Common use of Dental Services - Accidental Injury (Emergency Clause in Contracts

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 0% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 0% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 40% - After deductible Enteral formula or food taken orally * 0% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 0% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$30 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible $50 40% - After deductible Services connected to dental care when performed in an outpatient facility * 020% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$25 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 4020% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 4020% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 4020% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 4020% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 4020% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 400% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 400% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 400% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 0% - After deductible 400% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 400% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 0% - After deductible 400% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 400% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 400% - After deductible Enteral formula or food taken orally * 0% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 0% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 4020% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 4020% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 4020% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 4020% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 4020% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $100 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% $25 - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 0% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 0% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 0% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 0% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40Not Covered Inpatient/outpatient/in your home 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 020% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 020% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 020% - After deductible The level of coverage is the same as network provider.