Common use of COVERED DENTAL SERVICES Clause in Contracts

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative Services Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Palliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Minor Restorative Services Crowns & OnlaysFillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Biopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Root canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Non-surgical periodontal services and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75Total Health Solutions - members diagnosed with diabetes and/or coronary artery disease. See Total Health Solutions for eligbility details. 0% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered0%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative Services Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Not Covered Not Covered General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Not Covered Not Covered Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Palliative treatment Under age 19 20% 20% Age 19 and older 50% 50% Minor Restorative Services Crowns & OnlaysFillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal servicesBiopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and denturesRoot canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Non-surgical periodontal services and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50Total Health Solutions - members diagnosed with diabetes and/or coronary artery disease. See Total Health Solutions for eligibility details. 0% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered0%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Crowns & Onlays* Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery servicesPalliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Minor Restorative Services Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental officeBiopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Root canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical Non-surgical periodontal servicesservices and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Crowns & Onlays* Oral evaluations Under age 19 750% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Palliative treatment Under age 19 7520% 20% Age 19 and older 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Recementations Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period Surgical periodontal services* Simple extractions Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 7520% - After deductible 7520% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered50% 50% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Summary of Benefits

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative Services Crowns & Onlays(*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Oral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 7520% - After deductible 7520% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 40deductible 20% - After 12 month waiting period deductible Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After deductible 50% - After deductible Prosthodontics Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After deductible 50% - After deductible Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After deductible 50% - After deductible Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Non-surgical periodontal services and Periodontal Maintenance* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After a 12 month waiting period 20% - After a 12 month waiting period Total Health Solutions - members diagnosed with certain health conditions. See Total Health Solutions for eligibility details. 0% 0% Major Restorative Services Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Oral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Prosthodontics Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Crowns & Onlays* Oral evaluations Under age 19 750% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 20% 20% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Palliative treatment Under age 19 7520% 20% Age 19 and older 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Recementations Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period Surgical periodontal services* Simple extractions Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 7520% - After deductible 7520% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered20% 20% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative Services Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Oral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After a 12 month waiting period 4020% - After a 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Prosthodontics Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After a 12 month waiting period 50% - After a 12 month waiting period Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Crowns & Onlays* Oral evaluations Under age 19 750% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Palliative treatment Under age 19 7520% 20% Age 19 and older 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Recementations Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period Surgical periodontal services* Simple extractions Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 7520% - After deductible 7520% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered50% 50% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% 50% Non-surgical periodontal services and Periodontal Maintenance* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% - After 12 month waiting period 50% - After 12 month waiting period Total Health Solutions - members diagnosed with diabetes and/or coronary artery disease. See Total Health Solutions for eligbility details. 0% 0%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Non-surgical periodontal services and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Total Health Solutions - members diagnosed with certain health conditions. See Total Health Solutions for eligibility details. 0% 0% Major Restorative Services Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Crowns & Onlays* Oral evaluations Under age 19 750% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 20% 20% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery services* Palliative treatment Under age 19 7520% 20% Age 19 and older 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Recementations Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4020% - After 12 month waiting period 4020% - After 12 month waiting period Surgical periodontal services* Simple extractions Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 7520% - After deductible 7520% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered20% 20% Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% 20% Non-surgical periodontal services and Periodontal Maintenance* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After a 12 month waiting period 20% - After a 12 month waiting period Total Health Solutions - members diagnosed with diabetes and/or coronary artery disease. See Total Health Solutions for eligibility details. 0% 0%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Crowns & Onlays* Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Oral surgery servicesPalliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Minor Restorative Services Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental officeBiopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal servicesRoot canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 7540% - After deductible 7540% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not CoveredSummary of Benefits

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Major Restorative Services Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major (*) Predetermination is recommended for this service. See Section 5 for more information. You Pay You Pay Basic Preventive and Diagnostic Services Oral evaluations Under age 19 0% 0% Age 19 and older 0% 0% Cleanings (prophylaxis) Under age 19 0% 0% Age 19 and older 0% 0% X-rays Under age 19 0% 0% Age 19 and older 0% 0% Fluoride treatments Under age 19 0% 0% Age 19 and older Not Covered Not Covered Sealants Under age 19 0% 0% Age 19 and older Not Covered Not Covered Denture repairs, relines, and rebasing Under age 19 75% - After deductible 75% - After deductible Age 19 and older 50% 50% Space maintainers Under age 19 0% 0% Age 19 and older Not Covered Not Covered Palliative treatment Under age 19 20% 20% Age 19 and older 40% 40% Minor Restorative Services Crowns & OnlaysFillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 40% 40% Simple extractions Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Therapeutic Pulpotomies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Biopsies* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Root canal therapy* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% 40% Non-surgical periodontal services and Periodontal Maintenance* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75Total Health Solutions - members diagnosed with diabetes and/or coronary artery disease. See Total Health Solutions for eligibility details. 0% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered0%

COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative Services Crowns & Onlays* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Oral surgery services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After 12 month waiting period 4050% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older 4050% - After 12 month waiting period 4050% - After 12 month waiting period Surgical periodontal services* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Prosthodontics Bridges and dentures* Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Implants Under age 19 7550% - After deductible 7550% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered 50% - After 12 month waiting period 50% - After 12 month waiting period Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered