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. $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. $50 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 20% - After deductiblecare coordinated by your primary care physician and permitted self-referrals.

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 30 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 20% - After deductibledeductible Not Covered Dialysis Services Inpatient/outpatient/in your home 20% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 40 20% plus $40 - After deductibleAfterdeductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 150 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. $50 2030 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductibledeductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 50 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. $50 15 20% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% 20% - After deductible

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $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. $50 2040 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductibledeductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered