Common use of Unlimited Unlimited Clause in Contracts

Unlimited Unlimited. Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services AACPS • Division of Human Resources • HR/Benefits • DPS/JH 2095/2a (Rev. 10/17) Appendix C Dental and Vision Options XXXX ARUNDEL COUNTY PUBLIC SCHOOLS Active Employees and Retirees Benefits as of January 2017 Dental and Vision Options Active Employees and Retirees Dental Options CareFirst Traditional CareFirst PPO Concordia Plus DHMO MD1560* Benefits In-Network Out-of-Network In-Network Oral Examination 100% of AB 100% of AB 80% of AB $5 copay Routine Cleaning 100% of AB 100% of AB 80% of AB 100% Sealants (limited to permanent molars – until end of year in which a member turns 19) 100% of AB 100% of AB 80% of AB 100% Bitewing X-ray 100% of AB 100% of AB 80% of AB 100% Palliative Treatment 100% of AB 100% of AB 80% of AB 95% Other X-rays as required 100% of AB 100% of AB 80% of AB 100% Space Maintainers 100% of AB 100% of AB 80% of AB 95% Fillings 100% of AB 80% of AB 60% of AB** 100% Simple Extractions 100% of AB 80% of AB 60% of AB** 75%-85% Pulpotomy 100% of AB 80% of AB 60% of AB** 75%-80% Direct Pulp Caps 100% of AB 80% of AB 60% of AB** 75%-80% Root Canals 100% of AB 80% of AB 60% of AB** 75%-80% Apicoectomy 80% of AB** 80% of AB 60% of AB** 75%-80% Oral Surgical Services 80% of AB** 80% of AB 60% of AB** 75%-85% Surgical Extractions 80% of AB** 80% of AB 60% of AB** 75%-85% Oral Surgery 80% of AB** 80% of AB 60% of AB** 75%-85% General Anesthesia 80% of AB** 80% of AB 60% of AB** See note 1 Periodontics 50% of AB** 80% of AB 60% of AB** 50%-65% Crown 80% of AB** 80% of AB 60% of AB** 60%-80% Prosthetic Appliances (including implants) 50% of AB 80% of AB 60% of AB** 60%-80% Implants not covered Orthodontics Children and Adults 50% of AB 50% of AB 35% of AB See note 3 Annual Deductible $25 Ind./$50 Family None $50 Ind./$150 Family None Annual Benefit Maximum $1,500 $1,500 None/See note 2 Ortho Lifetime Maximum $1,500 $1,500 See note 3 (AB Allowed Benefit) Under the Concordia Plus DHMO (MD1560*) Plan, out-of-network services are reimbursed up to a maximum amount, based on the fee schedule provided by United Concordia. *The above DHMO Plan percentages are approximate and used for comparison purposes only. Please refer to the United Concordia (XXXX) Schedule of Benefits for actual copayment amounts. All coverage is subject to the Plan’s exclusions and limitations. **After Deductible Note 1—General Anesthesia is considered integral to other procedures under this plan and is not covered separately. Note 2—No annual maximum for in-network services. United Concordia will reimburse up to a maximum of $1,000 per family member per contract year for out-of-network services. Note 3—After $2,900 member copayment satisfied, benefits applicable to in-network services; provider should submit pre-treatment estimate. United Concordia will not reimburse covered members for any orthodontic services performed out-of-network.

Unlimited Unlimited. Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services AACPS • Division of Human Resources • HR/Benefits • DPS/JH 2095/2a (Rev. 10/1710/19) Appendix C Dental and Vision Options 2020 Active Employees and Retirees XXXX ARUNDEL COUNTY PUBLIC SCHOOLS Active Employees and Retirees Benefits as of January 2017 Dental and Vision Options Active Employees and Retirees Dental Options CareFirst Traditional CareFirst PPO Concordia Plus DHMO MD1560MD/ DC2060* Benefits In-Network Nework Out-of-Network In-Network Plan Pays Plan Pays Plan Pays Plan Pays Oral Examination 100% of AB 100% of AB 80% of AB $5 copay Routine Cleaning 100% of AB 100% of AB 80% of AB 100% Sealants (limited to permanent molars molars– until end of year in which a member turns 19) 100% of AB 100% of AB 80% of AB 100% Bitewing X-ray 100% of AB 100% of AB 80% of AB 100% Palliative Treatment 100% of AB 100% of AB 80% of AB 95% Other X-rays as required 100% of AB 100% of AB 80% of AB 100% Space Maintainers 100% of AB 100% of AB 80% of AB 95% Fillings 100% of AB 80% of AB 60% of AB** 100% Simple Extractions 100% of AB 80% of AB 60% of AB** 75%-85% Pulpotomy 100% of AB 80% of AB 60% of AB** 75%-80% Direct Pulp Caps 100% of AB 80% of AB 60% of AB** 75%-80% Root Canals 100% of AB 80% of AB 60% of AB** 75%-80% Apicoectomy 80% of AB** 80% of AB 60% of AB** 75%-80% Oral Surgical Services 80% of AB** 80% of AB 60% of AB** 75%-85% Surgical Extractions 80% of AB** 80% of AB 60% of AB** 75%-85% Oral Surgery 80% of AB** 80% of AB 60% of AB** 75%-85% General Anesthesia 80% of AB** 80% of AB 60% of AB** See note 1 Periodontics 50% of AB** 80% of AB 60% of AB** 50%-65% Crown 80% of AB** 80% of AB 60% of AB** 60%-80% Prosthetic Appliances (including implants) 50% of AB 80% of AB 60% of AB** 60%-80% Implants not covered Orthodontics Children and Adults 50% of AB 50% of AB 35% of AB See note 3 Annual Deductible $25 Ind./$50 Family None $50 Ind./$150 Family None Annual Benefit Maximum $1,500 $1,500 None/See note 2 Ortho Lifetime Maximum $1,500 $1,500 See note 3 (AB Allowed Benefit) Under the Concordia Plus DHMO (MD1560MD/DC 2060*) Plan, out-of-network services are reimbursed up to a maximum amount, based on the fee schedule provided by United Concordia. ** The above DHMO Plan percentages are approximate and used for comparison purposes only. Please refer to the United Concordia (XXXX) Schedule of Benefits for actual copayment amounts. All coverage is subject to the Plan’s exclusions and limitations. *** After Deductible Note 1—General Anesthesia is considered integral to other procedures under this plan and is not covered separately. Note 2—No annual maximum for in-network services. United Concordia will reimburse up to a maximum of $1,000 per family member per contract year for out-of-network services. Note 3—After $2,900 member copayment satisfied, benefits applicable to in-network services; provider should submit pre-treatment estimate. United Concordia will not reimburse covered members for any orthodontic services performed out-of-network. This is to be used as a guide. Actual benefits will be governed by the terms and conditions of the contract between CareFirst BlueCross BlueShield and Xxxx Arundel County Public Schools.

Unlimited Unlimited. Lifetime Maximum Unlimited, except for fertility services Unlimited, except for fertility services AACPS • Division of Human Resources • HR/Benefits • DPS/JH 2095/2a (Rev. 10/1710/19) Appendix APPENDIX C Dental and Vision Options 2019 Active Employees and Retirees XXXX ARUNDEL COUNTY PUBLIC SCHOOLS Active Employees and Retirees Benefits as of January 2017 Dental and Vision Options Active Employees and Retirees Dental Options CareFirst Traditional CareFirst PPO Concordia Plus DHMO MD1560MD/ DC1660* Benefits In-Network Nework Out-of-Network In-Network Plan Pays Plan Pays Plan Pays Plan Pays Oral Examination 100% of AB 100% of AB 80% of AB $5 copay Routine Cleaning 100% of AB 100% of AB 80% of AB 100% Sealants (limited to permanent molars molars– until end of year in which a member turns 19) 100% of AB 100% of AB 80% of AB 100% Bitewing X-ray 100% of AB 100% of AB 80% of AB 100% Palliative Treatment 100% of AB 100% of AB 80% of AB 95% Other X-rays as required 100% of AB 100% of AB 80% of AB 100% Space Maintainers 100% of AB 100% of AB 80% of AB 95% Fillings 100% of AB 80% of AB 60% of AB** 100% Simple Extractions 100% of AB 80% of AB 60% of AB** 75%-85% Pulpotomy 100% of AB 80% of AB 60% of AB** 75%-80% Direct Pulp Caps 100% of AB 80% of AB 60% of AB** 75%-80% Root Canals 100% of AB 80% of AB 60% of AB** 75%-80% Apicoectomy 80% of AB** 80% of AB 60% of AB** 75%-80% Oral Surgical Services 80% of AB** 80% of AB 60% of AB** 75%-85% Surgical Extractions 80% of AB** 80% of AB 60% of AB** 75%-85% Oral Surgery 80% of AB** 80% of AB 60% of AB** 75%-85% General Anesthesia 80% of AB** 80% of AB 60% of AB** See note 1 Periodontics 50% of AB** 80% of AB 60% of AB** 50%-65% Crown 80% of AB** 80% of AB 60% of AB** 60%-80% Prosthetic Appliances (including implants) 50% of AB 80% of AB 60% of AB** 60%-80% Implants not covered Orthodontics Children and Adults 50% of AB 50% of AB 35% of AB See note 3 Annual Deductible $25 Ind./$50 Family None $50 Ind./$150 Family None Annual Benefit Maximum $1,500 $1,500 None/See note 2 Ortho Lifetime Maximum $1,500 $1,500 See note 3 (AB Allowed Benefit) Under the Concordia Plus DHMO (MD1560MD/DC 1660*) Plan, out-of-network services are reimbursed up to a maximum amount, based on the fee schedule provided by United Concordia. ** The above DHMO Plan percentages are approximate and used for comparison purposes only. Please refer to the United Concordia (XXXX) Schedule of Benefits for actual copayment amounts. All coverage is subject to the Plan’s exclusions and limitations. *** After Deductible Note 1—General Anesthesia is considered integral to other procedures under this plan and is not covered separately. Note 2—No annual maximum for in-network services. United Concordia will reimburse up to a maximum of $1,000 per family member per contract year for out-of-network services. Note 3—After $2,900 member copayment satisfied, benefits applicable to in-network services; provider should submit pre-treatment estimate. United Concordia will not reimburse covered members for any orthodontic services performed out-of-network. This is to be used as a guide. Actual benefits will be governed by the terms and conditions of the contract between CareFirst BlueCross BlueShield and Xxxx Arundel County Public Schools.