Plans for Families and Adults with Comprehensive Coverage Features & Benefit Details

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1 Page 1 of 7 s for Families and Adults with Comprehensive Coverage Network Premier Altus Dental Participating Dentists Blue Cross PPO Dental Preferred Dentist Program Plus EPO Family EPO DentalGuard Preferred Premium range child under age 19** $36-$55 $31-$41 $36 $30-$35 $28-$44 $29-$37 Sample premium range typical family of 4** $133-$207 $116-$152 $90 $117-$137 $103-$165 $119-$150 Is this a smaller network? No No Yes No Yes No Is there out-of-network coverage? Annual deductible one enrollee $50 Annual deductible family $150 Maximum annual out-of-pocket child under 19 yrs. $1,000 Maximum annual out-of-pocket 2 or more children $2,000 Maximum annual benefit (adults 19 and over only) $1,250 Yes * of EPO insurance products are offered by DSM USA Insurance Company, Inc. of PPO, Premier and DeltaCare insurance products are offered by Dental Service of, Inc. **Premiums shown are samples for comparison purposes. Actual premiums will vary depending on your group composition and effective date; please call MA-ENROLL to obtain a quote.

2 Page 2 of 7 s for Families and Adults with Comprehensive Coverage Type I services: Preventive & Diagnostic Dental Co-insurance percent (what you pay) Comprehensive Evaluation Periodic Oral Exams Oral Evaluation under 3 years of age Teeth cleaning Full Mouth X-Rays Panoramic X-rays 1 per patient per location per lifetime patient per 36 Single tooth X-Rays Bitewing X-Rays 4 Procedures per Periodontal Cleaning 3 Fluoride Treatments Space Maintainers Sealants tooth per 36 All ages in-network 0% out-of-network 20% Dental EPO Family

3 Page 3 of 7 s for Families and Adults with Comprehensive Coverage Comprehensive Evaluation Periodic Oral Exams Teeth cleaning Full Mouth X-Rays Panoramic X-Rays 1 per patient per 60 patient per 60 patient per 36 patient per 36 Single tooth X-Rays Bitewing X-Rays Periodontal Cleaning Fluoride Treatments Space Maintainers Sealants For enrollees 19 yrs. and over 3 Dental EPO Family

4 Page 4 of 7 s for Families and Adults with Comprehensive Coverage Type II services: Basic Restorative Co-insurance percent (what you pay) All ages: in-network 25% out-of-network 45% Silver Fillings White Fillings tooth per surface per 12 Temporary Fillings Prefabricated Stainless Steel Crowns Periodontal Scaling and Root ing Root canals on permanent teeth Apicoectomy Vital Pulpotomy Simple extractions Surgical extractions General Anesthesia Intravenous Conscious Sedation Treatment for Minor Pain Relief tooth per quadrant per 36 tooth per lifetime tooth per lifetime 1 Procedure per quadrant per 24 Dental EPO Family 1 Procedure per quadrant per 24

5 Page 5 of 7 s for Families and Adults with Comprehensive Coverage For enrollees 19 yrs. and over Dental Silver Fillings White Fillings tooth per surface per 24 EPO Family Temporary Fillings Periodontal Scaling and Root ing Root canals on permanent teeth Apicoectomy Simple extractions Surgical extractions General Anesthesia Intravenous Conscious Sedation Treatment for Minor Pain Relief quadrant per 24 tooth per lifetime quadrant per 36

6 Page 6 of 7 s for Families and Adults with Comprehensive Coverage Type III services: Major Restorative Co-insurance percent (what you pay) All Ages in-network 50% out-of-network 70% Waiting period None tooth Crowns per 60 Partial & complete arch dentures per 84 arch per 60 Implants For enrollees 19 yrs. and over Waiting period 6 Crowns Partial & complete dentures tooth per 84 arch per 84 tooth per 60 tooth per 60 Dental EPO Family tooth per 60 tooth per 60 tooth per 60 Implants

7 Page 7 of 7 s for Families and Adults with Comprehensive Coverage EPO Dental Family Under 19: 19 and over: Type IV services: Orthodontia in-network 50% Co-insurance percent (what you pay) out-of-network 70% Medically necessary orthodontia Prior authorization is required; patient per lifetime

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