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. $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. $30 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - 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 or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $150 100 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. $30 Not Covered 25 20% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered 20% - 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 or for certain services in the benefit categoryservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 40 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - 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 or for certain services in the benefit categoryservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay

Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $150 200 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. $30 50 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 020% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 020% - 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 or for certain services in the benefit categoryservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay