Dental Accidental Injury Rider Kaiser Permanente Senior Advantage ( HMO) This rider is part of the Kaiser Permanente Senior Advantage (HMO) Evidence of Coverage (EOC) to which it is attached. All provisions of this rider become part of the EOC "Chapter 4: Medical Benefits Chart (what is covered and what you pay)" section. This entire benefit rider is therefore subject to all the terms and provisions of the EOC. Dental accidental injury services We cover dental services by a licensed dentist to repair accidental injury to sound, healthy, natural teeth at the cost-sharing shown in the Medical Benefits Chart "Dental accidental injury" section. 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. Dental accidental injury rider 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 resulting from biting or chewing. • Hospital services for dental care. • Orthodontic services. • Routine or preventive dental services. • Services to correct malocclusion resulting from an accidental injury, except for emergency stabilization. RSADENTACC19830124 1