DENTAL BENEFIT PROGRAM SUMMARY

Effective January 1, 2018

DELTA DENTAL PPO PLUS PREMIER - COMPREHENSIVE ENHANCED

Best Buy Co., Inc.

Delta Group Number 50602

BEST BUY DENTAL BENEFIT PROGRAM SUMMARY

This is a Summary of the Best Buy Dental Benefit Program (the "PROGRAM") Sponsored by Best Buy Co., Inc. ("BEST BUY")

for Eligible Employees (and their Eligible Dependents) of Best Buy Co., Inc. and some of its Affiliates

(the "EMPLOYER GROUP")

This Program has been established and is maintained and administered in accordance with the provisions of Group Dental Plan Contract Number 50602 (the "CONTRACT") issued by Delta Dental of Minnesota (“DELTA”) to Best Buy Enterprise Services, Inc, a subsidiary of Best Buy.

IMPORTANT This Summary is subject to the provisions of the Contract and cannot modify the Contract in any way; nor shall you accrue any rights because of any statement in or omission from this Summary.

DELTA DENTAL OF MINNESOTA

Administrative Offices National Dedicated Service Center

P.O. Box 59238 Minneapolis, Minnesota 55459

(651) 406-5939 or (866) 264-0528 www.deltadentalmn.org

TABLE OF CONTENTS

SUMMARY PLAN DESCRIPTION ................................................................................................................................ 1 

IMPORTANT INFORMATION ABOUT THIS PROGRAM AND THE BEST BUY HEALTH AND WELFARE WRAP PLAN .................................................................................................................................................................... 1 

ELIGIBILITY ..................................................................................................................................................................... 2 

SUMMARY OF DENTAL BENEFITS ........................................................................................................................... 3 

PREVENTIVE OPTION ......................................................................................................................................... 3 COMPREHENSIVE OPTION .................................................................................................................................. 3 COVERAGE YEAR .............................................................................................................................................. 4 

DESCRIPTION OF COVERED PROCEDURES ........................................................................................................ 4 

PRETREATMENT ESTIMATE ................................................................................................................................ 4 BENEFITS .......................................................................................................................................................... 5 EXCLUSIONS ................................................................................................................................................... 13 LIMITATIONS .................................................................................................................................................... 14 POST PAYMENT REVIEW .................................................................................................................................. 14 OPTIONAL TREATMENT PLANS ......................................................................................................................... 14 TERMINATION OF COVERAGE ........................................................................................................................... 15 CONTINUATION OF COVERAGE (INCLUDING COBRA) ........................................................................................ 15 TERMINATING CONTINUATION OF COVERAGE .................................................................................................... 15 

PROGRAM PAYMENTS .............................................................................................................................................. 15 

PARTICIPATING DENTIST NETWORK .................................................................................................................. 15 COVERED FEES ............................................................................................................................................... 16 CLAIM PAYMENTS ............................................................................................................................................ 16 COORDINATION OF BENEFITS (COB) ................................................................................................................ 17 ASSIGNMENT OF BENEFITS .............................................................................................................................. 17 CLAIM AND APPEAL PROCEDURES .................................................................................................................... 17 CANCELLATION OF DELTA CONTRACT ............................................................................................................... 20 

STANDARD PROVISIONS .......................................................................................................................................... 20 

CHANGE OR TERMINATION OF PROGRAM BENEFITS ........................................................................................... 20 AUTHORITY TO INTERPRET PROGRAM ............................................................................................................... 20 WAIVER AND ESTOPPEL ................................................................................................................................... 20 

RIGHT OF RECOVERY PROVISION ........................................................................................................................ 20 

GENERAL INFORMATION ......................................................................................................................................... 21 

DELTA INVOLVEMENT ....................................................................................................................................... 21 DELTA’S PRIVACY NOTICE................................................................................................................................ 21 HOW TO FIND A PARTICIPATING DENTIST .......................................................................................................... 21 USING YOUR DENTAL PROGRAM ...................................................................................................................... 22 CONTRACT CANCELLATION AND RENEWAL ........................................................................................................ 22 

EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) .......................................................................... 22 

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SUMMARY PLAN DESCRIPTION

A copy of this Summary Plan Description (the "Summary"), any future Summaries of Material Modifications to this Summary, and any new Summary replacing this Summary, are available in electronic form by following www.mybbyrewards.com>Health & Insurance> Learn About> Plan Information. If you have any questions regarding the information contained in this Summary, contact Delta Dental’s Best Buy dedicated Customer Service Center at 1-866-264-0528 to reach a representative who can help you.

In addition, for any eligible employee who can read and print (free of charge) any documents received in electronic form on a computer at his or her individual work station, Best Buy may deliver electronic copies of any future Summaries of Material Modifications to this Summary, and any new Summary replacing this Summary, directly by e-mail to that computer or by posting the documents on a web page that can be found by following >Health & Insurance> Learn About> Plan Information. If Best Buy delivers any such document to an eligible employee in any of those ways, Best Buy will also send him or her a written or electronic notice describing the document, its importance and the eligible employee's right to obtain a paper copy of the electronic document free of charge, by requesting the paper copy from the Benefits Center at 1-866-475-6733 (and following the prompts to connect with the benefits administrator).

IMPORTANT INFORMATION ABOUT THIS PROGRAM AND THE BEST BUY HEALTH AND WELFARE WRAP PLAN The following information is provided as required by the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). THIS PROGRAM, THE BEST BUY HEALTH AND WELFARE WRAP PLAN AND THEIR ADMINISTRATION

The name of this Program is the Best Buy Dental Benefit Program. This Program is part of the Best Buy Health and Welfare Plan sponsored by the Plan Sponsor (the "BEST BUY HEALTH AND WELFARE WRAP PLAN" or sometimes the "PLAN"). The Plan includes several group benefit programs and a Flexible Spending Program that allows you to pay your share of the cost of this Program and other benefit programs by making pre-tax contributions from your paychecks. PLAN SPONSOR (sometimes called "BEST BUY"):

Best Buy Co., Inc. Best Buy Corporate Campus 7601 Penn Ave. South Richfield, MN 55423-3645 Telephone: (612) 291-1000 EMPLOYER GROUP

In this Summary, the Plan Sponsor and the other employers participating in this Program are called the "EMPLOYER GROUP." The Employer Group includes the Plan Sponsor and any of its Affiliates participating in this Program with the consent of the Plan Sponsor's Board of Directors. For this purpose, “AFFILIATE" means any subsidiary, corporation, partnership or other organization in which the Plan Sponsor owns, directly or indirectly, a controlling interest.

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A complete list of the Employer Group members participating in this Program at any time may be obtained by Enrolled Employees and other Covered Persons on written request to the Plan Administrator. That list is also available for examination by those individuals.

PLAN ADMINISTRATOR:

Best Buy Co., Inc. Best Buy Corporate Campus 7601 Penn Ave. South Richfield, MN 55423-3645 Telephone: (612) 291-1000 AGENT FOR SERVICE OF LEGAL PROCESS:

General Counsel c/o Best Buy Co., Inc. Best Buy Corporate Campus 7601 Penn Ave. South Richfield, MN 55423-3645 Telephone: (612) 291-1000 The General Counsel of the Plan Sponsor is the person designated as agent for the service of legal process on the Program, as part of the Plan. EMPLOYER IDENTIFICATION NUMBER: 41-0907483 (for the Plan Sponsor) EMPLOYER PLAN NUMBER: 501 (for the Plan, including this Dental Benefit Program and each other included benefit program) PLAN TYPE: This Program is a group dental care benefit program, which is a part of the Plan Sponsor's health and welfare benefit plan called the Best Buy Health and Welfare Wrap Plan.

FUNDING: This Program is a self-funded portion of the Plan. Your contribution towards the cost of coverage under this Program will be determined by the Employer Group each year and communicated to you prior to the effective date of any changes in the cost of the coverage.

DELTA CONTRACT NUMBER: 50602 PROGRAM BENEFITS ARE ADMINISTERED UNDER A CONTRACT BETWEEN BEST BUY ENTERPRISES, INC., A MEMBER OF THE EMPLOYER GROUP, AND:

DELTA DENTAL OF MINNESOTA National Dedicated Service Center P.O. Box 59238 Minneapolis, Minnesota 55459 Telephone: (651) 406-5939 or (866) 264-0528 www.deltadentalmn.org ELIGIBILITY This Dental Program Benefit Summary (“Benefits Description”) summarizes the benefits available under this program, but does not describe other important information about the program. The Best Buy Health and Welfare Wrap Plan Document and Summary Plan Description, the “Booklet”, also contains important information about this program, including eligibility, COBRA continuation coverage, and legal rights under

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ERISA. The Booklet can be found at >Health & Insurance> Learn About> Plan Information. This Benefits Description, along with the Booklet is the summary plan description for this program and is a component of the plan document for the Best Buy Health and Welfare Wrap Plan. SUMMARY OF DENTAL BENEFITS

After you have satisfied the deductible, if any, your Program pays the following percentages of the treatment cost, up to a maximum fee per procedure. The maximum fee allowed by Delta is different for Delta Dental PPO dentists, participating dentists and nonparticipating dentists. If you see a nonparticipating dentist, your out-of-pocket expenses may increase. PREVENTIVE OPTION: Delta Dental Delta Dental PPO Premier Diagnostic and Preventive Service ................................... 100% 100% Basic Service ......................................................... 60% 60% Benefit Maximums

The Program pays up to a maximum of $750.00 for each Covered Person per Coverage Year subject to the coverage percentages identified above. Benefit Maximums may not be carried over to future coverage years. Deductible

There is no deductible under this option. COMPREHENSIVE OPTION: Delta Dental Delta Dental PPO Premier Diagnostic and Preventive Service ................................... 100% 100% Basic Service ......................................................... 80% 80% Endodontics ......................................................... 80% 80% Periodontics ......................................................... 80% 80% Oral Surgery ......................................................... 80% 80% Major Restorative Services ................................................. 50% 50% Prosthetic Repairs and Adjustments ................................... 80% 80% Prosthetics ......................................................... 50% 50% Orthodontics ......................................................... 50% 50% Benefit Maximums

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The Program pays up to a maximum of $1,500.00 for each Covered Person per Coverage Year subject to the coverage percentages identified above. Benefit Maximums may not be carried over to future coverage years. A lifetime limit applies to Orthodontics, as explained in the following paragraph. Orthodontics treatment is subject to a separate lifetime maximum of $1,500.00 per Covered Dependent Child, or $1,000 for each other Covered Person; and is limited to those orthodontic treatment plans commenced on or after the Covered Person’s eighth (8th) birthday. The determination of whether you qualify for the $1,500 or $1,000 lifetime maximum is based on the Covered Person’s age at the time of the first banding. If the Covered Person is a Dependent Child and banding occurs before the child turns age 19, the Dependent Child will qualify for the $1,500 lifetime maximum. If the Covered Person is age 19 or older at the time of first banding, the Covered Person will be limited to the $1,000 lifetime maximum. Because orthodontic treatment normally occurs over a long period of time, benefit payments are made over the course of treatment. The Covered Person must remain eligible under the Program in order to receive continued benefit payments. Deductible

There is a $50.00 deductible per Covered Person each Coverage Year not to exceed two (2) times that amount ($100.00) per Family Unit. The deductible does not apply to Diagnostic and Preventive or Orthodontic Services. COVERAGE YEAR

A Coverage Year is a 12-month period in which deductibles and benefit maximums apply. Your Coverage Year is January 1 to December 31. PLAN YEAR

The fiscal records of the Program are maintained on the basis of the Plan Year, which is a twelve-month period ending each on December 31. DESCRIPTION OF COVERED PROCEDURES PRETREATMENT ESTIMATE

(Estimate of Benefits) IT IS RECOMMENDED THAT A PRETREATMENT ESTIMATE BE SUBMITTED TO DELTA PRIOR TO TREATMENT IF YOUR DENTAL TREATMENT INVOLVES MAJOR RESTORATIVE, PERIODONTICS, PROSTHETICS OR ORTHODONTIC CARE (SEE DESCRIPTION OF COVERAGES), TO ESTIMATE THE AMOUNT OF PAYMENT. THE PRETREATMENT ESTIMATE IS A VALUABLE TOOL FOR BOTH THE DENTIST AND THE PATIENT. SUBMISSION OF A PRETREATMENT ESTIMATE ALLOWS THE DENTIST AND THE PATIENT TO KNOW WHAT BENEFITS ARE AVAILABLE TO THE PATIENT BEFORE BEGINNING TREATMENT. THE PRETREATMENT ESTIMATE WILL OUTLINE THE PATIENT’S RESPONSIBILITY TO THE DENTIST WITH REGARD TO CO-PAYMENTS, DEDUCTIBLES AND NON-COVERED SERVICES AND ALLOWS THE DENTIST AND THE PATIENT TO MAKE ANY NECESSARY FINANCIAL ARRANGEMENTS BEFORE TREATMENT BEGINS. THIS PROCESS DOES NOT PRIOR AUTHORIZE THE TREATMENT NOR DETERMINE ITS DENTAL OR MEDICAL NECESSITY. THE ESTIMATED DELTA DENTAL PAYMENT IS BASED ON THE PATIENT’S CURRENT ELIGIBILITY AND CURRENT AVAILABLE CONTRACT BENEFITS. THE SUBSEQUENT SUBMISSION OF OTHER CLAIMS, A CHANGE IN ELIGIBILITY, A CHANGE IN THE CONTRACT COVERAGE OR THE EXISTENCE OF OTHER COVERAGE MAY ALTER THE DELTA DENTAL FINAL PAYMENT AMOUNT AS SHOWN ON THE PRETREATMENT ESTIMATE FORM.

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After the examination, your dentist will establish the dental treatment to be performed. If the dental treatment necessary involves major restorative, periodontics, prosthetics or orthodontic care, a participating dentist should submit a claim form to Delta outlining the proposed treatment. A Pretreatment Estimate of Benefits statement will be sent to you and your dentist. You will be responsible for payment of any deductibles and coinsurance amounts or any dental treatment that is not considered a covered service under the Program. BENEFITS

The Program covers the following dental procedures when they are performed by a licensed dentist and when necessary and customary as determined by the standards of generally accepted dental practice. The benefits under this Program shall be provided whether the dental procedures are performed by a duly licensed physician or a duly licensed dentist, if otherwise covered under this Program, provided that such dental procedures can be lawfully performed within the scope of a duly licensed dentist. As a condition precedent to the approval of claim payments, Delta shall be entitled to request and receive, to such extent as may be lawful, from any attending or examining dentist, or from hospitals in which a dentist's care is provided, such information and records relating to a Covered Person as may be required to pay claims. Also, Delta may require that a Covered Person be examined by a dental consultant retained by the Program in or near the Covered Person's place of residence. The Program shall hold such information and records confidential. TO AVOID ANY MISUNDERSTANDING OF BENEFIT PAYMENT AMOUNTS, ASK YOUR DENTIST ABOUT HIS OR HER NETWORK PARTICIPATION STATUS WITHIN YOUR DELTA DENTAL PPO AND DELTA DENTAL PREMIER NETWORKS PRIOR TO RECEIVING DENTAL CARE. Delta does not determine whether a service submitted for payment or benefit under this Dental Benefit Program is a dental procedure that is dentally necessary to treat a specific condition or restore dentition for an individual. Delta evaluates dental procedures submitted to determine if the procedure is a covered benefit under your Program. Your Program includes a preset schedule of dental services that are eligible for coverage by the Program. Other dental services may be recommended or prescribed by your dentist, which are dentally necessary, offer you an enhanced cosmetic appearance, or are more frequent than covered by the Program. While these services may be prescribed by your dentist and are dentally necessary for you, they may not be a dental service that is covered under this Program or they may be a service where the Program provides a payment allowance for a service that is considered to be optional treatment. If the Program gives you a payment allowance for optional treatment that is covered by the Program, you may apply this payment allowance to the service prescribed by your dentist which you elected to receive. Services that are not covered by the Program or exceed the frequency of Program benefits do not imply that the service is or is not dentally necessary to treat your specific dental condition. You are responsible for dental services that are not covered or benefited by the Program. Determination of services necessary to meet your individual dental needs is between you and your dentist. ONLY those services listed are covered. Deductibles and maximums are listed under the Summary of Dental Benefits. Services covered are subject to the limitations within the Benefits, Exclusions and Limitations sections described below. For estimates of covered services, please see the “Pretreatment Estimate” section of this booklet. PREVENTIVE CARE - Available under Comprehensive Option and Preventive Option (Diagnostic & Preventive Services) Oral Evaluations - Any type of evaluation (checkup or exam) is covered 2 times per calendar year.

NOTE: Comprehensive oral evaluations will be benefited 1 time per dental office, subject to the 2 times per calendar year limitation. Any additional comprehensive oral evaluations performed by the

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same dental office will be benefited as a periodic oral evaluation and will be subject to the 2 times per calendar year.

Radiographs (X-rays) Bitewings- Covered at 1 series of bitewings per 12-month period. Full Mouth (Complete Series) or Panoramic – Covered 1 time per 24-month period. Periapical(s) – single X-rays Occlusal – Covered at 1 series per 12-month period. Dental Cleaning

Prophylaxis Maintenance – Covered 2 times per calendar year.

Prophylaxis is a procedure to remove plaque, tartar (calculus), and stain from teeth.

NOTE: A prophylaxis performed on a Covered Person under the age of 14 will be benefited as a child prophylaxis. A prophylaxis performed on a Covered Person age 14 or older will be benefited as an adult prophylaxis.

Periodontal Maintenance – Covered no more than 4 times per 12-month period Periodontal Maintenance is a procedure that includes removal of bacteria from the gum pocket areas, scaling and polishing of the teeth, periodontal evaluation and gum pocket measurements for patients who have completed periodontal treatment.

Fluoride Treatment (Topical application of fluoride) - Covered 1 time per calendar year for covered Dependent Children through the age of 14. Oral Hygiene Instructions - Instructions which include tooth-brushing techniques, flossing and use of oral hygiene aids are covered 1 time per lifetime. Sealants or Preventive Resin Restorations - Any combination of these procedures is covered 1 time per 4 years for permanent first and second molars of covered Dependent Children from the age of six (6) up through age seventeen (17) years. BASIC SERVICES – Available under Comprehensive Option and Preventive Option

Emergency Treatment - Emergency (palliative) treatment for the temporary relief of pain or infection. Emergency oral examinations Amalgam (silver) Restorations – Treatment to restore decayed or fractured permanent or primary teeth. Composite (white) Resin Restorations

Anterior (front) Teeth - Treatment to restore decayed or fractured permanent or primary anterior teeth.

Posterior (back) Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back) teeth

LIMITATION: Coverage for amalgam or composite restorations will be limited to only 1 service per tooth surface per 24-month period.

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Space Maintainers - Covered 1 time per lifetime on covered Dependent Children through the age of 16 for extracted primary posterior (back) teeth.

LIMITATION: Repair or replacement of lost/broken appliances is not a covered benefit. Other Basic Services Restorative cast post and core build-up, including pins and posts. See benefit coverage

description under Complex or Major Restorative Services. Pre-fabricated or Stainless Steel Crown. Covered 1 time per 24-month period for covered

Dependent Children through the age of 18. Therapeutic drug injections. Adjunctive General Services Intravenous Conscious Sedation and IV Sedation – Covered when performed in conjunction with

complex surgical service.

LIMITATION: Intravenous conscious sedation and IV sedation will not be covered when performed with non-surgical dental care.

EXCLUSIONS – Coverage is NOT provided for:

1. Deep sedation/general anesthesia, analgesia, analgesic agents, anxiolysis nitrous oxide, medicines, or drugs for non-surgical or surgical dental care.

2. Case presentation and office visits.

3. Athletic mouthguard, enamel microabrasion, and odontoplasty.

4. Services or supplies that have the primary purpose of improving the appearance of the teeth. This includes, but is not limited to whitening agents, tooth bonding and veneers.

5. Placement or removal of sedative filling, base or liner used under a restoration.

6. Amalgam or composite restorations placed for preventive or cosmetic purposes. Basic Endodontic Services (Nerve or Pulp Treatment) - Available under Comprehensive Option only

Endodontic Therapy on Primary Teeth

Pulpal Therapy

Therapeutic Pulpotomy

Endodontic Therapy on Permanent Teeth

Root Canal Therapy

Apicoectomy

Root Amputation on posterior (back) teeth

Complex or other Endodontic Services

Apexification – For covered Dependent Children through the age of 16.

Retrograde filling

Hemisection, includes root removal

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LIMITATION: All of the above procedures are covered 1 time per tooth per lifetime.

EXCLUSIONS - Coverage is NOT provided for:

1. Retreatment of endodontic services that have been previously provided or paid for under the Program.

2. Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or non-resorbable filling material(s) and the procedures used to prepare and place material(s) in the canals (root).

3. Root canal obstruction, internal root repair of perforation defects, incomplete endodontic treatment and bleaching of discolored teeth.

4. Intentional reimplantation. Periodontics (Gum & Bone Treatment) - Available under Comprehensive Option only

Basic Non Surgical Periodontal Care – Treatment for diseases for the gingival (gums) and bone supporting the teeth.

Periodontal scaling & root planing - Covered 1 time per 24 months

Full mouth debridement-- Covered 1 time per lifetime

Complex Surgical Periodontal Care – Surgical treatment for diseases for the gingival (gums) and bone supporting the teeth. The following services are considered complex surgical periodontal services under this Program.

Gingivectomy/gingivoplasty

Gingival flap

Apically positioned flap

Bone replacement graft

Osseous Surgery

Pedicle soft tissue graft

Free soft tissue graft

Subepithelial connective tissue graft

Soft tissue allograft

Combined connective tissue and double pedicle graft

Distal/proximal wedge

LIMITATION: Only 1 complex surgical periodontal service is a benefit covered 1 time per 36-month period per single tooth or multiple teeth in the same quadrant.

EXCLUSIONS – Coverage is NOT provided for:

1. Bacteriologic tests for determination of periodontal disease or pathologic agents.

2. The controlled release of therapeutic agents or biologic materials used to aid in soft tissue and osseous tissue regeneration.

3. Provisional splinting, temporary procedures or interim stabilization of teeth.

4. Deep sedation/general anesthesia, analgesia, analgesic agents, anxiolysis nitrous oxide or drugs, or medicaments for non-surgical and surgical periodontal care, regardless of the method of administration.

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Oral Surgery (Tooth, Tissue, or Bone Removal) - - Available under Comprehensive Option only

Basic Extractions

Removal of Coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth

Extraction of erupted tooth or exposed root

Complex Surgical Extractions

Surgical removal of erupted tooth

Surgical removal of impacted tooth

Surgical removal of residual tooth roots

Other Complex Surgical Procedures

Oroantral fistula closure

Tooth reimplantation – accidentally evulsed or displaced tooth

Surgical exposure of impacted or unerupted tooth to aid eruption

Biopsy of oral tissue

Transseptal fiberotomy

Alveoloplasty

Vestibuloplasty

Excision of lesion or tumor

Removal or nonodontogenic or odontogenic cyst or tumor

Removal of exostosis

Partial ostectomy

Incision & drainage of abscess

Frenulectomy (frenectomy or frenotomy) LIMITATIONS

1. Reconstructive Surgery benefits shall be provided for reconstructive surgery when such dental procedures are incidental to or follows surgery resulting from injury, illness or other diseases of the involved part, or when such dental procedure is performed on a covered Dependent Child because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending physician, to the extent as required by Minnesota Statute 62A.25 provided, however, that such procedures are dental reconstructive surgical procedures.

2. Inpatient or outpatient dental expenses arising from dental treatment up to age 18, including

orthodontic and oral surgery treatment, involved in the management of birth defects known as cleft lip and cleft palate as required by Minnesota Statute section 62A.042.

For Program options without orthodontic coverage: Dental orthodontic treatment not related to the management of the congenital condition of cleft lip and cleft palate is not covered under this Program. For Program options with orthodontic coverage: If coverage for the treatment of cleft lip or cleft palate is available under any other policy or contract of insurance, this Program shall be primary and the other policy or contract shall be secondary.

EXCLUSIONS - Coverage is NOT provided for:

1. Intravenous conscious sedation and IV sedation when performed with non-surgical dental care.

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2. Deep sedation/general anesthesia, analgesia, analgesic agents, anxiolysis nitrous oxide, medicines, or drugs for non-surgical or surgical dental care, regardless of the method of administration.

3. Services or supplies that are medical in nature, including dental oral surgery services performed in a hospital.

4. Surgical exposure of impacted or unerupted tooth for orthodontic reasons.

5. Surgical repositioning of teeth.

6. Inpatient or outpatient hospital expenses

7. Cytology sample collection – Collection of oral cytology sample via scraping of the oral mucosa.

8. Temporomandibular Joint Disorder (TMJ). COMPLEX OR MAJOR RESTORATIVE SERVICES - Available under Comprehensive Option only Services performed to restore lost tooth structure as a result of decay or fracture

Gold foil restorations - Receive an amalgam (silver filling) benefit equal to the same number of surfaces and allowances. The patient must pay the difference in cost between the Program’s Payment Obligation for the covered benefit and the dentist’s submitted fee for the optional treatment, plus any coinsurance for the covered benefit. Inlays – Benefit shall equal an amalgam (silver) restoration for the same number of surfaces.

LIMITATION: If an inlay is performed to restore a posterior (back) tooth with a metal, porcelain, or any composite (white) based resin material, the patient must pay the difference in cost between the Program’s Payment Obligation for the covered benefit and the dentist’s submitted fee for the optional treatment, plus any coinsurance for the covered benefit.

Onlays – Covered 1 time per 5-year period per tooth. Permanent Crowns - Covered 1 time per 5-year period per tooth. Implant Crowns – See Prosthetic Services. Crown Repair – Covered 1 time per 12-month period per tooth. Crown Lengthening - Covered 1 time per 5-year period per tooth. Restorative cast post and core build-up, including 1 post per tooth and 1 pin per surface. Covered 1 time per 5-year period when done in conjunction with covered services.

Canal prep & fitting of preformed dowel & post

EXCLUSIONS – Coverage is NOT provided for:

1. Procedures designed to alter, restore or maintain occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

2. Services or supplies that have the primary purpose of improving the appearance of your teeth. This includes but is not limited to tooth whitening agents or tooth bonding and veneer covering of the teeth.

3. Placement or removal of sedative filling, base or liner used under a restoration.

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4. Temporary, provisional or interim crown.

5. Occlusal procedures including occlusal guard and adjustments. Prosthetic Services (Dentures, Partials, and Bridges) - Available under Comprehensive Option only Reline, Rebase, Repairs, Replacement of Broken Artificial Teeth, Replacement of Broken Clasp(s) – Covered when:

the prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance; and

only after 6 months following initial placement of the prosthetic appliance (denture, partial or bridge).

Adjustments – Covered 2 times per 12-month period:

when the prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance; and

only after 6 months following initial placement of the prosthetic appliance (denture, partial or bridge).

Removable Prosthetic Services (Dentures and Partials) – Covered 1 time per 5-year period;

for Covered Persons age 16 or older;

for the replacement of extracted (removed) permanent teeth;

if 5 years have elapsed since the last benefited removable prosthetic appliance (denture or partial) and the existing appliance needs replacement because it cannot be repaired or adjusted.

Fixed Prosthetic Services (Bridge) – Covered 1 time per 5-year period;

for Covered Persons age 16 or older;

for the replacement of extracted (removed) permanent teeth;

if none of the individual units of the bridge has been benefited previously as a crown or cast restoration in the last 5 years;

if 5 years have elapsed since the last benefited removable prosthetic appliance (bridge) and the existing appliance needs replacement because it cannot be repaired or adjusted.

Restorative cast post and core build-up, including pins and posts. Covered 1 time per 5-year period when done in conjunction with covered fixed prosthetic services.

Implant Coverage - Covered 1 time in 5-year period, for covered persons over the age of 16.

EXCLUSIONS – Coverage is NOT provided for:

1. The replacement of an existing partial denture with a bridge.

2. Interim removable or fixed prosthetic appliances (dentures, partials or bridges)

3. Pediatric removable or fixed prosthetic appliances (dentures, partials or bridges)

4. Additional, elective or enhanced prosthodontic procedures including but not limited to connector bar(s), stress breakers, and precision attachments.

5. Procedures designed to alter, restore or maintain occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

6. Services or supplies that have the primary purpose of improving the appearance of your teeth.

7. Placement or removal of sedative filling, base or liner used under a restoration.

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8. Coverage shall be limited to the least expensive professionally acceptable treatment. ORTHODONTICS - Available under Comprehensive Option only Treatment necessary for the prevention and correction of malocclusion of teeth and associated dental and facial disharmonies.

Limited Treatment Treatments which are not full treatment cases and are usually done for minor tooth movement. Interceptive Treatment A limited (phase I) treatment phase used to prevent or assist in the severity of future treatment. Comprehensive (complete) Treatment Full treatment includes all records, appliances and visits.

Removable Appliance Therapy – An appliance that is removable and not cemented or bonded to the teeth. Fixed Appliance Therapy – A component that is cemented or bonded to the teeth Other Complex Surgical Procedures

Surgical exposure of impacted or unerupted tooth for orthodontic reasons Surgical repositioning of teeth

LIMITATION: Treatment in progress (appliances placed prior to eligibility under this Program) will be benefited on a pro-rated basis. LIMITATION: Covered Persons must be 8 years of age or older. EXCLUSIONS – Coverage is NOT provided for:

1. Monthly treatment visits that are inclusive of treatment cost;

2. Repair or replacement of lost/broken/stolen appliances;

3. Orthodontic retention/retainer as a separate service;

4. Retreatment and/or services for any treatment due to relapse;

5. Inpatient or outpatient hospital expenses; and

6. Provisional splinting, temporary procedures or interim stabilization of teeth. Orthodontic Payments: Because orthodontic treatment normally occurs over a long period of time, benefit payments are made over the course of treatment. The Covered Person must have continuous eligibility under the Program in order to receive ongoing orthodontic benefit payments. Benefit payments are made in equal amounts: (1) when treatment begins (appliances are installed), and (2) at twelve month intervals thereafter, until treatment is completed or until the lifetime maximum benefits are exhausted (see Benefit Maximums in this Program Summary). Before treatment begins, the treating dentist should submit a Pre-treatment Estimate. An Estimate of Benefits form will be sent to you and your dentist indicating the estimated Program payment amount. This form serves as a claim form when treatment begins. When treatment begins, the dentist should submit the Estimate of Benefit form with the date of placement and his/her signature. After benefit and eligibility verification by the Program, a benefit payment will be

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issued. A new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve as the claim form to be submitted 6 months from the date of appliance placement. Exclusions Coverage is NOT provided under this Program for: a) Dental services which a Covered Person would be entitled to receive for a nominal charge or without

charge, if this Contract were not in force, under any Worker's Compensation Law, Federal Medicare program, or Federal Veteran's Administration program. However, if a Covered Person receives a bill or direct charge for dental services under any governmental program, then this exclusion shall not apply. Benefits under this Contract will not be reduced or denied because dental services are rendered to a Covered Person who is eligible for or receiving Medical Assistance pursuant to Minnesota Statute Section 62A.045.

b) Dental services or health care services not specifically covered under this Program (including any hospital charges, prescription drug charges and dental services or supplies that are medical in nature).

c) New, experimental or investigational dental techniques or services may be denied until there is, to the satisfaction of the Program, an established scientific basis for recommendation.

d) Dental services performed for cosmetic purposes. NOTE: Dental services are subject to post-payment review of dental records. If services are found to be cosmetic, we reserve the right to collect any payment and the member is responsible for the full charge.

e) Dental services completed prior to the date the Covered Person became eligible for coverage.

f) Services of anesthesiologists.

g) Anesthesia Services, except by a Dentist or by an employee of the Dentist when the service is performed in his or her office and by a dentist or an employee of the dentist who is certified in their profession to provide anesthesia services.

h) Deep sedation/general anesthesia, analgesia, analgesic agents, anxiolysis nitrous oxide, medicines, or drugs for non-surgical or surgical dental care, regardless of the method of administration. NOTE: Intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services.

i) Dental services performed other than by a licensed dentist, licensed physician, his or her employees.

j) Dental services, appliances or restorations that are necessary to alter, restore or maintain occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

k) Services or supplies that have the primary purpose of improving the appearance of your teeth. This includes but is not limited to tooth whitening agents or tooth bonding and veneer covering of the teeth.

l) Orthodontic treatment services, unless specified in this Program Summary as a covered dental service benefit.

m) Case presentations, office visits and consultations.

n) Incomplete, interim or temporary services.

o) Athletic mouth guards, enamel microabrasion and odontoplasty.

p) Retreatment or additional treatment necessary to correct or relieve the results of treatment previously provided or paid for under the Program.

q) Bacteriologic tests.

r) Cytology sample collection.

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s) Separate services billed when they are an inherent component of a Dental Service where the benefit is reimbursed at an Allowed Amount.

t) Pediatric removable or fixed prosthetic appliances (dentures, partials or bridges).

u) Interim or temporary removable or fixed prosthetic appliances (dentures, partials or bridges).

v) The replacement of an existing partial denture with a bridge.

w) Additional, elective or enhanced prosthodontic procedures including but not limited to, connector bar(s), stress breakers and precision attachments.

x) Provisional splinting, temporary procedures or interim stabilization.

y) Placement or removal of sedative filling, base or liner used under a restoration.

z) Services or supplies that are medical in nature, including dental oral surgery services performed in a hospital.

aa) Occlusal procedures including occlusal guard and adjustments.

bb) Temporomandibular Joint Disorder (TMJ).

cc) Amalgam or composite restorations placed for preventive or cosmetic purposes. Limitations

a) Optional Treatment Plans: in all cases in which there are alternative treatment plans carrying different costs, the decision as to which course of treatment to be followed shall be solely that of the Covered Person and the dentist; however, the benefits payable hereunder will be made only for the applicable percentage of the least costly, commonly performed course of treatment, with the balance of the treatment cost remaining the payment responsibility of the Covered Person.

b) Reconstructive Surgery: benefits shall be provided for reconstructive surgery when such dental procedure is incidental to or follows surgery resulting from injury, sickness or other diseases of the involved part, or when such dental procedure is performed on a covered Dependent Child because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending physician, to the extent as required by MN Statute 62A.25 provided, however, that such services are dental reconstructive surgical services.

c) Benefits for inpatient or outpatient expenses arising from dental services up to age 18, including orthodontic and oral surgery services, involved in the management of birth defects known as cleft lip and cleft palate as required by Minnesota Statues Section 62A.042. For Programs without orthodontic coverage: Dental orthodontic services not related to the management of the congenital condition of cleft lip and cleft palate is not covered under this Dental Benefit Program. For Programs with orthodontic coverage: If coverage for the treatment of cleft lip or cleft palate is available under any other policy or contract of insurance, this Program shall be primary and the other policy or contract shall be secondary.

For other dental procedure exclusions and limitations, refer to the Description of Coverages in this Dental Benefit Program Summary. Post Payment Review

Dental services are evaluated after treatment is rendered for accuracy of payment, benefit coverage and potential fraud or abuse as defined in the Health Insurance Portability and Accountability Act of 1996 – Public Law 102-191. Any payments for dental services completed solely for cosmetic purposes or payments for services not performed as billed are subject to recovery. Delta’s right to conduct post payment review and its right of recovery exists even if a Pretreatment Estimate was submitted for the service. Optional Treatment Plans

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In all cases in which there are alternative treatment plans carrying different costs, the decision as to which course of treatment to be followed shall be solely that of the Covered Person and the dentist; however, the benefits payable hereunder will be made only for the applicable percentage of the least costly, commonly performed course of treatment, with the balance of the treatment cost remaining the payment responsibility of the Covered Person. TERMINATION OF COVERAGE

This Dental Program Benefit Summary (“Benefits Description”) summarizes the benefits available under this program, but does not describe other important information about the program. The Best Buy Health and Welfare Wrap Plan Document and Summary Plan Description, the “Booklet”, also contains important information about this program, including eligibility, COBRA continuation coverage, and legal rights under ERISA. The Booklet can be found at >Health & Insurance> Learn About> Plan Information. This Benefits Description, along with the Booklet is the summary plan description for this program and is a component of the plan document for the Best Buy Health and Welfare Wrap Plan. CONTINUATION OF COVERAGE (INCLUDING COBRA)

This Dental Program Benefit Summary (“Benefits Description”) summarizes the benefits available under this program, but does not describe other important information about the program. The Best Buy Health and Welfare Wrap Plan Document and Summary Plan Description, the “Booklet”, also contains important information about this program, including eligibility, COBRA continuation coverage, and legal rights under ERISA. The Booklet can be found at >Health & Insurance> Learn About> Plan Information. This Benefits Description, along with the Booklet is the summary plan description for this program and is a component of the plan document for the Best Buy Health and Welfare Wrap Plan.

