Common use of Summary of Benefits Clause in Contracts

Summary of Benefits. Plan Feature Employee Co-pay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO “Buy Up” Option (Voluntary) Summary of Benefits 1 Additional employee co-pay if approved specialist performs services. Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500

Summary of Benefits. Plan Feature Employee Co-pay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service 1 Additional employee co-pay if approved specialist performs services. Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO “Buy Up” Option (Voluntary) Summary of Benefits 1 Additional employee co-pay if approved specialist performs services. Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500

Summary of Benefits. Plan Feature Employee Co-pay Copay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions ex- tractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service Major Restorative • Crowns • Bridges • Complete Dentures Denture $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO copay DPPO “Buy Up” Option (Voluntary) Summary of Benefits 1 Additional employee co-pay if approved specialist performs services. Plan Feature In Network/Out of Network Class I (Preventative) 100%/100100% / 100% Class II (Basic/Restorative) 80%/8080% / 80% Class III (Major) 60%/6060% / 60% Class IV (Orthodontia - adult ortho is included) 50%/5050% / 50% Annual Deductible per Member (does not apply to Class I services) $50/$50 50 / $50 Orthodontia Lifetime Max $1,500/$1,5001,500 / $1,500 1 Additional employee copay if approved specialist performs services.

Summary of Benefits. Plan Feature Employee Co-pay Copay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO copay DPPO “Buy Up” Option (Voluntary) Summary of Benefits 1 Additional employee co-pay if approved specialist performs services. Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 1 Additional employee copay if approved specialist performs services. Orthodontia Lifetime Max $1,500/$1,500 Annual Maximum $1,500/$1,500

Summary of Benefits. Plan Feature Employee Co-pay Copay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO copay 1 Additional employee copay if approved specialist performs services. DPPO “Buy Up” Option (Voluntary) Summary of Benefits 1 Additional employee co-pay if approved specialist performs services. Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500 Annual Maximum $1,500/$1,500

Summary of Benefits. Plan Feature Employee Co-pay Copay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO copay DPPO “Buy Up” Option (Voluntary) Summary of Benefits 1 Additional employee co-pay if approved specialist performs services. Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not $50/$50 1 Additional employee copay if approved specialist performs services. apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500 Annual Maximum $1,500/$1,500