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Group Dental Plan No. 301016: Personal & Dependent Dental Care

The benefits described below apply separately to you and each of your covered dependents for expenses incurred for necessary dental services.

Deductible Amount

Combined Type I and Type 2 Procedures - Once per Lifetime


Type 3 Procedures -Each Benefit Period



Benefit Percentage

Type I and Type 2 Procedures:


Step 1 


Step 2


Step 3


Step 4



Type 3 Procedures:


Step 1 


Step 2


Step 3


Step 4


The Benefit Percentage Steps will be determined as follows:

Step 1 applies during the first Benefit Period the person becomes covered.

If the person visits a dentist during each Benefit Period and has a dental procedure performed, Step 2 and 3 will apply during the second and third Benefit Period, respectively, and Step 4 will apply during each Benefit Period after.

If, during any Benefit Period, the person fails to visit a dentist to have a dental procedure performed, Step 1 will automatically reapply during the following Benefit Period, and the person must advance to Steps 2, 3 and 4 as if he or she were newly covered.

Exception: If, during any Benefit Period, the person has a break in continuous coverage of more than one month, Step 1 will reapply for the balance of that Benefit Period and the person must advance to Steps 2, 3 and 4 as if he or she were newly covered.


Maximum Amount Per Benefit Period



Orthodontic Expense Benefits

Deductible Amount


Benefit Percentage


Maximum Benefit During Lifetime


We will determine orthodontic expense benefits according to the terms of the group plan for orthodontic expenses incurred by a Member.

DETERMINING BENEFITS. The benefits payable will be determined by totaling all of the Covered Expenses submitted. This amount is reduced by the Deductible, if any. The result is then multiplied by the Benefit Percentage shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount shown in the Schedule of Benefits.

DEDUCTIBLE. The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered Expenses that must be incurred and paid by each Covered person prior to any benefits being paid.

MAXIMUM AMOUNT. The Maximum Benefit During Lifetime shown in the Schedule of Benefits is the maximum amount that may be paid for the Covered Expenses incurred by a Member during his or her lifetime.

COVERED EXPENSES. Covered Expenses refer to the usual and customary charges made by a provider for necessary orthodontic treatment rendered while the person is covered under this section. Expenses are limited to the Maximum Amount shown in the Schedule of Benefits and Limitations.

Usual and Customary (“U&C”) describes those dental charges that we have determined to be the usual and customary charge for a given dental procedure within a particular ZIP code area. The U&C is based upon a combination of dental charge information taken from our own database as well as from data received from nationally recognized industry databases. From the array of charges ranked by amount, your Planholder (in most cases your employer) has selected a percentile that will be used to determine the maximum U&C for your plan. The U&C is reviewed and updated periodically. The U&C can differ from the actual fee charged by your provider and is not indicative of the appropriateness of the provider’s fee. Instead, the U&C is simply a plan provision used to determine the extent of benefit coverage purchased by your Planholder.

ORTHODONTIC TREATMENT. Orthodontic Treatment refers to the movement of teeth by means of active appliances to correct the position of maloccluded or malpositioned teeth.

TREATMENT PROGRAM. Treatment Program ("Program") means an interdependent series of orthodontic services prescribed by a provider to correct a specific dental condition. A Program will start when the active appliances are inserted. A Program will end when the services are done, or after eight calendar quarters starting with the day the appliances were inserted, whichever is earlier.

EXPENSES INCURRED. Benefits will be payable when a Covered Expense is incurred:

a. at the end of every quarter (three-month period) of a Program for a Member who pursues a Program, but not beyond the date the Program ends; or

b. at the time the service is rendered for a Member who incurs Covered Expenses but does not pursue a Program.

The Covered Expenses for a Program are based on the estimated cost of the Member's Program. They are prorated by quarter (three-month periods) over the estimated length of the Program, up to a maximum of eight quarters. The last quarterly payment for a Program may be changed if the estimated and actual cost of the Program differ.

BENEFITS PAYABLE UPON TERMINATION. If coverage terminates during a Program quarter, the quarterly benefit payable for that quarter will be pro-rated by day for the period of time that coverage was in-force and fee was received.

LIMITATIONS. Covered Expenses will not include and benefits will not be payable for expenses incurred:

  1. for a Program begun before the Member became covered under this section.
  2. in the first 12 months that a person is covered if the person is a Late Entrant.
  3. in any quarter of a Program if the Member was not covered under this section for the entire quarter.
  4. if the Member's coverage under this section terminates.
  5. for which the Member is entitled to benefits under any workmen’s compensation or similar law, or for charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit.
  6. for charges the Member is not legally required to pay or would not have been made had no coverage been in force.
  7. for services not required for necessary care and treatment or not within the generally accepted parameters of care.
  8. because of war or any act of war, declared or not.
  9. To replace lost or stolen appliances.



FirstHealth of the Carolinas
Flexible Spending Account Claim Procedures

Medical Spending Account Claims are processed through PayFlex. ( 
Dependent Care Spending Account Claims are processed through Human Resources. You must submit a Dependent Care Spending Account Claim Form with documentation (listed below) to Human Resources. Checks are prepared on non-payroll Thursdays for claims received by Monday of that week.  
Documentation required for a Dependent Care Spending Account Claim: 

  • Name of the provider and recipient of the service.
  • The tax identification or social security number of the organization or individual providing the dependent care services.
  • The date(s) the care was received.
  • The total charge.

Eligible claims are paid in full when they are received, up to the maximum amount you have elected to deposit in your account for the calendar year. Remember, expenses reimbursed for health and dependent care can not be claimed on your tax return. 

Time Limits for Filing Claims:
 To be eligible for reimbursement, claims must be received by March 31st of the year following the calendar year the expenses are incurred. If you leave FirstHealth employment, you have 90 days to submit claims for expenses incurred prior to your last day of employment. 

Any balances remaining after expenses have been filed for the year are forfeited. These funds can not be paid to you, nor can they be carried over to the next year.



Matching Savings Plan
Matching Savings Plan 
The Matching Savings Plan is another means to accumulate savings for retirement. In this plan, employees voluntarily contribute to their account with Fidelity Investments,Inc., on a tax-deferred,payroll deduction basis. At year end, if the employee meets eligibility requirements, FirstHealth will match portions oft heir contributions based on their salary and length of service.

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The Matching Savings Plan uses tax-deferred contributions as a means for employees to accumulate additional savings for retirement.

How the Plan Works
Employees are eligible to contribute to the plan as soon as they receive their first pay check. As a participant in the plan, employees may save up to 20% of their annual income (or less if IRS maximum contributions apply) on a pretax basis. Pretax means that the money contributed will come out of the paycheck before income taxes are deducted. This actually reduces income taxes while saving for retirement.

When the employee contributes to the plan, FirstHealth will also contribute to the plan at the end of each year. FirstHealth will match up to 4% of annual compensation. This matching contribution will depend on the employee’s contribution amount and eligible years of service. The chart below shows the matching percentages contributed by FirstHealth based on eligible years of service.

In order to have FirstHealth match employee savings in any given year, the employee must:

  • Have completed at least one calendar year of service with FirstHealth;
  • Have received pay for at least 1,000 hours of service during that calendar year; &
  • Be actively employed by FirstHealth for the entire calendar year.

If the employee retires, becomes disabled or dies before the end of the year, the contribution will still be made to the employee’s account for that year.

When an employee participates in the plan, they choose how their savings are invested. FirstHealth offers several investment options from which to select. Savings earn tax-deferred income, providing additional growth and tax savings. No taxes are due on the money saved or earned until that money is paid to the employee.

Access to Plan Benefits
The employee is always fully vested in the amount in the plan account. Because contributions are made on a pretax basis, there are certain IRS regulations, restrictions and tax implications regarding loans or withdrawals.

When you add up the benefits of the FirstHealth retirement program, you will see that the bottom line is valuable retirement income.

  • The Retirement Growth Plan provides FirstHealth paid retirement benefits through annual and discretionary contributions.
  • The Matching Savings Plan allows employees the opportunity to save for their own future and enjoy tax savings and FirstHealth contributions at the same time.
  • Social Security provides regular income in retirement. 

Years of Service
1 to 4 
5 to 9 
10 to 14
15 to 24
20 to 24
25 or more

50% of your contribution 
60% of your contribution 
70% of your contribution 
80% of your contribution 
90% of your contribution
100% of your contribution



Retirement Benefits Summary
Retirement Growth Plan
The Retirement Growth Plan allows you to accumulate contributions in a special account administered by Fidelity Investments, Inc..

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The Retirement Growth Plan provides retirement income for eligible employees.

How the Plan Works
The Retirement Growth Plan allows eligible employees to accumulate FirstHealth contributions in a special account to be used for retirement. FirstHealth contributes to the employee’s account,an amount based on the employee’s pay and FirstHealth’s performance. There are two parts tothe FirstHealth contribution:

  • Annual plan contribution, and
  • Discretionary contribution

The annual plan contribution is an amount equal to 1% of the employee’s annual earnings. This will be added to the employee’s Retirement Growth Plan account at the end of each year. In addition, the employee may receive a discretionary contribution from FirstHealth based on the organization’s performance for that year.

