IN-NETWORK OUT-OF-NETWORK Temporomandibular Joint Disorder Benefits: • Maximum Benefit Per Calendar Year $2,500 • Paid By Plan After Deductible 80% 60% Therapy Services: • Paid By Plan After Deductible 80% 60% Note: Medical Necessity Will Be Reviewed After 60 Visits Combined With Manipulations. Wigs (Cranial Prostheses), Toupees, Or Hairpieces Related To Cancer Treatment And Alopecia Areata: • Maximum Benefit Per Calendar Year 1 Wig (Cranial Prosthesis), Toupee, Or Hairpiece • Paid By Plan After In-Network Deductible 80% 80% All Other Covered Expenses: • Paid By Plan After Deductible 80% 60% -28- 7670-00-413597