Page 82

Effective Date:

Approval Date: 82

Jackson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Jasper Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Jefferson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Johnson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Jones Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Keokuk Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Lee Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Linn Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Louisa Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Lucas Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Lyon Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Madison Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Mahaska Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Marion Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Marshall Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Mills Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Mitchell Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Monona Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Monroe Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Montgomery Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Muscatine Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA O‟Brien Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Osceola Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Page Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Palo Alto Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Plymouth Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Pocahontas Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Polk Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Pottawattamie Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Poweshiek Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Ringgold Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Sac Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Scott Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Shelby Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Sioux Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Story Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Tama Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Taylor Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Union Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Van Buren Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Wapello Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Warren Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Washington Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Wayne Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Webster Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Winnebago Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Winneshiek Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Woodbury Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Worth Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Wright Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA