Common use of Dental Services - Accidental Injury (Emergency Clause in Contracts

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40$40 20% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 4020% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $200 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 500% - After deductible 50% - After deductible Fillings 500% - After deductible 50% - After deductible Simple extractions 500% - After deductible 50% - After deductible Denture repairs and relines/rebasing 500% - After deductible 50% - After deductible Crowns & onlays 500% - After deductible 50% - After deductible Therapeutic Pulpotomies 500% - After deductible 50% - After deductible Root canal therapy 500% - After deductible 50% - After deductible Non-surgical periodontal services 500% - After deductible 50% - After deductible Surgical periodontal services 500% - After deductible 50% - After deductible Periodontal maintenance 500% - After deductible 50% - After deductible Fixed bridges and dentures 500% - After deductible 50% - After deductible Implants 500% - After deductible 50% - After deductible Oral surgery services 500% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 500% - After deductible 50% - After deductible Biopsies 500% - After deductible 50% - After deductible Occlusal (night) guards 500% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 500% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. Not Covered In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 40% - After deductible Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% Standard $750 - After deductible 40% - After deductible Not Covered Enhanced $375 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $50 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 020% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% $300 - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Dental Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% Not Covered Covered Benefits - After deductible 0% - After deductible See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 2010% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $45 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% Standard $1,000 - After deductible 40% - After deductible Not Covered Enhanced $500 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Dental Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * Standard $1,000 - After deductible Not Covered Enhanced $500 Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $275 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $65 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 030% - After deductible 40Not Covered Dental Services (Pediatric) - for members under age 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 030% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $45 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 020% - After deductible 40Not Covered Dental Services (Pediatric) - for members under age 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40Not Covered Dental Services (Pediatric) - for members under age 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40Not Covered Dental Servces (Pediatric) - for members under age 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $50 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 20% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 020% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Early Intervention Services (EIS) Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $45 Not Covered Hearing diagnostic testing 20% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 20% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 20% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 20% - After deductible Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible Not Covered Therapeutic pulpotomies 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible Not Covered Palliative treatment 0% - After deductible Palliative treatment 50Not Covered Fillings 0% - After deductible 50Not Covered Simple extractions 0% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 500% - After deductible 50Not Covered Crowns & onlays 0% - After deductible Crowns & onlays 50Not Covered Therapeutic Pulpotomies 0% - After deductible 50Not Covered Root canal therapy 0% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 500% - After deductible 50Not Covered Surgical periodontal services 0% - After deductible Surgical periodontal services 50Not Covered Periodontal maintenance 0% - After deductible 50Not Covered Fixed bridges and dentures 0% - After deductible Periodontal maintenance 50Not Covered Implants 0% - After deductible 50Not Covered Oral surgery services 0% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 500% - After deductible 50Not Covered Biopsies 0% - After deductible Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 500% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 500% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2010% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2010% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2010% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 2010% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 2010% - After deductible The level of coverage is the same as network provider.. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Early Intervention Services (EIS) Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management 10% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 20% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $50 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible $40 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% Standard $750 - After deductible 40% - After deductible Not Covered Enhanced $375 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 010% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 010% - After deductible 40% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 010% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Dental Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 19: See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible Not Covered X-rays 0% - After deductible 0% - After deductible Not Covered Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Not Covered Fluoride treatments 0% - After deductible 0% - After deductible Not Covered Sealants 0% - After deductible 0% - After deductible Not Covered Space Maintainers 0% - After deductible 0% - After deductible Not Covered Palliative treatment 50% - After deductible 50% - After deductible Not Covered Fillings 50% - After deductible 50% - After deductible Not Covered Simple extractions 50% - After deductible 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Not Covered Crowns & onlays 50% - After deductible 50% Not Covered Covered Benefits - After deductible See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Not Covered Root canal therapy 50% - After deductible 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible 50% - After deductible Not Covered Implants 50% - After deductible 50% - After deductible Not Covered Oral surgery services 50% - After deductible 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Not Covered Biopsies 50% - After deductible 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 010% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - Emergencyroom- When services are due to accidental injury to sound tosound natural teeth. 0% - After deductible teet.h 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx In a physician’s/dentist’s office - When services are S K \ V LoffiFce- WL heDn serQvice¶s arVe due to accidental injury to sound toousnd natural teeth. 0% - After deductible 40% - After deductible teet.h 0%- Afterdeductible 40%- Afterdeductible Dental Services - Services- Outpatient Services connected to dental care when performed in an outpatient facility outpatientfacility * 0% - 0%- Afterdeductible 40%- Afterdeductible Dental Services (Pediatric)- for members under age 19: See Dental Services in Section 3 fboernefitlimitsand details. These services only apply to an enrolmledemberunder the age of 19. Oral evaluations 0%- Afterdeductible 0%- After deductible 40% - X-rays 0%- Afterdeductible 0%- After deductible Cleanings (prophylaxis) 0%- Afterdeductible 0%- After deductible Fluoride treatments 0%- Afterdeductible 0%- After deductible Sealants 0%- Afterdeductible 0%- After deductible Space Maintainers 0%- Afterdeductible 0%- After deductible Palliative treatment 0%- Afterdeductible 50%- After deductible Fillings 0%- Afterdeductible 50%- After deductible Simple extractions 0%- Afterdeductible 50%- After deductible Denture repairs and relines/rebasing 0%- Afterdeductible 50%- After deductible Crowns & onlays 0%- Afterdeductible 50%- After deductible Therapeutic Pulpotomies 0%- Afterdeductible 50%- After deductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Non-surgical periodontal services 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Surgical periodontal services 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Periodontal maintenance 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Fixed bridges and dentures 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Implants 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Oral surgery services 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible General anesthesia or IV sedation - dental sedatio-ndental office 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Biopsies 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Occlusal (night) guards 50% - After deductible 50% - 0%- Afterdeductible 50%- After deductible Orthodontic services (braces) - when medically necessary. 50% - brace-s)whenmedically necessar.y 0%- Afterdeductible 50%- After deductible 50% - After deductible Dialysis Services DialysisServices Inpatient/outpatientoutpatie/in nint your home 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable Outpatientdurable medical equipment* - Must equipmen-t*Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must 0%- Afterdeductible 40%- Afterdeductible Outpatientmedical supplies-*Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic 0%- Afterdeductible 40%- Afterdeductible Outpatientdiabetic supplies/equipment purchased at licensed medical supply provider (other supplpyrovider(other than a pharmacyapharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacyapharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - 0%- Afterdeductible 40%- Afterdeductible Outpatientprosthesis*- Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Enteral formula fomr ula or food taken orally * 20% - After deductible 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Hair prosthesis (wigs) - The wigs-)The benefit limit is limis $350 per hair prosthesis (wig) when worn for hair loss suffered as a result re of cancer treatment. 20% - After deductible 0%- Afterdeductible The level of coverage is the same as network provider.xxxxxx.xx Early Intervention Services (EIS) Coverage provided fomr embersfrom birth to 36 months. Theprovidermust be certified as an EIpSroviderby the Rhode Island Department of Human Services. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Education - Asthma Asthma management 0%- Afterdeductible 40%- Afterdeductible Emergency Room Services Hospitalemergencyroom 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0%- Afterdeductible 40%- Afterdeductible Hearing diagnostic testing 0%- Afterdeductible 40%- Afterdeductible Hearing aids- Thebenefit limis $1,500 per hearing aid fo a memberunder 19; thebenefit limis $700 per hearing aid for amember19 and older. 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Home Health Care* Intermittent skilled services when billed by a home heal care agency. 0%- Afterdeductible 40%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Hospice Care Inpatien/tin your home. When provided by an approved hospice care program. 0%- Afterdeductible 40%- Afterdeductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0%- Afterdeductible 40%- Afterdeductible Infertility Services Inpatient/outpatiennt/ia S K o\ ffiVce. LThreFe (3L) D infertility treatment cycles will be coveredplpaenryearwith a total of eight (8) infertility treatment cycles covered in P H liPfetimEe. H U ¶ V 0%- Afterdeductible 40%- Afterdeductible Infusion Therapy- Administration Services Outpatient- hospital 0%- Afterdeductible 40%- Afterdeductible In the S K o\ ffiVce/inLyoFur hLomeD Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Inpatient Services General hospitaol r specialtyhospitalservices*- unlimited days 0%- Afterdeductible 40%- Afterdeductible Rehabilitationfacility services-*limited to 45 days peprlan year. 0%- Afterdeductible 40%- Afterdeductible Physicianhospitalvisits 0%- Afterdeductible 40%- Afterdeductible