Common use of ACCESSING BENEFITS Clause in Contracts

ACCESSING BENEFITS. Participating Dentists Benefits When a member receives care from one of over 1,800 Participating Dentists, he or she simply presents his or her identification card showing dental coverage. The dentist bills us directly for all covered services. For dental care provided by a Participating Dentist, we will pay the lesser of the dentist's usual charge or the Usual, Customary and Reasonable Charge as determined by us. The dentist accepts our reimbursement as full payment and may not ▇▇▇▇ the member for any additional charges. Non-Participating Dentists Benefits For covered dental services provided by a Non-Participating Dentist, in or out of Connecticut, we pay the • 1 lesser of the dentist's charge or the applicable allowance for the procedure, as determined by us. The member is responsible for any difference between the amount paid by us and the fee charged by the dentist. This does not constitute your health plan or insurance policy. It is only a general description for the purposes of this Request for Proposal, of the Anthem Blue Cross Blue Shield Full Dental Plan. Refer to your Master Group Policy or Description of Benefits, on file with your employer, for a complete listing of benefits, maximums, exclusions and limitations. 8133 Rev. IVO Cattinkt,Miture Su Cron ant awSNW h e tuts writ of rname NW* MIL Iv, al katepenlelt fame of do FINI Cras ird Din NW At tatiatbs (19 Rechteled mall dde Ellie fnet troilUSliddAlscciallea CZ99r In addition to the services provided under your dental program, the following additional basic benefits are provided: • Inlays (not part of bridge) • Onlays (not part of bridge) ♦ Crown (not part of bridge) • Space Maintainers • Oral Surgery consisting of fracture and dislocation treatment, diagnosis and treatment of cyst and abscess, surgical extractions and impaction ♦ Apicoectomy The dental services listed above are subject to the following qualifications: We will pay for individual crowns, inlays and onlays only when amalgam or synthetic fillings would not be satisfactory for the retention of the tooth, as determined by us. We will not pay for a replacement provided less than five (5) years following a placement or replacement which was covered under this Rider. We will not pay for individual crowns, inlays or onlays to alter vertical dimension, for the purpose of precision attachment of dentures, or when they are splinted together for any reason. If the member is not covered by Dental Amendatory Rider C (Prosthodontics) we will pay for the following types of crowns, inlays or onlays, but only when there is clinical evidence that amalgam or synthetic fillings would not be satisfactory for the retention of the tooth: ♦ One tooth on either side or two teeth on one side of a replacement for missing teeth, as part of a fixed bridge. ♦ No benefits will be provided for the tooth replacements. • Space maintainers — payment will be made for devices to preserve space due to premature loss of primary teeth, but not for interceptive orthodontic devices. Payment will be made for up to two devices per member per lifetime. 8133 Rev. 1O/ Caresetki. kihsrs ems sad tin ShIsV Is *Inds nem of Mtn, Nair Rumba. an iteptridei trasanoi1114 Morns:mg Ws WO Also:Wi es Ikpistend wait et the Floe Cnsts and Mut NekdAafeciation. Anthem. 'F? Visit our website at www.anthem.cont Dentists who participate in our dental programs agree to accept our allowance as fully payment and may not ▇▇▇▇ the member for any additional charges except for the remaining coinsurance balance.

ACCESSING BENEFITS. Participating Dentists Benefits When a member receives care from one of over 1,800 Participating DentistsParticipatingDentists, he or she simply presents his or her identification card identificationcard showing dental coverage. The dentist bills us directly for all covered services. For dental care provided by a Participating Dentist, we will pay the lesser of the dentist's usual charge or the Usual, Customary and Reasonable Charge as determined by us. The dentist accepts our reimbursement as full payment and may not ▇▇▇▇ the member for any additional charges. Non-Participating Dentists Benefits For covered dental services provided by a Non-Participating Dentist, in or out of Connecticut, we pay the • 1 lesser of the dentist's charge or the applicable allowance for the procedure, as determined by us. The member is responsible for any difference between the amount paid by us and the fee charged by the dentist. This does not constitute your constituteyour health plan or insurance policy. It is only a general description for descriptionfor the purposes of this Request for Proposal, of the Anthem Blue Cross Blue Shield Full Dental Plan. Refer to your Master Group Policy or Description of Benefits, on file with your employer, for a complete listing of benefits, maximums, exclusions and limitations. 8133 Rev. IVO Cattinkt,Miture Su Cron ant awSNW h e tuts writ of rname NW* MIL Iv, al katepenlelt fame of do FINI Cras ird Din NW At tatiatbs (19 Rechteled mall dde Ellie fnet troilUSliddAlscciallea CZ99r In Decide be healthyY addition to the services provided under your dental program, the following additional basic benefits are provided: • Inlays (not part of bridge) • Onlays (not part of bridge) ♦ Crown (not part of bridge) • Space Maintainers • Oral Surgery consisting of fracture and dislocation treatment, diagnosis and treatment of cyst and abscess, surgical extractions and impaction ♦ Apicoectomy The dental services listed above are subject to the following qualifications: We will pay for individual crowns, inlays and onlays only when amalgam or synthetic fillings would not be satisfactory for the retention of the tooth, as determined by us. We will not pay for a replacement provided less than five (5) years following a placement or replacement which was covered under this Rider. We will not pay for individual crowns, inlays or onlays to alter vertical dimension, for the purpose of precision attachment of dentures, or when they are splinted together for any reason. If the member is not covered by Dental Amendatory Rider C (Prosthodontics) we will pay for the following types of crowns, inlays or onlays, but only when there is clinical evidence that amalgam or synthetic fillings would not be satisfactory for the retention of the tooth: ♦ One tooth on either side or two teeth on one side of a replacement for missing teeth, as part of a fixed bridge. ♦ No benefits will be provided for the tooth replacements. • Space maintainers — maintainers- payment will be made for devices to preserve space due to premature loss of primary teeth, but not for interceptive orthodontic devices. Payment will be made for up to two devices per member per lifetime. 8133 Rev. 1O/ CaresetkiParticipating Dentists Benefits Anthem Blue Cross Blue Shield will pay the lesser of fifty percent of the dentist's usual charge or fifty percent of the Usual, Customary and Reasonable Charge, as determined by us, for the dental services described in this Rider. kihsrs ems sad tin ShIsV Is *Inds nem of Mtn, Nair Rumba. an iteptridei trasanoi1114 Morns:mg Ws WO Also:Wi es Ikpistend wait et the Floe Cnsts and Mut NekdAafeciation. Anthem. 'F? Visit our website at www.anthem.cont Dentists who participate in our dental programs agree to accept our allowance as fully payment and may not ▇▇▇▇ the member for any additional charges except for the remaining coinsurance balance.