TERMINATING CONTINUATION OF COVERAGE

This Dental Program Benefit Summary (“Benefits Description”) summarizes the benefits available under this program, but does not describe other important information about the program. The Best Buy Health and Welfare Wrap Plan Document and Summary Plan Description, the “Booklet”, also contains important information about this program, including eligibility, COBRA continuation coverage, and legal rights under ERISA. The Booklet can be found at >Health & Insurance> Learn About> Plan Information. This Benefits Description, along with the Booklet is the summary plan description for this program and is a component of the plan document for the Best Buy Health and Welfare Wrap Plan. PROGRAM PAYMENTS PARTICIPATING DENTIST NETWORK A Delta Dental Premier dentist is a dentist who has signed a participating and membership agreement with his/her local Delta Dental Plan. The dentist has agreed to accept Delta’s Maximum Amount Payable as payment in full for covered dental care. Delta’s Maximum Amount Payable is a schedule of fixed dollar maximums established solely by Delta for dental services provided by a licensed dentist who is a participating dentist. You will be responsible for any applicable deductible and coinsurance amounts listed in the Summary of Dental Benefits section. A Delta Dental Premier dentist has agreed not to bill more than Delta’s allowable charge. A Delta Dental Premier dentist has also agreed to file the claim directly with Delta. A Delta Dental PPO network dentist is a dentist who has signed a Delta Dental PPO agreement with Delta. The dentist has agreed to accept the Delta Dental PPO Maximum Amount Payable as payment in full for covered dental care. You will be responsible for any applicable deductible and coinsurance amounts listed in the Summary of Dental Benefits section. A Delta Dental PPO dentist has agreed not to bill more than the Delta Dental PPO allowable charge. A Delta Dental PPO dentist has also agreed to file the claim directly with Delta.

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Names of participating dentists can be obtained, upon request, by calling Delta (at 651-406-5939 or 866- 264-0528) or using its Internet web site at www.deltadentalmn.org. You may also refer to the General Information section of this booklet for detailed information on how to locate a participating dentist using the Program’s Internet web site. COVERED FEES

Under this Program, YOU ARE FREE TO GO TO THE DENTIST OF YOUR CHOICE. You may have additional out-of-pocket costs if your dentist is not a Delta Dental Premier or Delta Dental PPO dentist with the Program. There may also be a difference in the payment amount if your dentist is not a participating dentist with Delta. This payment difference could result in some financial liability to you. The amount depends on the nonparticipating dentist's charges in relation to the Table of Allowances determined by Delta. TO AVOID ANY MISUNDERSTANDING OF BENEFIT PAYMENT AMOUNTS, ASK YOUR DENTIST ABOUT HIS OR HER NETWORK PARTICIPATION STATUS WITHIN THE DELTA DENTAL PREMIER AND DELTA DENTAL PPO NETWORKS PRIOR TO RECEIVING DENTAL CARE. CLAIM PAYMENTS

PAYMENTS ARE MADE BY THE PROGRAM ONLY WHEN THE COVERED DENTAL PROCEDURES HAVE BEEN COMPLETED. THE PROGRAM MAY REQUIRE ADDITIONAL INFORMATION FROM YOU OR YOUR PROVIDER BEFORE A CLAIM CAN BE CONSIDERED COMPLETE AND READY FOR PROCESSING. IN ORDER TO PROPERLY PROCESS A CLAIM, THE PROGRAM MAY BE REQUIRED TO ADD AN ADMINISTRATIVE POLICY LINE TO THE CLAIM. DUPLICATE CLAIMS PREVIOUSLY PROCESSED WILL BE DENIED. ANY BENEFITS PAYABLE UNDER THIS PROGRAM ARE NOT ASSIGNABLE BY ANY COVERED PERSON OR ANY ELIGIBLE DEPENDENT OF ANY COVERED PERSON. Delta Dental Premier Dentists:

Claim payments are based on the Program’s Payment Obligation which is the highest fee amount Delta approves for dental services provided by a Delta Dental Premier dentist to a Delta-covered patient. The Program Payment Obligation for Delta Dental Premier dentists is the lesser of: (1) The fee pre-filed by the dentist with their Delta organization; (2) The Maximum Amount Payable as determined by Delta; (3) The fee charged or accepted as payment in full by the Delta Dental Premier dentist regardless of the amount charged. All Program Payment Obligations are determined prior to the calculation of any patient co-payments and deductibles as provided under the patient’s Dental Benefit Program administered by Delta. Delta Dental PPO Dentists:

Claim payments are based on the Program’s Payment Obligation which is the highest fee amount Delta approves for dental services provided by a Delta Dental PPO dentist to a Delta-covered patient. The Program Payment Obligation for Delta Dental PPO dentists is the lesser of: (1) The fee pre-filed by the dentist with their Delta organization; (2) The Delta Dental PPO Maximum Amount Payable as determined by Delta; (3) The fee charged or accepted as payment in full by the Delta Dental PPO dentist regardless of the amount charged. All Program Payment Obligations are determined prior to the calculation of any patient co-payments and deductibles as provided under the patient’s Dental Benefit Program administered by Delta. Nonparticipating Dentists:

Claim payments are based on the Program’s Payment Obligation, which for nonparticipating dentists is the treating dentist's submitted charge or the Table of Allowances established solely by Delta, whichever is less. The Table of Allowances is a schedule of fixed dollar maximums established by Delta for services rendered by a licensed dentist who is a nonparticipating dentist. Claim payments are sent directly to the Covered Person.

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COORDINATION OF BENEFITS (COB)

The Program's rules for coordination of benefits will apply if you or any of your Dependents are covered under this Program and any other dental plan or insurance policy. In this explanation of the rules for coordination of benefits, this Program and each other dental plan or insurance policy providing overlapping coverage is sometimes called a "plan" or they are together called the "plans." These coordination of benefits rules determine which plan will pay claims when this Program and any other plan is involved. You should file all claims with this Program and also any other plan that may cover that expense. This allows the plans to decide which one will pay. When more than one plan provides overlapping coverage, the plan that is required to pay the claim first is called the primary plan. Each other plan is called a secondary plan. The type of coordination chosen by the Plan Sponsor for this Program is called non-duplication of benefits. This means that, when this Program is a secondary plan, the Program will coordinate benefit coverage by paying only the amount it would have paid if it had been the primary plan, less any actual amounts paid by primary plan. NOTE: When the Coordination of Benefits rules apply for Dependent Children, you must provide your dentist with the birth dates of both parents. ASSIGNMENT OF BENEFITS

Any benefits which may be payable under this Dental Benefit Program are not assignable. CLAIM AND APPEAL PROCEDUREs

Claims Procedure

You may make a benefit claim by following the procedures outlined in the previous Section under the title “Using Your Dental Program.” Claims for Program benefits shall be examined and determined for the Employer Group by DELTA DENTAL OF MINNESOTA, who will appoint an individual or committee to do so. However, certain requests may be referred to the Plan Administrator, or a recognized dental peer review organization. The review of claims includes the right to examine the patient and all records applicable to the particular claim at issue. For purposes of these Claim and Appeal Procedures, the person or committee examining a claim is called the “CLAIM ADMINISTRATOR.” If an Employee or other person claiming benefits under the Program (a “CLAIMANT”) makes a claim for benefits (as defined below), the Claim Administrator will examine the claim and notify the Claimant in writing, within the initial response period after receiving the claim for benefits, whether or not the Claimant is eligible for any of the benefits requested under the Program. The initial response period is 30 days for post-service claims that contain no errors or omissions. A “claim for benefits” is a benefit request made by a Claimant, including a request to extend an ongoing course of treatment, if that request complies with the Program's procedure for the benefit request. If special circumstances require time to investigate and decide the claim for benefits, the Claim Administrator will notify the Claimant, within the initial response period, that a specified extension of time is needed and the reason for the extension. No such extension may be longer than 15 days, and in that case only if due to matters beyond the control of the Claim Administrator). If a Claimant has received approval of an ongoing course of treatment under the Program, to be provided over period of time or a number of treatments, and a Claim Administrator decides to reduce or terminate the course of treatment before the end of that period or number of treatments, that decision is treated under these procedures as a denial of a claim for benefits. The Claim Administrator will notify the Claimant of any such denial far enough in advance to allow the Claimant to appeal and get a review of that decision on appeal (as provided below) before the treatment is reduced or terminated. This paragraph does not apply to benefits reduced by amendment or termination of the Program. If the Claim Administrator finds that any request for Program benefits does not comply with the Program's applicable procedure, the Claim Administrator shall promptly notify the Claimant that the request does not comply with the applicable procedure and what must be done to comply. If the Claim Administrator requires more information to review a claim for benefits, the Claim Administrator shall request the

