Common use of TERMS AND CONDITIONS IN THIS CONTRACT Clause in Contracts

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. 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 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 Section VI. Adult Dental Care 18 Section VII. Exclusions and Limitations 20 Section VIII. Claim Determinations 22 Section IX. Grievance Procedures 24 Section X. Utilization Review 26 Section XI. External Appeal 30 Section XII. Termination of Coverage 33 Section XIII. Extension of Benefits 34 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 Section XV. General Provisions 36

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. 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 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 Section VI. Adult Dental Care 18 Section VII. Exclusions and Limitations 20 Section VIII. Claim Determinations 22 Section IX. Grievance Procedures 24 Section X. Utilization Review 26 Section XI. External Appeal 30 Section XII. Termination of Coverage 33 Section XIII. Extension of Benefits 34 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 Section XV. General Provisions 3636 Section XVI. Schedule of Benefits 40 Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.

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. 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 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 17 Section VI. Adult Dental Care 18 19 Section VII. Exclusions and Limitations 20 21 Section VIII. Claim Determinations 22 23 Section IX. Grievance Procedures 24 25 Section X. Utilization Review 26 27 Section XI. External Appeal 30 31 Section XII. Termination of Coverage 33 34 Section XIII. Extension of Benefits 34 35 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 36 Section XV. General Provisions 3637 Section XVI. Schedule of Benefits 41 Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.

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. 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 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 15 Section VI. Adult Dental Care 18 Section VII. Exclusions and Limitations 20 17 Section VII. Claim Determinations 19 Section VIII. Claim Determinations 22 Grievance Procedures 21 Section IX. Grievance Procedures 24 Utilization Review 23 Section X. Utilization Review 26 External Appeal 27 Section XI. External Appeal Termination of Coverage 30 Section XII. Termination of Coverage 33 Section XIII. Extension of Benefits 34 31 Section XIVXIII. Temporary Suspension Rights for Armed Forces’ Members 35 32 Section XIV. General Provisions 33 Section XV. General Provisions 36Schedule of Benefits 38 Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.

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. 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 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 Section VI. Adult Dental Care Exclusions and Limitations 18 Section VII. Exclusions and Limitations Claim Determinations 20 Section VIII. Claim Determinations Grievance Procedures 22 Section IX. Grievance Procedures Utilization Review 24 Section X. Utilization Review 26 External Appeal 28 Section XI. External Appeal 30 Section XII. Termination of Coverage 33 31 Section XIIIXII. Extension of Benefits 34 32 Section XIVXIII. Temporary Suspension Rights for Armed Forces’ Members 35 33 Section XIV. General Provisions 34 Section XV. General Provisions 36Schedule of Benefits 39 Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.

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. 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 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 17 Section VI. Adult Dental Care 18 19 Section VII. Exclusions and Limitations 20 21 Section VIII. Claim Determinations 22 23 Section IX. Grievance Procedures 24 25 Section X. Utilization Review 26 27 Section XI. External Appeal 30 31 Section XII. Termination of Coverage 33 34 Section XIII. Extension of Benefits 34 35 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 36 Section XV. General Provisions 3637 Section XVI. Schedule of Benefits 41 Riders, Contract Amendments. End of Contract Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services.