Common use of Out-of-Network Benefits Clause in Contracts

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 TABLE OF CONTENTS Section I. Definitions 7 Section II. How Your Coverage Works 11 Participating Providers 11 The Role of Primary Care Dentists 11 Services Subject to Preauthorization 11 Medical Necessity 12 Important Telephone Numbers and Addresses 13 Section III. Cost-Sharing Expenses and Allowed Amount 14 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 19 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 Section VIII. Claim Determinations 25 Section IX. Grievance Procedures 27 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 Section XIII. Extension of Benefits 36 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 37 Section XV. General Provisions 38 Section XVI. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-of- network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 0000. TABLE OF CONTENTS Section I. Definitions 7 4 Section II. How Your Coverage Works 11 9 Participating Providers 11 9 The Role of Primary Care Dentists 11 9 Services Subject to Preauthorization 11 10 Medical Necessity 12 11 Important Telephone Numbers and Addresses 13 12 Section III. Cost-Sharing Expenses and Allowed Amount 14 13 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 19 20 Section VI. Adult Dental Care 21 Care… 23 Section VII. Exclusions and Limitations 23 26 Section VIII. Claim Determinations 25 29 Section IX. Grievance Procedures 27 32 Section X. Utilization Review 29 35 Section XI. External Appeal 32 40 Section XII. Termination of Coverage 35 44 Section XIII. Extension of Benefits 36 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 37 Section XV. General Provisions 38 Section XVI. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.46

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-of- pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Cost- Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxxxxxx, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Senior Vice President TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Access to Providers and Changing Providers 8 Services Subject to Preauthorization 11 9 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 9 Section III. Cost-Sharing Expenses and Allowed Amount 14 11 Section IV. Who is Covered 16 14 Section V. Pediatric Dental Care 19 18 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 20 Section VII. Claim Determinations 22 Section VIII. Claim Determinations 25 Utilization Review 24 Section IX. Grievance Procedures 27 External Appeal 28 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 30 Section XIIIXI. Extension of Benefits 36 33 Section XIVXII. Temporary Suspension Rights for Armed Forces’ Members 37 34 Section XVXIII. General Provisions 38 35 Section XVIXIV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.Policy SECTION I

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-of- network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxxxxxx, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Senior Vice President TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Access to Providers and Changing Providers 8 Services Subject to Preauthorization 11 9 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 10 Section III. Cost-Sharing Expenses and Allowed Amount 14 11 Section IV. Who is Covered 16 14 Section V. Pediatric Dental Care 19 20 Section VI. Adult Dental Care 21 22 Section VII. Exclusions and Limitations 23 25 Section VIII. Claim Determinations 25 27 Section IX. Grievance Procedures 27 Section X. Utilization Review 29 Section XI. X. External Appeal 32 33 Section XIIXI. Termination of Coverage 35 36 Section XIIIXII. Extension of Benefits 36 38 Section XIVXIII. Temporary Suspension Rights for Armed Forces’ Members 37 39 Section XVXIV. General Provisions 38 40 Section XVIXV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.Policy SECTION I

