Common use of MEMBERS 19 YEARS OLD AND OLDER Clause in Contracts

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage for replacements limited to one (1) in a 60-month period. Oral Surgery Services Limited to coverage when services are not covered under the member’s medical insurance. • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s). 50% 50% 20% 20% • Oral Surgery Services 50% 50% 20% 20% • Biopsies Limited to the biopsy and examination of oral tissue, soft or hard. 50% 50% 20% 20% Occlusal (Night) guards Limited to one (1) every five (5) years. 50% 50% 50% 50% Orthodontic Services (Braces) Predetermination is recommended. Only medically necessary braces are covered. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage • Fluoride Treatments Two (2) fluoride treatment for replacements limited members under 19 years old per benefit year. 0% 0% Not Covered Not Covered • Sealants For permanent molars only. Limited to one (1) per tooth in a 6024-month periodperiod for members under 19 years old. Oral Surgery Services Limited 0% 0% Not Covered Not Covered • Space Maintainers 50% 50% 20% 20% • Palliative Treatment Minor treatment to coverage when services are not covered under the member’s medical insurancerelieve sudden, intense pain. 50% 50% 20% 20% • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(sFillings See Section for details. 50% 50% 20% 20% • Simple Extractions Removal of erupted tooth (non-surgical). 50% 50% 20% 20% • Oral Surgery Services Denture Repairs and Relines/ Rebasing Full or partial dentures. Relines/Rebasing limited to once in a 60-month period. 50% 50% 20% 20% • Biopsies Limited to the biopsy and examination of oral tissue, soft or hard. 50% 50% 20% 20% Occlusal (Night) guards Limited to one (1) every five (5) yearsCrowns & Onlays Predetermination is recommended. 50% 50% 50% (12 month waiting period applies) 50% Orthodontic Services (Braces12 month waiting period applies) Predetermination is recommended. Only medically necessary braces are covered• Therapeutic Pulpotomies Limited to members under 14 years old. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS ICovered

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage for replacements limited • Root Canal Therapy - Anterior(front) Teeth 50% 50% 20% 20% • Root Canal Therapy - Posterior (back)Teeth 50% 50% 20% 20% • Non-Surgical Periodontal Services 50% 50% 20% 20% • Surgical Periodontal Services Predetermination is recommended. 50% 50% 50% (12 month waiting period applies) 50% (12 month waiting period applies) • Periodontal Maintenance Limited to one two (12) services in a 60-month period. Oral Surgery Services Limited to coverage when services are not covered under the member’s medical insurance. • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s)year. 50% 50% 20% 20% • Oral Surgery Services 50% 50% 20% 20% • Biopsies Limited to the biopsy Fixed Bridges and examination of oral tissue, soft or hard. 50% 50% 20% 20% Occlusal (Night) guards Limited Dentures Coverage for replacements limited to one (1per tooth/unit) every five (5) yearsin a 60-month period. 50% 50% 50% 50% Orthodontic Services (Braces) Crowns over implants are considered a prosthodontic service. Predetermination is recommended. Only medically necessary braces are covered. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I• Single Tooth Implant Coverage if placed as an alternative treatment to a conventional 3-unit bridge. Replacing only one missing tooth. 50% 50% Not Covered Not Covered

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage for replacements limited to one (1) in a 60-month period. Oral Surgery Services Limited to coverage when services are not covered under the member’s medical insurance. • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s). 50% 50% 2050% 20520% • Oral Surgery Services 50% 50% 2050% 2050% • Biopsies Limited to the biopsy and examination of oral tissue, soft or hard. 50% 50% 2050% 2050% Occlusal (Night) guards Limited to one (1) every five (5) years. 50% 50% 50% 50% Orthodontic Services (Braces) Predetermination is recommended. Only medically necessary braces are covered. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage for replacements limited to one • Root Canal Therapy - Anterior(front) Teeth 50% 50% 50% 50% • Root Canal Therapy - Posterior (1) in a 60back)Teeth 50% 50% 50% 50% • Non-month period. Oral Surgery Surgical Periodontal Services Limited to coverage when services are not covered under the member’s medical insurance. 50% 50% 50% 50% • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s)Surgical Periodontal Services Predetermination is recommended. 50% 50% 20% 20% Not Covered Not Covered • Oral Surgery Services 50% 50% 20% 20% • Biopsies Periodontal Maintenance Limited to the biopsy and examination of oral tissue, soft or hard. 50% 50% 20% 20% Occlusal two (Night2) guards Limited to one (1) every five (5) yearsservices in a benefit year. 50% 50% 50% 50% Orthodontic Services • Fixed Bridges and Dentures Coverage for replacements limited to one (Bracesper tooth/unit) in a 60-month period. Crowns over implants are considered a prosthodontic service. Predetermination is recommended. Only medically necessary braces are covered. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I• Single Tooth Implant Coverage if placed as an alternative treatment to a conventional 3-unit bridge. Replacing only one missing tooth. Coverage for 50% 50% Not Covered Not Covered

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage for replacements limited • Root Canal Therapy - Anterior(front) Teeth 50% 50% 20% 20% • Root Canal Therapy - Posterior (back)Teeth 50% 50% 20% 20% • Non-Surgical Periodontal Services 50% 50% 20% 20% • Surgical Periodontal Services Predetermination is recommended. 50% 50% 50% (12 month waiting period applies) 50% (12 month waiting period applies) • Periodontal Maintenance Limited to one two (12) services in a 60-month period. Oral Surgery Services Limited to coverage when services are not covered under the member’s medical insurance. • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s)year. 50% 50% 20% 20% • Oral Surgery Services 50% 50% 20% 20% • Biopsies Limited to the biopsy Fixed Bridges and examination of oral tissue, soft or hard. 50% 50% 20% 20% Occlusal (Night) guards Limited Dentures Coverage for replacements limited to one (1per tooth/unit) every five (5) yearsin a 60-month period. Crowns over implants are considered a prosthodontic service. Predetermination is recommended. 50% 50% 50% (12 month waiting period applies) 50% Orthodontic Services (Braces12 month waiting period applies) Predetermination is recommended• Single Tooth Implant Coverage if placed as an alternative treatment to a conventional 3-unit bridge. Only medically necessary braces are coveredReplacing only one missing tooth. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I50% (12 month waiting period applies) 50% (12 month waiting period applies)

MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage • Fluoride Treatments Two (2) fluoride treatment for replacements limited members under 19 years old per benefit year. 0% 0% Not Covered Not Covered • Sealants For permanent molars only. Limited to one (1) per tooth in a 6024-month periodperiod for members under 19 years old. Oral Surgery Services Limited to coverage when services are not covered under the member’s medical insurance. 0% 0% Not Covered Not Covered • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s). Space Maintainers 50% 50% 20% 20% • Oral Surgery Services 50% 50% 20% 20% • Biopsies Limited Palliative Treatment Minor treatment to the biopsy and examination of oral tissuerelieve sudden, soft or hard. 50% 50% 20% 20% Occlusal (Night) guards Limited to one (1) every five (5) yearsintense pain. 50% 50% 50% 50% Orthodontic Services • Fillings See Section for details. 50% 50% 50% 50% • Simple Extractions Removal of erupted tooth (Braces) non-surgical). 50% 50% 50% 50% • Denture Repairs and Relines/ Rebasing Full or partial dentures. Relines/Rebasing limited to once in a 60-month period. 50% 50% 50% 50% • Crowns & Onlays Predetermination is recommended. Only medically necessary braces are covered. 50% 50% Not Covered Not Covered DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I• Therapeutic Pulpotomies Limited to members under 14 years old. 50% 50% Not Covered Not Covered