Common use of Benefits Coverage Clause in Contracts

Benefits Coverage. Minor treatment for tooth guidance appliances 50% of approved amount Minor treatment to control harmful habits 50% of approved amount Interceptive and comprehensive orthodontic treatment 50% of approved amount Post-treatment stabilization 50% of approved amount Cephalometric film (skull) and diagnostic photos 50% of approved amount Note: For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to Blue Cross for predetermination before treatment begins. Page 3 of 3 000006964662 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten. If your group is self-funded, please see any other plan documents your group uses. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Essential Vision benefits are provided by Heritage Vision Plans. Heritage Vision Plans is an independent company providing vision benefit services for Blues members. To find a Heritage Vision Plans network provider, call 0-000-000-0000 or visit Heritage Vision Plans online at xxxxxxxxxxxxxxxxxxx.xxx.

Benefits Coverage. Minor treatment for tooth guidance appliances 50% of approved amount Minor treatment to control harmful habits 50% of approved amount Interceptive and comprehensive orthodontic treatment 50% of approved amount Post-treatment stabilization 50% of approved amount Cephalometric film (skull) and diagnostic photos 50% of approved amount Note: For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to Blue Cross for predetermination before treatment begins. Page 3 of 3 000006964662 Vision Coverage This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten. If your group is self-funded, please see any other plan documents your group uses. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Essential Vision benefits are provided by Heritage Vision Plans. Heritage Vision Plans is an independent company providing vision benefit services for Blues members. To find a Heritage Vision Plans network provider, call 0-000-000-0000 or visit Heritage Vision Plans online at xxxxxxxxxxxxxxxxxxx.xxx.

Benefits Coverage. Minor treatment for tooth guidance appliances 50% of approved amount Minor treatment to control harmful habits 50% of approved amount Interceptive and comprehensive orthodontic treatment 50% of approved amount Post-treatment stabilization 50% of approved amount Cephalometric film (skull) and diagnostic photos 50% of approved amount Note: For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to Blue Cross for predetermination before treatment begins. Page 3 of 3 000006964662 Schedule C - Self Funded Vision Benefits Coverage Schedule Vision Coverage This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten. If your group is self-funded, please see any other plan documents your group uses. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Essential Vision benefits are provided by Heritage Vision Plans. Heritage Vision Plans is an independent company providing vision benefit services for Blues members. To find a Heritage Vision Plans network provider, call 0-000-000-0000 or visit Heritage Vision Plans online at xxxxxxxxxxxxxxxxxxx.xxx.

Benefits Coverage. Minor treatment for tooth guidance appliances 50% of approved amount Minor treatment to control harmful habits 50% of approved amount Interceptive and comprehensive orthodontic treatment 50% of approved amount Post-treatment stabilization 50% of approved amount Cephalometric film (skull) and diagnostic photos 50% of approved amount Note: For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to Blue Cross for predetermination before treatment begins. Page 3 of 3 000006964662 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten. If your group is self-funded, please see any other plan documents your group uses. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan document will control. Essential Vision benefits are provided by Heritage Vision Plans. Heritage Vision Plans is an independent company providing vision benefit services for Blues members. To find a Heritage Vision Plans network provider, call 0-000-000-0000 or visit Heritage Vision Plans online at xxxxxxxxxxxxxxxxxxx.xxx.