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. $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. $50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $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. $50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 20% - After deductible 30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 20% - After deductibleNot Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 30 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 40 20% plus $40 - After deductible Afterdeductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in coordinated by your home 0% - After deductible 20% - After deductibleprimary care physician and permitted self-referrals.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 100 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. $50 20% - After deductible 25 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 20% - After deductibleNot Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 40 20% plus $40 - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductibleAfterdeductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 20% - After deductible 30 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Not Covered Inpatient/outpatient/in your home 020% - After deductible 20% - After deductibleNot Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% plus $40 - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $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. $50 20% - After deductible 40 Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Not Covered Inpatient/outpatient/in your home 0% - After deductible 20% - After deductibleNot Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 50 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. $50 15 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 40 20% plus $40 - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible