PLANS FOR FAMILIES AND ADULTS Features & Benefit Details

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1 Page 1 of 7 s with comprehensive coverage s with basic coverage PLAN NETWORK Premier EPO EPO Altus Dental Participating Dentists Premier EPO EPO Altus Dental Participating Dentists **Premium child under 19 yrs. $55.13 $44.00 $36.92 $55.13 $44.00 $36.92 ** Sample Premium family of 4 $ $ $ $ $ $ Is this a smaller network? No Yes No No Yes No Annual deductible one enrollee $50 $50 Annual deductible family $150 $150 Maximum annual out-of-pocket child under 19 yrs. $1,000 $1,000 Maximum annual out-of-pocket 2 or more children $2,000 $2,000 Maximum annual per person benefit (adults 19 and over only) $1,250 $750 Maximum annual per person benefit (child) No maximum No maximum * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc. **Premiums shown are samples for comparison purposes. Actual premiums may vary depending on your age, effective date, and family composition. Please call MA-ENROLL to obtain a quote.

2 Page 2 of 7 s with comprehensive coverage s with basic coverage EPO EPO Type I services: Preventive & Diagnostic Dental Co-insurance percent (what you pay) in-network 0% out-of-network 20% in-network 0% out-of-network 20% Benefit Standard Limits means that the limits are the standard limits or the equivalent. 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 months Single tooth X-Rays Bitewing X-Rays Periodontal Cleaning Fluoride Treatments 3 months Space Maintainers Sealants tooth per 36 months * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc.

3 Page 3 of 7 s with comprehensive coverage s with basic coverage EPO EPO Benefit Standard Limits means that the limits are the standard limits or the equivalent. Comprehensive Evaluation Periodic Oral Exams Teeth cleaning Full Mouth X-Rays Panoramic X-Rays Bitewing X-Rays 1 per patient per 60 months patient per 60 months Single tooth X-Rays Periodontal Cleaning Fluoride Treatments Space Maintainers Sealants 3 months * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc.

4 Page 4 of 7 s with comprehensive coverage s with basic coverage EPO EPO Type II services: Basic Restorative Services Co-insurance percent (what you pay) in-network 25% out-of-network 45% in-network 25% out-of-network 45% Benefit Standard Limits means that the limits are the standard limits or the equivalent. Silver Fillings White Fillings Temporary Fillings Prefabricated Stainless Steel Crowns Root canals on permanent teeth Apicoectomy Vital Pulpotomy Periodontal Scaling and Root ing Simple extractions Surgical extractions General Anesthesia Intravenous Conscious Sedation Minor Treatment for Pain Relief tooth per surface per 12 months per 36 months * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc.

5 Page 5 of 7 s with comprehensive coverage s with basic coverage EPO EPO Benefit Standard Limits means that the limits are the standard limits or the equivalent. Silver Fillings White Fillings Temporary Fillings Periodontal Scaling and Root ing Root canals on permanent teeth Apicoectomy Simple extractions Surgical extractions General Anesthesia Intravenous Conscious Sedation Minor Treatment for Pain Relief tooth per surface per 24 months * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc.

6 Page 6 of 7 s with comprehensive coverage s with basic coverage EPO EPO Type III services: Major Restorative Dental Co-insurance percent (what you pay) in-network 50% out-of-network 70% Under 19: 19 and over: in-network 50% in-network 100% out-of-network 70% out-of-network 100% Benefit Standard Limits means that the limits are the standard limits or the equivalent. Waiting period None Crowns Partial & complete dentures tooth per 60 months arch per 84 months arch per 60 months Implants Benefit Standard Limits means that the limits are the standard limits or the equivalent. arch per 60 months Waiting period 6 months N/A N/A N/A Crowns Partial & complete dentures tooth per 84 months arch per 84 months Implants * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc.

7 Page 7 of 7 s with comprehensive coverage s with basic coverage EPO EPO Type IV services: Orthodontia Co-insurance percent (what you pay) Under 19: in-network 50% out-of-network 70% 19 and over: in-network 100% out-of-network 100% Under 19: in-network 50% out-of-network 70% Benefit Standard Limits means that the limits are the standard limits or the equivalent. Medically necessary orthodontia Prior authorization is required; per patient per lifetime 19 and over: in-network 100% out-of-network 100% Benefit Standard Limits means that the limits are the standard limits or the equivalent. Medically necessary orthodontia Lock-out periods A lock-out period occurs if you purchase a plan and then drop coverage. You cannot re-purchase the plan for the following amount of time 12 months 12 months 24 months 12 months 12 months 24 months * of Massachusetts EPO insurance products are offered by DSM USA Insurance Company, Inc. of Massachusetts PPO, Premier and DeltaCare insurance products are offered by Dental Service of Massachusetts, Inc.