Common use of COVERED DENTAL SERVICES Clause in Contracts

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Not Covered Not Covered General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Not Covered Not Covered Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & OnlaysNon-surgical periodontal services and Periodontal Maintenance* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services20% - After a 12 month waiting period 20% - After a 12 month waiting period Total Health Solutions - members diagnosed with certain health conditions. See Total Health Solutions for eligibility details. 0% 0% Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After a 12 month waiting period 4050% - After a 12 month waiting period Oral surgery services* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After a 12 month waiting period 20% - After a 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Non-surgical periodontal services and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Total Health Solutions - members diagnosed with certain health conditions. See Total Health Solutions for eligibility details. 0% 0% Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & OnlaysNon-surgical periodontal services and Periodontal Maintenance* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services50% - After 12 month waiting period 50% - After 12 month waiting period Total Health Solutions - members diagnosed with certain health conditions. See Total Health Solutions for eligibility details. 0% 0% Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After 12 month waiting period 4050% - After 12 month waiting period Oral surgery services* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% - After 12 month waiting period 50% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After 12 month waiting period 4050% - After 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery servicesPalliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental officeBiopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Root canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical Non-surgical periodontal servicesservices and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & OnlaysNon-surgical periodontal services and Periodontal Maintenance* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After deductible and a 12 month waiting period 4050% - After deductible and a 12 month waiting period Oral surgery services* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After deductible and a 12 month waiting period 4020% - After deductible and a 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After deductible and a 12 month waiting period 50% - After deductible and a 12 month waiting period Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After deductible and a 12 month waiting period 50% - After deductible and a 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After deductible and a 12 month waiting period 50% - After deductible and a 12 month waiting period Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Teledentistry Examination Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery servicesPalliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental officeBiopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal servicesRoot canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 7540% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered40%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 750% - After deductible 750% - After deductible Age 19 and older 0% 0% Teledentistry Examination Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Sealants Under age 19 750% - After deductible 750% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges Denture repairs, relines, and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% rebasing Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not CoveredCovered Palliative treatment Under age 19 20% 20% Age 19 and older 0% 0% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & OnlaysOral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 7520% - After deductible 7520% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 40deductible 20% - After 12 month waiting period deductible Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After deductible 50% - After deductible Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After deductible 50% - After deductible Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After deductible 50% - After deductible Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery servicesPalliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental officeBiopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal servicesRoot canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 7540% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered40%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Oral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 750% - After deductible 750% - After deductible Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Sealants Under age 19 750% - After deductible 750% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges Denture repairs, relines, and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% rebasing Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not CoveredCovered Palliative treatment Under age 19 20% 20% Age 19 and older 0% 0% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 750% - After deductible 750% - After deductible Age 19 and older 0% 0% Teledentistry Examination Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Sealants Under age 19 750% - After deductible 750% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges Denture repairs, relines, and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% rebasing Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not CoveredCovered Palliative treatment Under age 19 20% 20% Age 19 and older 0% 0% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Oral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After 12 month waiting period 4050% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After 12 month waiting period 4050% - After 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Non-surgical periodontal services and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Total Health Solutions - members diagnosed with certain health conditions. See Total Health Solutions for eligibility details. 0% 0% Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Not Covered Not Covered General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Not Covered Not Covered Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Crowns & Onlays* Oral evaluations Under age 19 750% - After deductible 750% - After deductible Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Sealants Under age 19 750% - After deductible 750% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Bridges Denture repairs, relines, and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% rebasing Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not CoveredCovered Palliative treatment Under age 19 20% 20% Age 19 and older 0% 0% Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20%