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specified information from the Claimant within a reasonable time after receiving the request. The Claimant shall have up to 45 days to provide the missing information. From the beginning of that period until the missing information is provided (or the end of that period, if earlier), the time period provided in the preceding paragraph for the Claim Administrator’s decision shall be extended. After receiving any such information from the Claimant or, if earlier, at the end of such 45-day period, the Claim Administrator shall review the information and notify the Claimant of the Claim Administrator’s decision within the extended time period for that decision. Notice of Claim Denial and Appeal Rights

If the Claim Administrator decides that a Claimant is not eligible for the claimed benefits, or is eligible for less than the claimed benefits, the Claim Administrator will provide the Claimant with written or electronic notice of the decision. The notice will state, in a manner calculated to be understood by the Claimant: a) The specific reasons for the claim denial;

b) A specific reference to each provision of the Program documents on which the denial is based;

c) A description of any additional information or material necessary for the Claimant to perfect his or her claim (and an explanation of why it is needed);

d) An explanation of the following Claims Review Procedure, and the time limits that apply under that procedure;

e) The Claimant’s right to bring a suit under ERISA Section 502(a), if the Claimant's appeal is denied after any review under the following Sections entitled “Appeal and Review Procedure” and “Notice of Denial of Petition and Right to Lawsuit;” and

f) In the case of a benefits claim decision that depends on medical information:

(1) If an internal rule, guideline, protocol or similar criterion (an “internal criterion”) was relied on in making the adverse determination, either a copy of such internal criterion, or a statement that such internal criterion was relied upon and that a copy of such of such internal criterion will be provided free of charge to the Claimant upon request; or

(2) If the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific of clinical judgment for the determination, applying the terms of the Program to the Claimant’s medical circumstances, or a statement that such an explanation will be provided free of charge to the Claimant upon request.

Claims Review Procedure

If a Claimant believes, after receiving notice of the Claim Administrator’s decision on the Claimant’s claim, that the Claimant is eligible for the claimed benefits, or that he or she is entitled to greater or different benefits, the Claimant shall have the opportunity to have his or her claim fully and fairly reviewed by a Reviewer. The "REVIEWER" shall be a committee of one or more individuals who are not under the supervision of any individual who denied the claim as Claim Administrator, A Claimant may obtain a review by filing a petition for review with the Plan Administrator within 180 days after the Claimant receives the notice issued by the Claim Administrator. This petition shall state the specific reasons the Claimant believes he or she is entitled to benefits, or greater or different benefits; and may include other information supporting the claim for benefits. Within 30 days after receipt by the Plan Administrator of a Claimant’s petition for review, the Plan Administrator shall cause the Reviewer to provide the Claimant (and his or representative, if any): a) An opportunity to present the Claimant’s position to the Reviewer orally or in writing, including the

right to submit written comments, documents, records and other relevant information;

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b) Upon written request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the Claimant’s claim for benefits, with such relevance to be determined under applicable regulations of the U.S. Department of Labor; and

c) Upon written request and free of charge, notice of the identity of the Reviewer, if the Reviewer is not the Plan Sponsor; and any medical or vocational experts whose advice was obtained for Delta in connection with the Claimant’s adverse benefit determination, whether or not such advice was relied upon in such determination.

If the Reviewer requires more information to review a petition for review, the Reviewer shall request the specified information from the Claimant within a reasonable time after receiving the petition. The Claimant shall have the same amount of time provided in the section above titled "Claims Procedure" to provide missing any information; and the time for a decision on the petition will be delayed in the same manner provided in the "Claims Procedure" section for delay of any initial decision on a claim for benefits. The Reviewer shall take into account all comments, documents, records and other information submitted by the Claimant and relevant to the claim for benefits. In the case of a decision based on medical judgment, the Reviewer shall not give any deference to the original decision of the Claim Administrator and, if a decision on the claim for benefits would involve the exercise of medical judgment, the Reviewer shall consult with a health care professional who is (a) licensed under state law (and has training and experience) in the applicable field of medicine, and (b) independent of any health care professional who participated in the initial decision on the claim for benefits. The Reviewer shall notify the Claimant of the Reviewer’s decision in writing within the appeal response period after receiving the claim for benefits, whether or not the Claimant is eligible for any of the benefits requested under the Program. The appeal response period is 60 days for post-service claims. If the decision is made more than 5 days before the end of the appeal response period, the Reviewer will send the notice of decision as soon as possible, but not later than 5 days after the decision is made. If, because of the need for a hearing or other special circumstances, that appeal response period is not sufficient, a decision on a post-service claim may be deferred for up to another 60-day period at the election of the Review Committee, but written notice of this deferral and an explanation of the special circumstances must be given to the Claimant. The Reviewer's decision is final unless the Claimant files a court action concerning the denied claim no later than 180 days after the date the Claimant is notified of the Reviewer's decision. Notice of Denial of Petition and Right to Lawsuit

If the Reviewer makes an adverse determination with respect to the benefits claimed in a petition for review, the Reviewer shall give the Claimant a notice that shall set forth in writing, in a manner calculated to be understood by the Claimant: a) Each specific reason for such determination;

b) A specific reference to each provision of the Program on which the determination is based;

c) A statement that the Claimant is entitled to receive, upon written request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the Claimant’s claim for benefits, with such relevance to be determined under applicable regulations of the U. S. Department of Labor;

d) That the Reviewer’s decision is final unless the Claimant files a court action concerning the denied claim, under ERISA Section 502(a) or other applicable law, no later than 180 days after the date the Claimant is notified of the Reviewer's decision; and

e) In the case of a benefits claim decision that depends on medical information:

(1) If an internal rule, guideline, protocol or similar criterion (an “internal criterion”) was relied on in making the adverse determination, either a copy of such internal criterion, or a statement

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that such internal criterion was relied upon and that a copy of such of such internal criterion will be provided free of charge to the Claimant upon request; and

(2) If the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific of clinical judgment for the determination, applying the terms of the Program to the Claimant’s medical circumstances, or a statement that such an explanation will be provided free of charge to the Claimant upon request.

CANCELLATION OF DELTA CONTRACT

The Program's Contract may be canceled by Delta only on an anniversary date of the Contract, or at any time the Employer Group fails to make the required payments or meet the terms of the Contract. The Plan Sponsor may also cancel the Contract at any time, for reasons stated in the Contract. Upon any cancellation of the Contract, Covered Persons of the Employer Group have no right to continue coverage under the Contract, or convert to an individual dental coverage contract. However, the Plan Sponsor may choose to continue the Program through another contract administrator. STANDARD PROVISIONS

Change or Termination of Program Benefits

As Plan Sponsor, Best Buy reserves the right to modify, suspend or terminate all or any part of the Program or the Plan at any time or from time to time. Any such Program modifications or termination shall be in writing and shall be executed by a duly authorized representative of Best Buy. Any change or termination of Program benefits:

a) Does not require the consent of any Covered Person or beneficiary; and

b) Must be in writing.