In order to be eligible for the annual and the discretionary FirstHealth contributions in any given year, an employee must:

  • Have completed at least one calendar year of service with FirstHealth;
  • Have received pay for at least 1,000 hours of service during that calendar year; &
  • Be actively employed by FirstHealth for the entire calendar year.

If the employee retires, becomes disabled or dies before the end of the year, the contribution will still be made to their account for that year.

Eligible employees have several options for investing the contributions in their Retirement Growth Plan account. Investment earnings are tax-deferred, so that no taxes are paid on the money in the account until that money is paid to the employee.

Access to Plan Benefits
Because the Retirement Growth Plan is designed to provide retirement income, there are certain restrictions on receiving plan benefits. The employee (or their beneficiary) will receive the benefit when the employee retires, becomes disabled or dies. If employment is terminated for any other reason, the employee will receive only the vested portion of their plan account. Vesting is earned in the Retirement Growth Plan based on eligible years of service with FirstHealth.


Years of Service


Social Security
FirstHealth will match the federal government’s mandatory employee Social Security contribution.

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The Social Security program is an important part of every employee’s total retirement income.During their working career, every employee will contribute to Social Security benefits through the FICA tax deducted automatically from their pay. In addition, FirstHealth pays an equal amount toward Social Security benefits each year on behalf of each employee.

Social Security not only provides a regular monthly income during retirement, it also provides for disability benefits, survivor benefits and health care benefits through Medicare.



Short Term Disability Plan

The following is a summary of the voluntary Short Term Disability Plan offered to FirstHealth employees through pre-tax payroll deduction. Employees applying for coverage during the initial eligibility may apply for coverage without being subject to pre-existing conditions. Employees applying for coverage beyond their initial eligibility date must complete an Evidence of Insurability form in addition to their application.

Definitions of Disability
In order for an employee to be considered disabled, he/she must not be able to perform his/her job, nor be doing any work for payment, as a result of an injury or sickness. The employee must be under the regular care of a Physician

Weekly Income Benefits are not paid for any period of disability caused by:

  • An intentionally self-inflicted injury
  • An act of war, declared or undeclared
  • The Insured's commission of a felony
  • Sickness or injury which is covered by a Workers' Compensation Act or other workers' disability law

Benefits Summary

Benefit Amount

60% of weekly base salary

Maximum Benefit

$1,200 per week

Waiting Period

8th day of disability

Benefit Duration

16 Weeks

Note: This Summary of Benefits is provided for general information purposes only. Please refer to the Certificate of Insurance for a complete explanation of plan benefits and eligibility requirements

Hourly Weekly Weekly Pay Period  
Base Rate Base Rate Benefit Deduction  
 $      7.00  $   280.00  $   168.00  $        6.59  
 $      8.00  $   320.00  $   192.00  $        7.53  
 $      9.00  $   360.00  $   216.00  $        8.47  
 $    10.00  $   400.00  $   240.00  $        9.42  
 $    11.00  $   440.00  $   264.00  $      10.36  
 $    12.00  $   480.00  $   288.00  $      11.30  
 $    13.00  $   520.00  $   312.00  $      12.24  
 $    14.00  $   560.00  $   336.00  $      13.18  
 $    15.00  $   600.00  $   360.00  $      14.12  
 $    16.00  $   640.00  $   384.00  $      15.06  
 $    17.00  $   680.00  $   408.00  $      16.01  
 $    18.00  $   720.00  $   432.00  $      16.95  
 $    19.00  $   760.00  $   456.00  $      17.89  
 $    20.00  $   800.00  $   480.00  $      18.83  
 $    50.00  $2,000.00  $1,200.00  $      47.08 Maximum

Current Hourly Base Rate

$__________ A

Weekly Base Rate (A x 40)

$__________ B

Weekly Benefit (B x 0.60)

$__________ C

Premium Factor


Pay Period Deduction (C x D)

$__________ E



FirstHealth Outpatient Pharmacy

Employees and dependents covered under FirstHealth's medical insurance with FirstCarolinaCare Insurance Company are eligible for discounts on prescriptions* filled at the FirstHealth Outpatient Pharmacy.

The FirstHealth Outpatient Pharmacy also offers dozens of over-the-counter medications such as Tylenol, Motrin and Claritin for less than you will pay in most area drug stores and supermarkets!

The Outpatient Pharmacy offers delivery services available at RMH & MMH as well as convenient payment options:

  • Cash
  • Check
  • Mastercard/Visa
  • Flexible Spending Account Card
  • Payroll deductions - Must present badge for payroll deductions

To transfer a prescription, complete the Rx transfer form.


FirstHealth Outpatient Pharmacy

(In-network provider)

(Out-of-network provider)




Not covered




Not covered


* This includes new and refill prescriptions.


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