A dental organization shall make available to an enrollee, upon request, a clear and concise description of the following terms of coverage:
(1) the dental care services and other benefits to which the enrollee is entitled under the dental plan;
(2) any exclusions or limitation on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible or co-payment features and any requirements for referrals to specialists;
(3) a description as to how services, including emergency dental care and out-of-area service, may be obtained;
(4) a general description of payment and co-payment amounts, if any, for dental care services, which the enrollee is obligated to pay; and
(5) a telephone number by which the enrollee may obtain additional information regarding coverage.