Schedule of Dental Benefits Form

attached to and made part of Blue Cross and Blue Shield of Massachusetts, Inc. Dental Blue Policy BCBS-DENT (1-1-2014)

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dEB19PYSoB-0117.doc Schedule of Dental Benefits Pediatric Essential Benefits

This is the Schedule of Dental Benefits that is a part of your Dental Blue Policy. This schedule describes the dental services that are covered by your Dental Blue Policy for members who are eligible for pediatric essential dental benefits. It also shows the cost-sharing amounts you must pay for these covered services. Do not rely on this schedule alone. You should read all parts of your Dental Blue Policy to become familiar with the key points. Be sure to read the descriptions of covered services and the limitations and exclusions. You should keep your Dental Blue Policy and this Schedule of Dental Benefits handy so that you can refer to them. The words that are shown in italics have special meanings. These words are explained in Part 8 of your Dental Blue Policy. Who Is Eligible for Pediatric Essential Dental Benefits The dental benefits described in this Schedule of Dental Benefits are provided for a member only until the end of the calendar month in which the member turns age 19. Annual Deductible Your deductible each plan year: $50 per member (no more than $150 for three or
more members who are eligible for pediatric essential dental benefits and who are enrolled under the same family membership) The deductible is the cost you have to pay during the annual coverage period (as shown above) before benefits will be paid. The deductible applies to Group 2 and Group 3 services only. A deductible does not apply to Group 1 services or to Orthodontic services. See the chart that starts on the next page for how much you pay for covered services you receive after you meet the deductible (when it applies). Annual Out-of-Pocket Maximum Your out-of-pocket maximum each plan year: $350 per member (no more than $700 for two or more members who are eligible for pediatric essential dental benefits and who are enrolled under the same family membership) Your out-of-pocket maximum is the most you could pay during the annual coverage period (as shown above) for your share of the costs for covered services—your cost-sharing amounts. This out-of-pocket maximum helps you plan for health care expenses. Even though you pay the following costs, they do not count toward your out-of-pocket maximum: your premiums; any balance-billed charges; all costs for dental services for members who are not eligible for pediatric essential dental benefits; and all services this dental plan does not cover.

Schedule of Dental Benefits (continued) Pediatric Essential Benefits

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dEB19PYSoB-0117.doc Annual Overall Benefit Limit for What the Plan Pays Your overall benefit limit: None You do not have an overall benefit limit for pediatric essential dental benefits. But, there are limits that apply for specific covered services, such as for periodic oral exams. Some of these limits are described in this Schedule of Dental Benefits in the chart that starts below. Do not rely on this chart alone. Your dental policy along with this Schedule of Dental Benefits fully describes all of the limits and exclusions that apply for your dental benefits. Be sure to read all parts of your dental policy. What You Pay for Covered Services—Your Cost-Sharing Amounts You should be sure to read all parts of your dental policy—including this Schedule of Dental Benefits—to understand the requirements that you must follow to receive your dental benefits. You will receive these dental benefits as long as: • You are a member who is eligible to receive pediatric essential dental benefits. • Your dental service is a covered service as described in this Schedule of Dental Benefits. • Your dental service is necessary and appropriate. • Your dental service conforms to Blue Cross and Blue Shield utilization review guidelines. • You use a participating dentist to get a covered service. (The only exceptions are noted in your dental policy.) Covered Services for Members Under Age 19 Your Cost Is*: Group 1— Preventive Services and Diagnostic Services No charge Oral exams • One complete initial oral exam per provider or location (includes initial history and charting of teeth and supporting structures) • Periodic or routine oral exams; twice in a calendar year • Oral exams for a member under age three; twice in a calendar year • Limited oral exams; twice in a calendar year

X-rays • Single tooth x-rays; no more than one per visit • Bitewing x-rays; twice in a calendar year • Full mouth x-rays; once in three calendar years per provider or location • Panoramic x-rays; once in three calendar years per provider or location Routine dental care • Routine cleaning, minor scaling, and polishing of the teeth; twice in a calendar year • Fluoride treatments; once in 90 days • Sealants; once per tooth in three years per provider or location (sealants over restored tooth surfaces not covered) • Space maintainers Group 2—Basic Restorative Services 25% of allowed charge Fillings • Amalgam (silver) fillings; one filling per tooth surface in 12 months • Composite resin (white) fillings; one filling per tooth surface in 12 months after deductible

Schedule of Dental Benefits (continued) Pediatric Essential Benefits

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dEB19PYSoB-0117.doc Covered Services for Members Under Age 19 Your Cost Is*: Group 2—Basic Restorative Services (continued) 25% of allowed charge Root canal treatment • Root canals on permanent teeth; once per tooth • Vital pulpotomy • Retreatment of prior root canal on permanent teeth; once per tooth in 24 months • Root end surgery on permanent teeth; once per tooth after deductible Crowns (see also Group 3) • Prefabricated stainless steel crowns; once per tooth (primary and permanent) Gum treatment • Periodontal scaling and root planing; once per quadrant in 36 months • Periodontal surgery; once per quadrant in 36 months Prosthetic maintenance • Repair of partial or complete dentures and bridges; once in 12 months • Reline or rebase partial or complete dentures; once in 24 months • Recementing of crowns, inlays, onlays, and fixed bridgework; once per tooth Oral surgery • Simple tooth extractions; once per tooth • Erupted or exposed root removal; once per tooth • Surgical extractions; once per tooth (approval required for complete, boney impactions) • Other necessary oral surgery Other necessary services • Dental care to relieve pain (palliative care) • General anesthesia for covered oral surgery Group 3—Major Restorative Services 50% of allowed charge Crowns • Resin crowns; once per tooth in 60 months • Porcelain/ceramic crowns; once per tooth in 60 months • Porcelain fused to metal/high noble crowns; once per tooth in 60 months after deductible Tooth replacement • Removable complete or partial dentures, including services to fabricate, measure, fit, and adjust them; once in 84 months • Fixed prosthetics, only if there is no other less expensive adequate dental service; once in 60 months Other necessary services • Occlusal guards when necessary; once in calendar year • Fabrication of an athletic mouth guard

Schedule of Dental Benefits (continued) Pediatric Essential Benefits

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dEB19PYSoB-0117.doc Covered Services for Members Under Age 19 Your Cost Is*: Orthodontic Services 50% of allowed charge Medically necessary orthodontic care that has been preauthorized for a qualified member • Braces for a member who has a severe and handicapping malocclusion • Related orthodontic services for a member who qualifies

*Important Note: Your benefits will be calculated based on the allowed charge. In most cases, you will not have to pay charges that are more than the allowed charge when you use a participating dentist to furnish covered services. But, when you use a non-participating dentist, you may also have to pay all charges that are in excess of the allowed charge for covered services. This is called “balance billing.” Refer to your dental policy for a more complete description of “allowed charge.”