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. $40 20% plus $40 - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

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. $40 50 20% plus $40 - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

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. $40 20% plus $40 - After deductible Afterdeductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible

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. $40 20% plus $40 - After deductible 25 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductibleNot Covered

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. $40 30 20% plus $40 - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible