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 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * Standard $750 - 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 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. $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 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * Standard $750 0% - 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 serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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. $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 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * Standard $750 - After deductible Not Covered Enhanced $375 Not Covered Dialysis Services 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 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. $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 45 Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * Standard $750 1,000 - After deductible Not Covered Enhanced $375 500 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 Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered