SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 1 of 9 Features & Benefit Details

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Milo Burke
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1 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 1 of 9 PLAN NETWORK Premium range child under age 19* Sample premium range typical family of 4* Is this a smaller network? Is there out-of-network coverage? Annual deductible one enrollee** Annual deductible family*** Maximum annual out-of-pocket child under 19 yrs. Maximum annual out-of-pocket 2 or more children under 19 yrs. Maximum annual benefit adults 19 and over only Family $39 - $47 $109 - $175 $40 - $61 $146 - $230 Altus Dental Participating Dentists MetLife Preferred Program DentalGuard Preferred $30 - $39 $39 $31 - $36 $34 - $42 $118 - $154 $98 $122 - $142 $128 - $159 Yes No No Yes No No Yes $50 $150 $350 $700 $1,250 *Premiums shown are samples for comparison purposes. Actual premiums will vary depending on your group composition and effective date; please visit MAhealthconnector.org or call MA-ENROLL to obtain a quote. **Waived for diagnostic and preventive services and for some plans, medically necessary orthodontia. ***Waived for diagnostic and preventive services only.

2 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 2 of 9 Family Type I services: Preventive & Diagnostic Dental Co-insurance percentage (what you pay) All ages in-network 0% out-of-network 20% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. 2 Procedures per Comprehensive 1 per patient per location per Evaluation Periodic Oral Exams Oral Evaluation under 3 Years of Age 2 Procedures per patient per Teeth Cleaning 12 Limited Oral Evaluation 2 Procedures per patient per 12 * Full Mouth X-Rays Panoramic X-Rays Single Tooth X-Rays Bitewing X-Rays Fluoride Treatments patient per 36 2 Procedures per patient per 12 3 Space Maintainers tooth per 36 Sealants *Not combined with other covered exam procedures. 4 Procedures per 12 patient per

3 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 3 of 9 Family For enrollees 19 yrs. and over Benefit Standard Limits means that the limits are the standard limits or the equivalent. 2 Procedures per Comprehensive Evaluation 1 per patient per 60 Periodic Oral Exams 2 Procedures per patient per Teeth Cleaning 12 Limited Oral Evaluation 2 Procedure/s per patient per 12 * Full Mouth X-Rays Panoramic X-Rays Single Tooth X-Rays Bitewing X-Rays patient per 60 2 Procedures per patient per 12 patient per 36 patient per 36 patient per 6 patient per 6 patient per 6 patient per Periodontal Cleaning 3 Palliative Care (some restrictions may apply) *Not combined with other covered exam procedures. **Less the number of teeth cleanings [prophylaxis] received during that 12 month period. 4 Procedures per ** as Type II Service 2 Procedures per 12

4 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 4 of 9 Family Type II services: Basic Restorative Co-insurance percent (what you pay) All ages: in-network 25% out-of-network 45% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. 4 Procedures per patient per Periodontal Cleaning 3 ** Silver Fillings tooth per White Fillings surface per 12 * ** Temporary Fillings Prefabricated Stainless Steel Crowns tooth per quadrant per 24 Periodontal Scaling and Root ing quadrant per 36 Root canals on permanent teeth tooth per Apicoectomy Vital Pulpotomy tooth per Simple Extractions (prior authorization Surgical Extractions may be required) Anesthesia Palliative Care (some restrictions may apply) Periodontal Surgery Bridge or Denture Repair quadrant per 36 tooth per 36 *** *** 12

5 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 5 of 9 Rebase or Reline Dentures patient per 24 month Recement Crowns and *** Onlays *For white fillings, paid as an alternate benefit on multi- surface restorations on posterior teeth. **Less the number of teeth cleanings [prophylaxis] received during that 12 month period. ***6 after initial placement. patient per *** patient per *** patient per 24 *** arch per 24

6 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 6 of 9 Family For enrollees 19 yrs. And over Benefit Standard Limits means that the limits are the standard limits or the equivalent. Silver Fillings tooth per * White Fillings surface per 24 Temporary Fillings Prefabricated Stainless Steel Crowns (pre-authorization may be required) quadrant per 36 1 Procedure/s per patient per 12 tooth per 60 tooth per tooth per quadrant per 36 (Periodontal) Scaling and Root ing quadrant per 24 Root canals on permanent teeth tooth per Apicoectomy Vital Pulpotomy tooth per Simple Extractions (pre-authorization Surgical Extractions may be required) Anesthesia (some restrictions 3 Procedures per Palliative Care may apply) 12 tooth per 36 Periodontal Surgery Bridge or Denture Repair Rebase or Reline Dentures 36 as Type I Service ** arch per 36 ** Recement Crowns and Onlays tooth per ** *For white fillings, paid as an alternate benefit on restorations on molar teeth. **6 after initial placement. arch per 24

7 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 7 of 9 Family Type III services: Major Restorative Co-insurance percent (what you pay) All ages: in-network 50% out-of-network 70% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. Waiting period None Crown, resin tooth per 60 Porcelain/ceramic crowns tooth per 60 Porcelain fused to metal/noble/high noble crowns tooth per 60 Partial & complete dentures arch per 84 Fixed Bridges and Crowns (when part of a tooth per 60 bridge) *6 after initial placement. * *

8 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 8 of 9 Family Type III services: Major Restorative Co-insurance percent (what you pay) All ages: in-network 50% out-of-network 70% For enrollees 19 yrs. And over Benefit Standard Limits means that the limits are the standard limits or the equivalent. Waiting period 6 Prefabricated Stainless Steel Crowns tooth per Crown, resin patient per tooth per 60 tooth per Porcelain/ceramic crowns Porcelain fused to metal/noble/high noble crowns Partial & complete dentures tooth per 60 tooth per 60 patient per 60 patient per 84 Fixed Bridges and Crowns tooth per 60 (when part of a bridge) * only when teeth cannot be restored with regular fillings. ** only if no other less expensive adequate dental service is available. tooth per 84 tooth per 84 as Type II Service tooth per 60 * * arch per 84 arch per 84 **

9 SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 9 of 9 Family Type IV services: Orthodontia Co-insurance percent (what you pay) Under 19: in-network 50% out-of-network 70% 19 and over: For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. patient per Medically necessary orthodontia (pre-authorization is required)

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

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