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 (*) 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 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 6 month waiting period 20% - After deductible and a 6 month waiting period 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 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period Summary 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 Basic Preventive Non-surgical periodontal services 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 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 6 month waiting period 20% - After deductible and a 6 month waiting period 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 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Therapeutic PulpotomiesPeriodontal Maintenance* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period BiopsiesMajor Restorative Services Crowns & Onlays* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 2050% - After deductible 20and a 12 month waiting period 50% - After deductible Root canal therapyand a 12 month waiting period Oral surgery services* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period Summary of BenefitsGeneral anesthesia or IV sedation – in a dental office* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period Surgical periodontal services* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% - After deductible and a 12 month waiting period 50% - After deductible and a 12 month waiting period Prosthodontics Bridges and dentures* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% - After deductible and a 12 month waiting period 50% - After deductible and a 12 month waiting period Implants Under age 19 50% - After deductible 50% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. 50% - After deductible and a 12 month waiting period 50% - After deductible and 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 (*) 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 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 6 month waiting period 20% - After deductible and a 6 month waiting period 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 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Therapeutic Pulpotomies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible and a 12 month waiting period Biopsies* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Root canal therapy* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 12 month waiting period 20% - After deductible Non-surgical periodontal services and a 12 month waiting period Summary of BenefitsPeriodontal Maintenance* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Major Restorative Services Crowns & Onlays* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 50% - After deductible 50% - After deductible

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 Basic Preventive Non-surgical periodontal services 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 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible and a 6 month waiting period 20% - After deductible and a 6 month waiting period 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 0% 0% Minor Restorative Services Fillings Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Recementations Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Simple extractions Under age 19 50% - After deductible 50% - After deductible Age 19 and older 20% - After deductible 20% - After deductible Therapeutic PulpotomiesPeriodontal Maintenance* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 2050% - After deductible and a 12 month waiting period 2050% - After deductible and a 12 month waiting period BiopsiesTotal 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 50% - After deductible 50% - After deductible Age 19 and older 2050% - After deductible 2012 month waiting period 50% - After deductible Root canal therapy12 month waiting period Oral surgery services* Under age 19 50% - After deductible 50% - After deductible Age 19 and older 2050% - After 12 month waiting period 50% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 50% - After deductible 50% - After deductible Age 19 and a older 50% - After 12 month waiting period 2050% - After 12 month waiting period Surgical periodontal services* Under age 19 50% - After deductible 50% - After deductible Age 19 and a older 50% - After 12 month waiting period Summary of Benefits50% - After 12 month waiting period Prosthodontics Bridges and dentures* 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 Implants Under age 19 50% - After deductible 50% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are 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