All covered Services are subject to any applicable Cost Share as described in the “What You Pay” section and in the “Benefit Summary.” The benefits under this Plan are not subject to a pre-existing condition waiting period. 1. Accidental Injury to Teeth The Services of a licensed dentist will be covered for repair of accidental injury to sound, healthy, natural teeth. Evaluation of the injury and development of a written treatment plan must be completed within 30 days from the date of injury. Treatment must be completed within the period established in the treatment plan unless delay is medically indicated and the written treatment plan is modified. Accidental Injury to Teeth Exclusions  Conditions not directly resulting from the accident; and treatment not completed within the time period established in the written treatment plan.  Dental appliances and dentures.  Dental implants.  Dental Services for injuries to teeth caused by biting or chewing.  Hospital Services for dental care.  Orthodontic treatment.  Routine or preventive dental Services.  Services to correct malocclusion resulting from an accidental injury, except for emergency stabilization. 2. Administered Medications Administered Medications such as drugs, injectables, and radioactive materials used for therapeutic or diagnostic purposes, are covered if they are administered to you in a Participating Hospital, Participating Medical Office or during home visits. 3. Acupuncture Services Acupuncture Services are provided by a Participating Provider in the Participating Provider’s office. East Asian medicine practitioners use acupuncture to influence the health of the body by the insertion of very fine needles. Acupuncture treatment is primarily used to relieve pain, reduce inflammation, and promote healing. Covered Services include:  Evaluation and treatment.  Acupuncture.  Electro-acupuncture. To locate a Participating Provider, visit www.chpgroup.com. The CHP Group is a Participating Provider we contract with to provide acupuncture Services. If you need assistance searching for a Participating Provider, or to verify the current participation status of a provider, or if you do not have access to the online directory, please contact Member Services. Self-referred Acupuncture Services We cover self-referred outpatient visits for acupuncture Services, up to the visit limit shown on your “Benefit Summary.” You do not need a referral or prior authorization. EWCLGHDHP1983ACT0124 40 WAPEBB-CD-ACT