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. 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 President & CEO BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 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. 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 President & CEO BlueCross BlueShield of Western Northeastern New York 000 00 Xxxxxxx Xxxx Xxxxxxx Xx. BuffaloXxxxx Latham, New York 14202 12110 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. This Contract is a New York State of Health, The Official 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 President & CEO BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. BuffaloServices Corp. Schenectady, New York 14202 By: President TABLE OF CONTENTS Section I. Definitions 4 Section II. How Your Coverage Works 8 9 Participating Providers 8 9 The Role of Primary Care Dentists 8 9 Services Subject to Preauthorization 9 10 Medical Necessity 9 10 Important Telephone Numbers and Addresses 10 11 Section III. Access to Care and Transitional Care 12 Section IV. Cost-Sharing Expenses and Allowed Amount 11 14 Section IV. V. 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. XI. Utilization Review 26 Section XI. External Appeal 30 Section XII. Termination of Coverage 33 Section XIIIXIIIV. Extension of Benefits 34 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 Section XV. General Provisions 3636 Schedule of Benefits Attached SECTION I

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 ContractMVP Health Services Corp. Schenectady, You may call Us at 0-000-000-0000 NY By: President & CEO BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 TABLE OF CONTENTS Section I. Definitions 4 Section II. How Your Coverage Works 8 10 Participating Providers 8 10 The Role of Primary Care Dentists 8 10 Services Subject to Preauthorization 9 12 Medical Necessity 9 12 Important Telephone Numbers and Addresses 10 13 Section III. Access to Care and Transitional Care 14 Section IV. Cost-Sharing Expenses and Allowed Amount 11 17 Section IV. V. Who is Covered 13 21 Section V. VI. Pediatric Dental Care 16 28 Section VIVII. Adult Dental Care 18 30 Section VIIVIII. Exclusions and Limitations 20 32 Section VIIIIX. Claim Determinations 22 Section IX. Grievance Procedures 24 35 Section X. Utilization Review 26 Grievance Procedure 37 Section XI. Utilization Review 40 Section XII. External Appeal 30 46 Section XIIXIII. Termination of Coverage 33 50 Section XIIIXIV. Extension of Benefits 34 52 Section XIVXV. Temporary Suspension Rights for Armed Forces’ Members 35 53 Section XVXVI. General Provisions 3654 Section XVII. Schedule of Benefits 02 Adult SECTION I