identification Number of Plan Sponsor

Plan Name and Number

Plan Year End

Agent for Service of Legal Process

Benefits Committee and Plan Administrator

Eligibility Administration

Claims Administrator

Claims Administrator for Eligibility Claims

COBRA Administrator for Continuation Coverage

Allocation and Delegation of Fiduciary Responsibilities by the Benefits Committee

Trust and Insurance

Self-Funded Benefits

Your ERISA Rights

General Information

Receive Information About Your Program and Benefits

Continue Group Health Plan Coverage

Prudent Actions by Plan Fiduciaries

Enforce Your Rights

Assistance With Your Questions

Dental Program

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Introduction

Dental care is an integral part of your and your covered eligible dependents’ overall wellness. The dental options available under the R.R. Donnelley & Sons Company Group Benefits Plan (“Group Benefits Plan”) enable you to select the level of coverage and cost that best meet your needs. These options offer you and your eligible dependents coverage for such dental services as routine exams, X-rays, oral surgery, and fillings.

Your Dental Program options are listed in your enrollment information. As long as you are eligible, you can elect coverage under one of the following two PPO coverage options:

CIGNA Dental PPO; and

CIGNA Dental PPO Plus.

For Department of Labor (DOL) filing purposes, several R.R. Donnelley & Sons Company (“RR Donnelley”) welfare benefit programs, combined, make up the Group Benefits Plan. Generally, each welfare program under the Group Benefits Plan is described in a separate Summary Plan Description (SPD).

You pay the full cost of dental coverage under the Program for you and your covered eligible dependents. Your cost is based on the coverage option and coverage category you elect. Therefore, it is important that you know how the Program works. Become an informed consumer of dental services, read all of the benefits information available, and ask questions so that you can make coverage decisions that are best for you and your family.

This SPD summarizes the Dental Program. It explains your coverage as of January 1, 2006 (unless noted otherwise). It details who is eligible for coverage, when coverage begins and ends, and which expenses are and are not covered under the Program. It also describes how to file a claim and your rights under the Program. Please read this information to familiarize yourself with your coverage.

CIGNA HealthCare (CIGNA) is the claims administrator and network manager for the Program. CIGNA and Connecticut General Life Insurance Company are subsidiaries of CIGNA Corporation.

You are eligible for coverage under the Program only if you are an employee of a participating employer or subsidiary. If you are an employee of an employer or subsidiary that does not participate in the Group Benefits Plan, you are not eligible for the benefits described in this SPD. To find out if you are eligible for these benefits, contact the eligibility administrator.

This SPD and any supplemental information attempt to be as complete, accurate, and up-to-date a description as possible of your coverage under the Program. However, since treatments and practices continually change, this document cannot adequately define every potentially covered service or exclusion. In the event of such circumstances, the claims administrator will make the determination of covered services. If there is any discrepancy between this SPD versus the Group Benefits Plan, the actual Group Benefits Plan document always governs.

In addition, nothing in this SPD should be interpreted as an employment contract. This summary merely describes the coverage offered to eligible employees as of January 1, 2006. RR Donnelley reserves the right to change or terminate the Group Benefits Plan or Program in whole or in part, at any time.

This content contains a summary in English of your rights and benefits under the Program. If you have difficulty understanding any part of this content, call the RR Donnelley Benefits Center at 1-877-RRD-4BEN (1-877-773-4236). Benefits Center Representatives are available between the hours of 8 a.m. and 5 p.m. CT, Monday through Friday, except holidays.

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