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 TABLE OF CONTENTS Section I. Definitions 7 Section II. How Your Coverage Works 11 12 Participating Providers 11 12 The Role of Primary Care Dentists 11 12 Services Subject to Preauthorization 11 12 Medical Necessity 12 13 Important Telephone Numbers and Addresses 13 14 Section III. Cost-Sharing Expenses and Allowed Amount 14 15 Section IV. Who is Covered 16 17 Section V. Pediatric Dental Care 19 Section VI. Adult Dental Care Exclusions and Limitations 21 Section VII. Exclusions and Limitations Claim Determinations 23 Section VIII. Claim Determinations Grievance Procedures 25 Section IX. Grievance Procedures Utilization Review 27 Section X. Utilization Review 29 External Appeal 30 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 33 Section XIIIXII. Extension of Benefits 36 34 Section XIVXIII. Temporary Suspension Rights for Armed Forces’ Members 37 35 Section XVXIV. General Provisions 38 36 Section XVIXV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract 41 This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-of- pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Cost- Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxx, The Official Health Plan MarketplaceSenior Vice President, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Group Products and Marketing TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Services Subject to Preauthorization 11 8 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 9 Section III. Cost-Sharing Expenses and Allowed Amount 14 10 Section IV. Who is Covered 16 13 Section V. Pediatric Dental Care 19 17 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 19 Section VII. Claim Determinations 21 Section VIII. Claim Determinations 25 Utilization Review 23 Section IX. Grievance Procedures External Appeal 27 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 30 Section XIIIXI. Extension of Benefits 36 32 Section XIVXII. Temporary Suspension Rights for Armed Forces’ Members 37 33 Section XVXIII. General Provisions 38 34 Section XVIXIV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract Policy SECTION I Definitions Defined terms will appear capitalized throughout the Policy. Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention. Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of this Policy for a description of how the Allowed Amount is calculated. If your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost-Sharing requirements. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non- Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Policy: This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage Policy issued by BlueCross BlueShield The Guardian Life Insurance Company of Western New York. This ContractAmerica, together with including the attached Schedule of Benefits, applications, Benefits and any amendment attached riders. Child, Children: The Subscriber’s Children, including any natural, adopted or rider amending step-children, unmarried disabled Children, newborn Children, or any other Children as described in the terms Who is Covered section of this ContractPolicy. Coinsurance: Your share of the costs of a Covered Service, constitute calculated as a percent of the entire agreement between You and Us. You have Allowed Amount for the right to return this Contract. Examine it carefully. If service that You are not satisfied, You may return this Contract required to Us and ask Us pay to cancel ita Provider. Your request must be made in writing within ten (10) days from The amount can vary by the date You receive this Contract. We will refund any Premium paid including any Contract fees or other chargestype of Covered Service.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-of- network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxxxxxx, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Senior Vice President TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Access to Providers and Changing Providers 8 Services Subject to Preauthorization 11 9 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 10 Section III. Cost-Sharing Expenses and Allowed Amount 14 11 Section IV. Who is Covered 16 14 Section V. Pediatric Dental Care 19 20 Section VI. Adult Dental Care 21 22 Section VII. Exclusions and Limitations 23 27 Section VIII. Claim Determinations 25 29 Section IX. Grievance Procedures 27 Utilization Review 30 Section X. Utilization Review 29 External Appeal 35 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 38 Section XIIIXII. Extension of Benefits 36 40 Section XIVXIII. Temporary Suspension Rights for Armed Forces’ Members 37 41 Section XVXIV. General Provisions 38 42 Section XVIXV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.Policy SECTION I

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-of- network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 TABLE OF CONTENTS Section I. Definitions 7 4 Section II. How Your Coverage Works 11 9 Participating Providers 11 9 The Role of Primary Care Dentists 11 9 Services Subject to Preauthorization 11 10 Medical Necessity 12 11 Important Telephone Numbers and Addresses 13 12 Section III. Cost-Sharing Expenses and Allowed Amount 14 13 Section IV. Who is Covered 16 15 Section V. Pediatric Dental Care 19 18 Section VI. Adult Dental Care Exclusions and Limitations 21 Section VII. Exclusions and Limitations 23 Claim Determinations 24 Section VIII. Claim Determinations 25 Section IX. Grievance Procedures 27 Section X. IX. Utilization Review 29 30 Section X. External Appeal 35 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 39 Section XIIIXII. Extension of Benefits 36 41 Section XIVXIII. Temporary Suspension Rights for Armed Forces’ Members 37 42 Section XVXIV. General Provisions 38 43 Section XVIXV. Schedule of Benefits 42 Riders50 SECTION I Definitions Defined terms will appear capitalized throughout the Contract Acute: The onset of disease or injury, Contract Amendmentsor a change in the Member's condition that would require prompt medical attention. End Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual this Contract for preferred provider organization coverage a description of how the Allowed Amount is calculated. If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost- Sharing requirements. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Contract: This Contract issued by BlueCross BlueShield of Western New York. This Contract, together with including the attached Schedule of Benefits, applications, Benefits and any amendment attached riders. Child, Children: The Subscriber’s Children, including any natural, adopted or rider amending step- children, unmarried disabled Children, newborn Children, or any other Children as described in the terms Who is Covered section of this Contract. Coinsurance: Your share of the costs of a Covered Service, constitute calculated as a percent of the entire agreement between You and Us. You have Allowed Amount for the right to return this Contract. Examine it carefully. If service that You are not satisfied, You may return this Contract required to Us and ask Us pay to cancel ita Provider. Your request must be made in writing within ten (10) days from The amount can vary by the date You receive this Contract. We will refund any Premium paid including any Contract fees or other chargestype of Covered Service.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive get Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive get out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. NY43 VISION CTR INDIVIDUAL 2022 This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL Vision insurance ONLY. This Contract is a New York State of HealthBy: Xxxxxxxxxxx Del Xxxxxxx, The Official Chief Executive Officer MVP Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Services Corp. TABLE OF CONTENTS Section I. SECTION I - Definitions 7 Section II. 4 SECTION II - How Your Coverage Works 11 7 C. Participating Providers 11 The Role of Primary Care Dentists 11 Services Subject to Preauthorization 11 Medical Necessity 12 Providers. 7 D. Vision Providers. 7 G. Important Telephone Numbers and Addresses 13 Section IIIAddresses. Cost-8 SECTION III – Cost Sharing Expenses and Allowed Amount 9 SECTION IV - Who Is Covered 11 SECTION V - Vision Care 14 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 19 Section VI. Adult Dental Care 21 Section VII. SECTION VI - Exclusions and Limitations 23 Section VIII. 15 SECTION VII - Grievance Procedures 16 SECTION VIII - Claim Determinations 25 Section IX. Grievance Procedures 27 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. 19 SECTION IX - Termination of Coverage 35 Section XIII. 20 SECTION X - Extension of Benefits 36 Section XIV. 22 SECTION XI - Temporary Suspension Rights for Armed Forces’ Members 37 Section XV. 23 SECTION XII - General Provisions 38 Section XVI. 24 Schedule of Benefits 42 Riders, Contract AmendmentsAttached SECTION I - Definitions Defined terms will appear capitalized throughout the Contract. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx XxAllowance: Means a flat dollar amount payable under the Policy towards a Covered Expense. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with Allowances are shown in the attached Schedule of Benefits. If the Providers charge is less than the Allowance, applicationswe will only pay up to the providers charge. Appeal: A request for Us to review a decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non- Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Contract: This Contract issued by MVP Health Services Corp., including the Schedule of Benefits and any amendment or rider amending attached riders. The Contract explains the terms of this benefits available to You under the Group Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-of- pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Cost- Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxxxxxx, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Senior Vice President TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Access to Providers and Changing Providers 8 Services Subject to Preauthorization 11 9 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 10 Section III. Cost-Sharing Expenses and Allowed Amount 14 11 Section IV. Who is Covered 16 14 Section V. Pediatric Dental Care 19 18 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 20 Section VII. Claim Determinations 22 Section VIII. Claim Determinations 25 Utilization Review 24 Section IX. Grievance Procedures 27 External Appeal 28 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 31 Section XIIIXI. Extension of Benefits 36 33 Section XIVXII. Temporary Suspension Rights for Armed Forces’ Members 37 34 Section XVXIII. General Provisions 38 35 Section XVIXIV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.Policy SECTION I