A change may affect any class of Covered Persons included in the Program. Authority to Interpret Program

With respect to issues not addressed in the provisions of the Contract or other Program documents, or where those provisions require interpretation or the application of the Contract or other Program provisions to specific factual situations, including questions of eligibility for benefits, the Plan Administrator, or another fiduciary designated by the Plan Sponsor, shall have the final authority to use its discretion to make a determination with respect to such issues or such provisions. Waiver and Estoppel

Any failure by the Plan Administrator to strictly enforce any of the terms, conditions or provisions of the Contract or other Program documents or any defense in any particular instance or instances shall not be construed or operate as a waiver by the Plan Administrator of any such Contract or Program provision or defense; and shall not impair the right of the Plan Administrator to insist upon strict compliance or performance in accordance with the terms and conditions of the Program. The written terms of this Program may not be modified by any oral or written representation from the Plan Administrator or its delegates. The Plan Administrator shall not be prevented, from denying or limiting the coverage or benefits available under the Program in accordance with the written provisions of the Contract or other Program documents, by any action including written or oral communications, or by any mistake of fact that suggests the existence of coverage or a level of coverage or benefits which are not available under the Program to the individual asserting the right to such coverage or benefits. RIGHT OF RECOVERY PROVISION

Immediately upon paying or providing any benefit under this Program, the Plan shall become entitled (or “SUBROGATED”) to all rights of recovery a Covered Person has against any party potentially responsible for making any payment to a Covered Person due to a Covered Person’s injuries or illness, to the full

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extent of benefits provided or to be provided by this Program. In addition, if a Covered Person receives any payment from any potentially responsible party as a result of an injury or illness, the Plan has the right to recover from, and be reimbursed by, the Covered Person for all amounts this Program has paid and will pay as a result of that injury or illness, up to and including the full amount the Covered Person receives from all potentially responsible parties. A “COVERED PERSON” includes, for the purposes of this provision, anyone on whose behalf the Program pays or provides any benefit, including, but not limited to, the Enrolled Employee, the minor child or other Eligible Dependent of an Enrolled Employee or any other person entitled to receive any benefits under the Program. As used throughout this provision, the term “RESPONSIBLE PARTY” means any party possibly responsible for making any payment to a Covered Person due to a Covered Person’s injuries or illness or any insurance coverage, including, but not limited to, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, med-pay coverage, workers’ compensation coverage, no-fault automobile insurance coverage, or any first party insurance coverage. The Covered Person shall do nothing to prejudice the subrogation and reimbursement rights of the Plan and shall, when requested fully cooperate with the Plans efforts to recover its benefits paid. It is the duty of the Covered Person to notify the Plan Administrator within 45 days after the date when any notice is given to any party, including an attorney, of the intention to pursue or investigate a claim to recover damages due to injuries sustained by the Covered Person. Each Covered Person acknowledges that the Plan’s subrogation and reimbursement rights are a first priority claim against all potential responsible parties and are to be paid to the Plan before any other claim for the Covered Person’s damages. Under this Program, the Plan shall be entitled to full reimbursement first from any potential responsible party payments, even if such payment to the Plan will result in a recovery to the Covered Person that is not enough to make the Covered Person financially whole or to compensate the Covered Person in part or in whole for the damages sustained. It is further agreed that the Plan is not required to participate in or pay attorney fees to the attorney hired by the Covered Person to pursue the Covered Person’s damage claim. The terms of this entire subrogation and reimbursement provision shall apply and the Plan is entitled to full recovery, regardless of whether any liability for payment is admitted by any potentially responsible party and regardless of whether the settlement or judgment received by the Covered Person identifies the dental benefits the Program provided. The Plan is entitled to recover from any and all settlements or judgments, even those designated as “pain and suffering” or “non-economic damages” only. If any claim is made that any part of this subrogation and reimbursement provision is unclear, or questions arise concerning the meaning or intent of any of its terms, the Covered Person and this Plan agree that the Plan Administrator shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. GENERAL INFORMATION DELTA INVOLVEMENT

The benefits under the Program are not guaranteed by Delta, under the Contract or otherwise. As Claims Administrator, Delta pays or denies claims on behalf of the Program and reviews requests for review of claims as described in the Claim and Appeals Procedures section. DELTA’S PRIVACY NOTICE

Delta will not disclose to non-affiliated third parties any non-public personal financial or health information concerning persons covered under this Dental Benefit Program, except as permitted by law or required to adjudicate claims submitted for dental services provided to persons covered under this Program. HOW TO FIND A PARTICIPATING DENTIST

Finding a dentist in the area is easy. Simply access the Dentist Search through www.deltadentalmn.org or by calling Delta Customer Service: 1-866-264-0528.

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USING YOUR DENTAL PROGRAM

Dentists who participate with Delta under this Program are independent contractors. The relationship between you and the participating dentist you select to provide your dental services is strictly that of provider and patient. Neither Delta nor the Employer Group makes any representations as to the quality of treatment outcomes of individual dentists, nor recommends that a particular dentist be consulted for professional care. All claims should be submitted within 12 months of the date of service. If your dentist is a participating dentist, the claim form will be available at the dentist's office. If your dentist is nonparticipating, claim forms are available by calling the phone number of Delta Customer Service: 1-866-264-0528.

. The Program also accepts the standard American Dental Association (ADA) claim form used by most dentists. The dental office will file the claim form with Delta. However, you may be required to assist in completing the patient information portion on the form (Items 1 through 14). During your first dental appointment, it is very important to advise your dentist of the following information: YOUR DELTA GROUP NUMBER

YOUR EMPLOYER (GROUP NAME)

YOUR IDENTIFICATION NUMBER (your covered Dependents must use YOUR Identification number)

YOUR BIRTHDAY AND THE BIRTH DATES OF YOUR SPOUSE AND DEPENDENT CHILDREN CONTRACT CANCELLATION AND RENEWAL

The Group Dental Plan Contract may be canceled by the Plan Sponsor on an anniversary date of the Contract, or at any time the Employer Group fails to make the required payments or meet the terms of the Contract. Upon cancellation of the Contract, Covered Persons of the Employer Group have no right to continue coverage administered by Delta, or to convert to an individual dental coverage contract. However, the Plan Sponsor may continue the Program for all Covered Persons under another dental benefit service contract made the by Plan Sponsor. EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA)

This Dental Program Benefit Summary (“Benefits Description”) summarizes the benefits available under this program, but does not describe other important information about the program. The Best Buy Health and Welfare Wrap Plan Document and Summary Plan Description, the “Booklet”, also contains important information about this program, including eligibility, COBRA continuation coverage, and legal rights under ERISA. The Booklet can be found at >Health & Insurance> Learn About> Plan Information. This Benefits Description, along with the Booklet is the summary plan description for this program and is a component of the plan document for the Best Buy Health and Welfare Wrap Plan.

4811-7509-5560\2 4/19/2018 1:34 PM

DELTA DENTAL OF MINNESOTA

FOR CLAIMS AND ELIGIBILITY National Dedicated Service Center

P.O. Box 59238 Minneapolis, Minnesota 55459

(651) 406-5901 or (800) 448-3815

FOR APPEALS P.O. Box 551

Minneapolis, Minnesota 55440-0551

CORPORATE LOCATION 500 Washington Avenue South

Suite 2060 Minneapolis, MN 55415

(651) 406-5900 or (800) 328-1188 www.deltadentalmn.org