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. $300 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 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 Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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. $300 250 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 2040% - After deductible Services connected to dental care when performed in an outpatient facility * 020% - After deductible 2040% - 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 Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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. 040% - After deductible 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 100 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 30 20% - After deductible Services connected to dental care when performed in an outpatient facility * 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 service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 200 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 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Dental 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 Dental Care (Pediatric) - for members under age 19 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% 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 Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 200 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 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 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 service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 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 55 20% - After deductible Services connected to dental care when performed in an outpatient facility * 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 service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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 - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. teet.h $300 200 The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. teet.h $50 20% - After deductible 40 20%- Afterdeductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility * 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare 0%- Afterdeductible 20%- Afterdeductible Dental 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 Dental Care (Pediatric) - Pediatric)- for members under age 19 19: See Dental Services in Section 3 for benefit limits and fboernefitlimitsand details. These services only apply to an enrolled member under enrolmledemberunder the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental sedatio-ndental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. brace-s)whenmedically necessar.y 50% 50% Dialysis Services Inpatient/outpatientoutpatie/in nint your home 0% - After deductible 20% - After deductible 0%- Afterdeductible 20%- Afterdeductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - Must equipmen-t*Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Outpatient medical supplies* - Must 20%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplies-*Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Outpatient diabetic 20%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 0% - After deductible 20% - After deductible Outpatient prosthesis* - 20%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - After deductible 20%- Afterdeductible 40%- Afterdeductible Enteral formula or food taken orally * 0% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 0% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider.xxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0% The level of coverage is the same as network xxxxxx.xx Asthma management 0% 20%- Afterdeductible Emergency Room Services Hospitalemergencyroom $200 The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing exam $40 20%- Afterdeductible Hearing diagnostic testing 0% 20%- Afterdeductible Hearing aids- Thebenefitlimitis $2,000 per hearing aid fo a memberunder 21, thebenefitlimitis $700 per hearing aid for amember21 and older. 20%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Intermittent skilled services when billed by a home heal care agency. 0%- Afterdeductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 20%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% 20%- Afterdeductible Infertility Services Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L) D infertility treatment cycles will be coveredplpaenryearwith a total of eight (8) infertility treatment cycles covered in P H liPfetimEe. H U ¶ V 20%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 20%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 20%- Afterdeductible General hospitaol r specialtyhospitalservices*- unlimited days 0%- Afterdeductible 20%- Afterdeductible Rehabilitationfacility services-*limited to 45 days peprlan year. 0%- Afterdeductible 20%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 20%- After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 200 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 40 20% - After deductible Services connected to dental care when performed in an outpatient facility * 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 service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 100 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 Services connected to dental care when performed in an outpatient facility * 0% - After deductible 2030 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 Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 2040% - 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 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - 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 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20% - 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.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 250 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 2040% - After deductible Services connected to dental care when performed in an outpatient facility * 020% - After deductible 2040% - 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 Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 020% - After deductible 2040% - 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 2040% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 020% - After deductible 2040% - 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 2040% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 020% - After deductible 2040% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 020% - After deductible 2040% - 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.