Common use of Outside our Service Area Clause in Contracts

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There may be an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact us. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services in conjunction with medically necessary general anesthesia or a medical emergency. We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary general anesthesia for a member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia services.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There Your Participating Provider may be require an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact us. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services  Dental Services in conjunction with medically necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.  Nightguards. We cover removable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover use of nitrous oxide during dentally necessary treatment as deemed appropriate by the Participating Provider.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There An Emergency Dental Care office visit Copayment may be an additional fee added to any other applicable Copayments or Coinsurance apply when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedicationmedication when used prior to dental treatment to avoid any delay in dental treatment. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Non-Participating Providers may charge additional fees for Emergency Dental Care, based on that Non-Participating Dental Office’s policy. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows:  Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency.  Nightguards. We do not cover general anesthesia servicesremovable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover use of nitrous oxide during Dentally Necessary treatment as deemed appropriate by the Participating Provider.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, Cost Share and reimbursement. You pay the amount shown in the “Benefit Summary.” There An Emergency Dental Care office visit Copayment may be an additional fee added apply in addition to any other applicable Copayments or Coinsurance Cost Share when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedicationmedication when used prior to dental treatment to avoid any delay in dental treatment. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Non-Participating Providers may charge additional fees for Emergency Dental Care, based on that Non-Participating Dental Office’s policy. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows: Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia services.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There An Emergency Dental Care office visit Copayment may be an additional fee added to any other applicable Copayments or Coinsurance apply when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedicationmedication when used prior to dental treatment to avoid any delay in dental treatment. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Non-Participating Providers may charge additional fees for Emergency Dental Care, based on that Non-Participating Dental Office’s policy. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows: Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There Your Participating Provider may be require an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact us. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services Dental Services in conjunction with medically necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There An Emergency Dental Care office visit Copayment may be an additional fee added to any other applicable Copayments or Coinsurance apply when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedicationmedication when used prior to dental treatment to avoid any delay in dental treatment. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Non-Participating Providers may charge additional fees for Emergency Dental Care, based on that Non-Participating Dental Office’s policy. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows:  Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.  Nightguards. We cover removable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover use of nitrous oxide during Dentally Necessary treatment as deemed appropriate by the Participating Provider.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There An Emergency Dental Care office visit Copayment may be an additional fee added to any other applicable Copayments or Coinsurance apply when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from outside the Service Area will be reimbursed at the Usual and Customary Charge. Non-Participating Providers when you may charge additional fees for Emergency Dental Care, based on that Non- Participating Dental Office’s policy. You are outside responsible for any balance owed after our payment of the Service Area, you are provided limited coverage for Services, including local anesthesia Usual and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incidentCustomary Charge and your payment of any Copayment or Coinsurance. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows:  Medically Necessary general anesthesia and covered dental Services in conjunction with medically necessary Medically Necessary anesthesia. We cover Medically Necessary general anesthesia services when provided in conjunction with the dental Services described in the “Benefits” section, if the general anesthesia services are Medically Necessary because the Member is a child under age seven or a medical emergencyis physically or mentally disabled. We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member who is a child under age seven, or in a hospital’s emergency department in order to provide dental Services in conjunction who is physically or mentally disabled, along with a medical emergencythe Medically Necessary general anesthesia.  Nightguards. We cover removable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover use of nitrous oxide during Dentally Necessary treatment as deemed appropriate by the Participating Provider.  Temporomandibular Joint (TMJ) Disorders. We cover Dental Services related to treatment of Temporomandibular Joint (TMJ) Disorders when received from a Participating Provider subject to the benefit limitations shown in the “Benefit Summary,” except that we do not cover general anesthesia servicesServices related to treatment of Temporomandibular Joint (TMJ) Disorders. For purposes of this benefit, Dental Services means: • Reasonable and appropriate for the treatment of a disorder of the temporomandibular joint, under all the factual circumstances of the case; and • Effective for the control or elimination of one or more of the following, caused by a disorder of the temporomandibular joint: Pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food; and • Dentally Necessary; and • Not experimental or primarily for cosmetic purposes.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There Your Participating Provider may be require an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact us. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services  Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.  Nightguards. We cover removable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover use of nitrous oxide during dentally necessary treatment as deemed appropriate by the Participating Provider.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There may be an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact us. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service AreaArea will be reimbursed at the Usual and Customary Fee. Non- Participating Providers may charge additional fees for Emergency Dental Care, you based on that Non- Participating Dental Office’s policy. You are provided limited coverage responsible for Servicesany balance owed after our payment of the Usual and Customary Fee and your payment of any applicable Deductible, including local anesthesia and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incidentCopayment, or Coinsurance. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Medically necessary general anesthesia and covered dental Services in conjunction with medically necessary anesthesia. We cover medically necessary general anesthesia services when provided in conjunction with the dental Services described in the “Benefits” section, if the general anesthesia services are medically necessary because the Member is a child under age seven or a medical emergencyis physically or mentally disabled. We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary general anesthesia for a member Member who is child under age seven, or in a hospital’s emergency department in order to provide dental Services in conjunction who is physically or mentally disabled, along with a medical emergency. We do not cover the medically necessary general anesthesia servicesanesthesia.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, Cost Share and reimbursement. You pay the amount shown in the “Benefit Summary.” There An Emergency Dental Care office visit Copayment may be an additional fee added apply in addition to any other applicable Copayments or Coinsurance Cost Share when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedicationmedication when used prior to dental treatment to avoid any delay in dental treatment. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Non-Participating Providers may charge additional fees for Emergency Dental Care, based on that Non-Participating Dental Office’s policy. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows: Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There Your Participating Provider may be require an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact usProvider. If you require Emergency Dental Care from Non-Participating Providers when you are outside the Service Area, you are provided limited coverage for Services, including local anesthesia and premedicationmedication when used prior to dental treatment to avoid any delay in dental treatment. We will not cover more than the amount shown in the “Benefit Summary” for each incident. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services We cover other dental Services as follows:  Dental Services in conjunction with medically necessary Medically Necessary general anesthesia or a medical emergencyemergency (subject to the “Exclusions and Limitations” section). We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary Medically Necessary general anesthesia for a member Member or in a hospital’s emergency department in order to provide dental Services in conjunction with a medical emergency. We do not cover general anesthesia servicesServices.  Nightguards. We cover removable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover use of nitrous oxide during Dentally Necessary treatment as deemed appropriate by the Participating Provider.

Outside our Service Area. If you are temporarily outside our Service Area, we provide a limited benefit for Emergency Dental Care you receive from Non-Participating Providers or Non-Participating Dental Offices, if we determine that the Services could not be delayed until you returned to our Service Area. Elective care and reasonably foreseen conditions. Elective care and care for conditions that could have been reasonably foreseen are not covered under your Emergency Dental Care or Urgent Dental Care benefits. Follow-up and continuing care is covered only at Participating Dental Offices. You pay the amount shown in the “Benefit Summary.” Deductible, Copayments, Coinsurance, and reimbursement. You pay the amount shown in the “Benefit Summary.” There Your Participating Provider may be require an additional fee added to any other applicable Copayments or Coinsurance when you receive Emergency Dental Care or an Urgent Dental Care appointment from a Participating Provider by the next business day after you contact us. If you require Emergency Dental Care from outside the Service Area will be reimbursed at the Usual and Customary Charge. Non-Participating Providers when you may charge additional fees for Emergency Dental Care, based on that Non- Participating Dental Office’s policy. You are outside responsible for any balance owed after our payment of the Service Area, you are provided limited coverage for Services, including local anesthesia Usual and premedication. We will not cover more than the amount shown in the “Benefit Summary” for each incidentCustomary Charge and your payment of any applicable Copayment or Coinsurance. Urgent Dental Care. We cover Urgent Dental Care received in our Service Area from Participating Providers and Participating Dental Offices only if the Services would have been covered under other headings of this “Benefits” section (subject to the “Exclusions and Limitations” section) if they were not urgent. Examples include treatment for toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment. We do not cover Urgent Dental Care (or other Services that are not Emergency Dental Care) received outside of our Service Area or received from Non-Participating Providers and Non-Participating Dental Offices. Other Benefits Dental Services  Medically necessary general anesthesia and covered dental Services in conjunction with medically necessary anesthesia. We cover medically necessary general anesthesia services when provided in conjunction with the dental Services described in the “Benefits” section, if the general anesthesia services are medically necessary because the Member is a child under age seven or a medical emergencyis physically or mentally disabled. We cover the dental Services described in the “Benefits” section when provided in a hospital or ambulatory surgical center, if the Services are performed at that location in order to obtain medically necessary general anesthesia for a member Member who is a child under age seven, or who is physically or mentally disabled, along with the medically necessary general anesthesia.  Nightguards. We cover removable dental appliances designed to minimize the effects of bruxism (teeth grinding) and other occlusal factors.  Nitrous oxide. We cover nitrous oxide during dentally necessary treatment as deemed appropriate by the Participating Provider.  Temporomandibular joint disorders. We cover Services related to treatment of temporomandibular joint disorders, except that we do not cover Orthodontic Services related to treatment of temporomandibular joint disorders. EXCLUSIONS AND LIMITATIONS The Services listed in this “Exclusions and Limitations” section are either completely excluded from coverage or partially limited under this EOC. These exclusions and limitations apply to all Services that would otherwise be covered under this EOC and are in addition to the exclusions and limitations that apply only to a hospitalparticular Service as listed in the description of that Service in this EOC. Exclusions  Cosmetic Services, supplies, or prescription drugs that are intended primarily to improve appearance, repair, and/or replace cosmetic dental restorations.  Dental conditions for which Service or reimbursement is required by law to be provided at or by a government agency.  Dental implants, including bone augmentation and fixed or removable prosthetic devices attached to or covering the implants; all related Services, including diagnostic consultations, impressions, oral surgery, placement, removal, and cleaning when provided in conjunction with dental implants; and Services associated with postoperative conditions and complications arising from implants, unless your Group has purchased coverage for dental implants as an additional benefit.  Drugs obtainable with or without a prescription. These may be covered under your medical benefits.  Experimental or investigational treatments, procedures, and other Services that are not commonly considered standard dental practice or that require United States (U.S.) Food and Drug Administration (FDA) governmental approval. A Service is experimental or investigational if:  the Service is not recognized in accordance with generally accepted dental standards as safe and effective for use in treating the condition in question, whether or not the Service is authorized by law for use in testing or other studies on human patients; or  the Service requires approval by FDA authority prior to use and such approval has not been granted when the Service is to be rendered.  Fees a provider may charge for an Emergency Dental Care or Urgent Dental Care visit.  Full mouth reconstruction and occlusal rehabilitation, including appliances, restorations, and procedures needed to alter vertical dimension, occlusion, or correct attrition or abrasion.  Genetic testing.  Medical or Hospital Services, unless otherwise specified in the EOC.  Missed appointment fees a provider may charge for a missed appointment.  Orthodontic Services, unless your Group has purchased orthodontic coverage as an additional benefit.  Orthognathic surgery, except this exclusion does not apply to orthognathic surgical Services performed by a Participating Dentist for treatment of a congenital anomaly such as cleft palate when the Services are required for a covered Dependent child and the Dependent is not enrolled under a Company medical Plan that covers these Services.  Prosthetic devices following your decision to have a tooth (or teeth) extracted for nonclinical reasons or when a tooth is restorable.  Replacement of prefabricated, noncast crowns, including noncast stainless steel crowns that were not placed by a Participating Provider.  Services for conditions that are covered by workers’ compensation or that are the employer’s emergency department responsibility.  Services furnished by a family member.  Services provided or arranged by criminal justice institutions for Members confined therein, unless care would be covered as Emergency Dental Care.  Speech aid prosthetic devices and follow up modifications.  Treatment to restore tooth structure lost due to attrition, erosion, or abrasion. Limitations  “Hospital call fees,” “call fees” or similar Charges associated with Dentally Necessary Services that are performed at ambulatory surgical centers or hospitals, unless the Services are provided in that setting in order to provide obtain medically necessary general anesthesia for a Member who is a child under age seven, or who is physically or mentally disabled.  Repair or replacement needed due to normal wear and tear of fixed and removable prosthetic devices that are less than five years old is not covered.  Sedation and general anesthesia (including, but not limited to, intramuscular IV sedation, non-IV sedation, and inhalation sedation) are not covered, except when pursuant to the “nitrous oxide” provision described in the “Other Dental Services” section, and when medically necessary for members who are under seven, developmentally disabled or physically handicapped, pursuant to the “medically necessary general anesthesia and covered dental Services in conjunction with a medical emergencymedically necessary anesthesia” provision as described in the “OtherDental Services” section. We REDUCTIONS Notice to Covered Persons If you are covered by more than one dental benefit plan, and you do not cover general anesthesia servicesknow which is your primary plan, you or your provider should contact any one of the dental plans to verify which plan is primary. The dental plan you contact is responsible for working with the other plan to determine which is primary and will let you know within thirty calendar days.