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. $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. $25 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 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 Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $100 200 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. $25 2050 40% - After deductible Services connected to dental care when performed in an outpatient facility * 020% - After deductible 2040% - After deductible Inpatient/outpatient/in your home 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 Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $100 200 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. $25 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 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 Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $100 150 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. $25 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 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

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $100 150 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. $25 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 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