PLANS FOR FAMILIES AND ADULTS 2018 Features & Benefit Details

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1 PLANS FOR FAMILIES AND ADULTS 2018 Features & Details Plans with Comprehensive Coverage PLAN NETWORK Participating Dentists EPO Participating Dentists EPO and EPO Is this a smaller network? No No Yes No No Yes Yes Annual deductible one enrollee $50 $50 $100 Annual deductible family 1 $150 $150 $300 Maximum annual out-of-pocket child under 19 years $350 $350 $350 Maximum annual out-of-pocket 2 or more children $700 $700 $700 Maximum annual per person benefit (adults 19 and over only) $1,250 $750 $750 Maximum annual per person benefit (child) No Maximum No Maximum 1 Deductible is waived for diagnostic and preventative procedures. * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

2 Type I services: Preventative & Diagnostic Dental Co-Insurance percent (what you pay) All ages: 0% Out-of-network 20% All ages: 0% Out-of-network 20% mean 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 2 Procedures per patient per12 1 Procedure per patient per 36 and All ages: 0%; Out-ofnetwork Single Tooth X-Rays As Needed 2 Procedures per Bitewing X-Rays patient per 12 Periodontal Cleaning 1 Procedure per 3 Fluoride Treatments Space Maintainers Covered Sealants 1 Procedure per tooth per 36 * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

3 Comprehensive Evaluation Periodic Oral Exams Teeth Cleaning Full Mouth X-Rays Panoramic X-Rays Bitewing X-Rays 1 per patient per 60 Once every 6 patient per 60 Once every 6 and Single Tooth X-Rays Covered Periodontal Cleaning Fluoride Treatments Space Maintainers Sealants 3 * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

4 Type II Services: Basic Restorative Services Co-Insurance percent (what you pay) Silver Fillings White Fillings 2 Temporary Fillings Prefabricated Stainless Steel Crowns Root canals on permanent teeth Apicoectomy Vital pulpotomy Periodontal Scaling and Root Planing Simple Extractions Surgical Extractions General Anesthesia Intravenous Conscious Sedation tooth per surface per 12 tooth per 60 Four per patient per day tooth per lifetime quadrant per 24 25% Out-of-network 45% 25% Out-of-network 45% and EPO Basic 60% Out-ofnetwork No Limit per day No Limit per day per quadrant per 36 per quadrant per 36 Covered Allowed with covered surgeries Minor Treatment for Pain Relief Covered 2 Check with your provider for out-of-pocket costs prior to services. * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

5 Silver Fillings White Fillings 3 Temporary Fillings Periodontal Scaling and Root Planing 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 tooth per 60 quadrant per 24 : 25% Out-of-network: 45% In-: 25% Out-of-network: 45% and : 70% Out-of-network: per tooth per lifetime per tooth per lifetime tooth per lifetime Covered Allowed with covered surgical procedures 3 occurrences in 12 Twice per year Twice per year 3 Check with your provider for out-of-pocket costs prior to services. * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

6 Type III Services: Major Restorative Dental Co-Insurance Percent (what you pay) means that the limits are the standard limits or the equivalent. : 50% : 50% and 60%; Out-ofnetwork Waiting Period None Crowns tooth per 60 Partial & Complete Dentures arch per 60 Implants : 50% : Out-of-network: ; Out-ofnetwork Waiting Period 6 N/A N/A N/A N/A Crowns Partial & Complete Dentures tooth per 60 tooth per 60 per tooth per 84 per tooth per 84 Implants * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

7 Type IV Services: Orthodontia Co- Insurance percent (what you pay) Medically necessary orthodontia Medically necessary orthodontia Prior authorization is required; 1 procedure per patient per lifetime A lock-out period occurs if you purchase a plan and then drop coverage. You cannot repurchase the plan for the following amount of time: : 50% : 50% and 60% Out-ofnetwork : Out-of-network: Lock-Out Periods : Out-of-network: * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental

8 Type IV Services: Orthodontia Co- Insurance percent (what you pay) Medically necessary orthodontia Medically necessary orthodontia Standard Limits Prior authorization is required; 1 procedure per patient per lifetime Standard Limits A lock-out period occurs if you purchase a plan and then drop coverage. You cannot repurhcase the plan for the following amount of time: 50% Out-of-network 70% 50% Out-of-network 70% Out-of-network Out-of-network Lock-Out Periods and 60% Out-ofnetwork * of Massachusetts EPO insurance products are offered by DSM Massachusetts Insurance Company, Inc. of Massachusetts and PPO insurance products are offered by Dental