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-of- pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Cost- Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxx, The Official Health Plan MarketplaceSenior Vice President, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Group Products and Marketing TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Services Subject to Preauthorization 11 8 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 9 Section III. Cost-Sharing Expenses and Allowed Amount 14 11 Section IV. Who is Covered 16 13 Section V. Pediatric Dental Care 19 18 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 20 Section VII. Claim Determinations 22 Section VIII. Claim Determinations 25 Utilization Review 24 Section IX. Grievance Procedures 27 External Appeal 28 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 31 Section XIIIXI. Extension of Benefits 36 33 Section XIVXII. Temporary Suspension Rights for Armed Forces’ Members 37 34 Section XVXIII. General Provisions 38 35 Section XVIXIV. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.Policy SECTION I

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 TABLE OF CONTENTS Section I. Definitions 7 Section II. How Your Coverage Works 11 Participating Providers 11 The Role of Primary Care Dentists 11 Services Subject to Preauthorization 11 Medical Necessity 12 Important Telephone Numbers and Addresses 13 Section III. Cost-Sharing Expenses and Allowed Amount 14 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 19 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 Section VIII. Claim Determinations 25 Section IX. Grievance Procedures 27 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 Section XIII. Extension of Benefits 36 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 37 Section XV. General Provisions 38 Section XVI. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract Policy provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-of- network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. See the Schedule of Benefits section of this Policy for more information. READ THIS ENTIRE CONTRACT POLICY CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACTPOLICY. This Contract Policy is governed by the laws of New York State. The insurance evidenced by this Contract Policy provides DENTAL insurance ONLY. This Contract is a New York State The Guardian Life Insurance Company of HealthAmerica Xxxxxxx Xxxxxxxxx, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 Senior Vice President TABLE OF CONTENTS Section I. Definitions 7 3 Section II. How Your Coverage Works 11 8 Participating Providers 11 8 The Role of Primary Care Dentists 11 8 Access to Providers and Changing Providers 8 Services Subject to Preauthorization 11 9 Medical Necessity 12 9 Important Telephone Numbers and Addresses 13 10 Section III. Cost-Sharing Expenses and Allowed Amount 14 11 Section IV. Who is Covered 16 14 Section V. Pediatric Dental Care 19 20 Section VI. Adult Dental Care 21 22 Section VII. Exclusions and Limitations 23 31 Section VIII. Claim Determinations 25 33 Section IX. Grievance Procedures 27 Utilization Review 35 Section X. Utilization Review 29 External Appeal 38 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 42 Section XIIIXII. Extension of Benefits 36 44 Section XIVVIII. Temporary Suspension Rights for Armed Forces’ Members 37 45 Section XVXIV. General Provisions 38 46 Section XVI. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.Policy SECTION I