Dental Insurance Benefit Summary

Page 1 Group name: Betenbough Homes, LLC Policy number: 024883 Form created: 08/28/2025 Regular dental care is one of the best ways to maintain a winning smile and protect your overall health. With Equitable’s dental plan, you can receive the care you need, including routine cleanings and fillings, and potentially major dental procedures, orthodontia and teeth-whitening benefits. Under your comprehensive PPO dental plan, you are allowed to see both in and out of network providers. Benefit Plan & Features This is only a partial list of covered dental services. Please carefully review your certificate of insurance for a full list of covered services, as well as all limitations and exclusions that apply to your plan. Benefit Plan and Features Class definition: Class 2 – All Active Full Time Employees enrolled in High Plan Coverage Details In-Network Benefit Out-of-Network Benefit Reimbursement Contracted Allowances MAC Coinsurance 100/100/60 100/100/60 Annual Individual / Family Deductible (Waived for Preventive Services) $50/3x individual $50/3x individual Annual Individual Maximum Benefit $1,750 $1,750 Alternate Benefit Included Included Missing Tooth Clause Applies Applies Orthodontia* Individual Deductible/ Lifetime Maximum Child: $0/$1,500 Child: $0/$1,500

Page 2 Orthodontia* is eligible if the initial banding or appliance is inserted while you are covered for Orthodontia under Equitable’s policy, or while you were covered for Orthodontia under your immediate prior carrier. Preventive Services In-Network Benefit Out-of-Network Benefit Evaluations • Periodic Oral Evaluation 100% 100% • Limited Oral Evaluation – problem focused 100% 100% • Comprehensive Oral Evaluation 100% 100% Treatments • Routine Dental Prophylaxis 100% 100% • Fluoride Treatment 100% 100% • Sealants – child 100% 100% X-Rays • Complete Series/ Panoramic X-Rays 100% 100% • Periapical X-Rays 100% 100% • Bitewing X-Rays 100% 100% Basic Services In-Network Benefit Out-of-Network Benefit Emergency Palliative Treatment 100% 100% Surgical Extractions and Removal of Impacted Teeth 100% 100% Basic Restorative Services (amalgam, composite resin, acrylic, synthetic or plastic fillings) 100% 100% Simple Extractions 100% 100% Surgical Endodontics 100% 100% Non-Surgical Endodontics 100% 100% Non-Surgical Periodontal 100% 100% Oral Surgery 100% 100% Periodontal Maintenance 100% 100% Periodontal Surgery 100% 100% Major Services In-Network Benefit Out-of-Network Benefit Inlays/Onlays/Crowns 60% 60% Dentures – complete, partial, overdenture (upper and lower) 60% 60% Implants 60% 60% Bridges 60% 60% Orthodontic Services In-Network Benefit Out-of-Network Benefit Child Orthodontic Services 50% 50%

Page 3 Provider network You can choose from one of the 132,000 credentialed providers at any of the 600,000 access points nationwide in the Equitable Dental Network. You can locate an in-network provider by visiting: . Using a www.equitable.com/finddentist network dentist will significantly lower your out-of-pocket expense because these dental professionals have agreed to provide covered services at discounted fees. Equitable does not contract directly with dentists. Equitable’s dental network is supported by several partner companies which may vary by state. This information is provided on our website at . www.equitable.com/dentalprovider Please reference the following network names when confirming in-network participation with your provider. • Careington • Dental Benefit Providers (DBP) • Dentemax Plus • HealthSmart • PPO USA Connection Dental Network (GEHA) • Total Dental Administrators (TDA) • Zelis Dental Network • United Concordia AdvantagePlus Out-of-network dentists have the right to balance bill members for the difference between the provider charge and our maximum allowable charge. Out-of-network dentists are not obligated by contractual agreement to submit claims on behalf of members. Claim forms may be requested by contacting the telephone number or email address indicated on your ID card or above. Provider Availability Please contact your dentist for immediate attention in the event of an emergency. An emergency exists if services are necessary to treat a condition or illness that, without immediate attention, would seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, or cause the member to be in danger to self or others. You may also call our customer service department during business hours for help in locating a network dentist. Understanding your benefits Commonly Used Terms Standard Benefit Waiting Period A dental insurance waiting period is a set period before you receive coverage for some specific dental procedures. Waiting periods vary based on your plan. Please refer to your certificate of insurance for any associated waiting periods (e.g., 6 months). In-Network Provider Dentists who have agreed to provide dental services at discounted rates for participants. You can save up to 34% on average off of provider charge by visiting an in network provider. You will not be liable for the difference between the discounted rate and the provider charge if you visit an in-network provider. Out-of-Network Provider Dentists who have not agreed to provide dental services at discounted rates for participants. You are free to visit out-of-network providers, but you may be balance billed for the difference between our allowed amount and the provider charge. Annual Individual Maximum Annual maximum for each individual covered under the plan for procedures other than orthodontia. Lifetime Orthodontia Maximum Maximum for orthodontia procedures which pays up to the maximum over a lifetime including treatment covered under other dental plans. • • • • • • • •

Page 4 Frequently Asked Questions When can I enroll? You can enroll when you are initially eligible for benefits and during any subsequent annual enrollment period defined by your employer or if there is a life status change, such as involuntary termination under another policy. Are my dependents eligible for coverage? Your spouse or domestic partner, and your dependent children up to the end of the month they reach age 26 are eligible. Who is eligible for Orthodontic Services? Covered members to age 19 How does a PPO Work? PPO stands for Preferred Provider Organization. PPOs help you save money because in- network dentists - dentists who are contracted by our leased networks - agree to charge the plan’s lower rates. How do I find an in-network provider? To find a provider near you, please visit www.equitable.com/finddentist Can I see a provider outside of the network? Yes, you can see a provider outside of the network, but your out-of-pocket cost will likely be higher as out-of-network providers have not agreed to discounted rates on their services. How do I learn more about my benefits? Go to www.equitable.com/employeebenefits and log on to EB360® to view your account details. If I have additional questions, who can I talk to? Please don’t hesitate to contact us at 1-866-274-9887. Do I need a dental ID card in order to receive benefits? ID cards are not needed in order to receive treatment from a dentist, but can help to simplify your office experience so we encourage that they are printed and brought with you to your dental visit. ID cards can be printed from www.equitable.com/employeebenefits . Is there a late entrant penalty? A late entrant waiting period of 12 months is applicable for all but Preventive services if you do not enroll within your enrollment eligibility period. Am I required to have a pre-treatment estimate submitted in order to be eligible for coverage? No, a pre-treatment estimate is not required in order to receive benefits for covered services, but it will allow you to know what your out-of-pocket expenses are prior to services being performed. We recommend that a pre-treatment estimate be submitted for all anticipated work that you consider to be expensive. A pre-treatment estimate is not a pre- authorization or guarantee of payment or eligibility; rather it is an indication of the estimated benefits available if the described procedures are performed based on eligible services and subject to benefits availability at the time that the pre-treatment is processed.

Page 5 What if I started dental work under a different plan (i.e., treatment in progress)? These special provisions apply only to those persons who were insured under a given benefit section of a prior carrier, and become insured under a similar benefit section of our policy on the effective date of the policy. Benefits for covered charges which are a part of a course of treatment which began while you were insured by a prior carrier will be paid as follows if such benefits are covered under your policy with us and are not eligible under the prior carrier based on their definition of incurred date: Non-Orthodontic Services: • For Cast Restorations (Crowns, Inlays, Onlays) and Bridges, if the tooth was prepared while you were covered under the prior carrier’s policy. • For any other Prosthetics or modification of Prosthetics, if the master impression was made while you were covered under the prior carrier’s policy. • For Root Canal Therapy, if the pulp chamber was opened while you were covered under the prior carrier’s policy. • For all other non-orthodontic services, the charge is considered incurred on the date the services are performed. If performed while covered under the prior carrier, they are not eligible for payment by us. Orthodontic Services: • If you were covered for Orthodontia under your prior carrier, we will pay for active work in progress if the initial banding or appliance insertion occurred while covered under the prior carrier, up to our maximum benefit per individual per lifetime considering any amounts already paid under the prior carrier. We will require a copy of the last Orthodontic Explanation of Benefits paid by the prior carrier showing total amount paid toward the Orthodontic maximum in order to determine remaining benefits. If the insurance ends during the course of the treatment plan, the monthly benefits will end. • If you were not covered for Orthodontia under your prior carrier and become covered for Orthodontia under this policy, we will not pay for work in progress. Services must begin while this policy is in force in order to be eligible. Services are considered to have begun when the initial banding or appliance is inserted. Waiting periods, if, any, must be satisfied before payment begins, and then only treatment rendered after the waiting period has been met will be eligible for payment. If the insurance ends during the course of the treatment plan, the monthly benefits will end. Center for Disease Control and Prevention. (2020). Adult Oral 1 Restorations or appliances used for the purpose of periodontal (10) • • • • • •

Page 6 Center for Disease Control and Prevention. (2020). Adult Oral 1 Health. Retrieved from: Https://www.cdc.gov Center for Disease Control and Prevention. (2020). Children’s Oral 2 Health. Retrieved from: Https://www.cdc.gov Important Information Limitations and Exclusions Payment of benefits is limited under this certificate as Limitations: shown below. Refer to certificate of coverage for full limitations and exclusions. Orthodontic services must begin while this insurance is in force. (1) If the insurance ends during the course of the treatment plan, the monthly benefits will end. Services are considered to have begun when the initial banding or appliance is inserted. Services must begin after the end of any applicable waiting (2) period. Waiting periods for each category of service shown in your certificate of coverage. When multiple dental services of similar types are provided, the (3) frequency limit under the plan will combine all the similar types of services under the stated frequency limit in combination. Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes under this plan, these separate steps of one service are considered to be part of the more comprehensive service. Even if the dentist submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the pulp chamber, additional x-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, we will only pay benefits for the root canal therapy. Alternate Benefit: If We determine that a service, less costly than (4) the covered service the dentist performed, could have been performed to treat a dental condition, We will pay benefits based upon the less costly service if such service: • would produce an equivalent therapeutic or diagnostic result as to the diagnosis or treatment of the individual’s dental condition; and • would qualify as a covered service. For example, if a high noble metal crown and a predominantly base metal crown are both professionally acceptable methods for restoring a tooth, we may base our determination on the less costly predominantly base metal material. If we pay benefits based upon a less costly service in accordance with this subsection, the dentist may charge for the difference between the service that was performed and the less costly service. This is the case even if the service is performed by an in-network dentist. Basic restorative services are limited as follows: (5) a. Amalgam, composite resin, acrylic, synthetic or plastic restorations for treatment of caries. If the tooth can be restored with such materials, any other restoration such as a crown or jacket is not a covered service. b. Micro filled resin restorations which are non-cosmetic. c. Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as recurrent caries or fracture, and replacement is medically necessary. We will not pay benefits under this certificate for any of Exclusions: the following: Any procedures not specifically listed as a covered service in (1) your certificate of coverage. Services which are not deemed to be necessary care or (2) Restorations or appliances used for the purpose of periodontal (10) splinting. Counseling or instruction about oral hygiene, plaque control, (11) nutrition and tobacco. Personal supplies or devices including, but not limited to: water (12) piks, toothbrushes, or dental floss. Decoration or inscription of any tooth, device, appliance, crown (13) or other dental work. Charges for missed appointments. (14) Services: (15) • covered under any workers’ compensation or occupational disease law; • covered under any employer liability law; • for which the employer of the person receiving such services is required to pay; or • received at a facility maintained by your employer, labor union, mutual benefit association, or VA hospital. Services covered under other coverage provided by your (16) employer. Temporary or provisional restorations. (17) Temporary or provisional appliances. (18) Prescription drugs. (19) Services for which the submitted documentation indicates a (20) poor prognosis. Fixed and removable appliances for correction of harmful (21) habits unless Orthodontics is listed as a covered service in your certificate of coverage. Application of desensitizing agents. (22) Repair or replacement of an orthodontic device. (23) The following, when charged by the dentist on a separate (24) basis: • claim form completion; • infection control, such as gloves, masks, and sterilization of supplies; or • local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide. Caries susceptibility tests. (25) Appliances or treatment for bruxism (grinding teeth), including (26) but not limited to occlusal guards and night guards, unless Occlusal Guards is listed as a covered service in your certificate of coverage, then only the occlusal guard is covered. Precision attachments associated with fixed and removable (27) prostheses. Adjustment of a denture made within 6 months after (28) installation by the same dentist who installed it. Duplicate prosthetic devices or appliances. (29) Replacement of a lost or stolen appliance, cast restoration or (30) denture. Intra and extra-oral photographic images, unless Orthodontics (31) is listed as a covered service in your certificate of coverage. Cone beam imaging. (32) Diagnostic casts, unless part of overall treatment plan (33) allowance for orthodontia if Orthodontia is shown as a covered service in your certificate of coverage. Labial veneers. (34) Modification of removable prosthodontic and other removable (35) prosthetic services. Occlusal adjustments (36) The following services are not covered services: (37) • • • • • • • • •

Page 7 Group name: Betenbough Homes, LLC Services which are not deemed to be necessary care or (2) treatment and/or medically necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature. Services for which the insured person would not be required to (3) pay in the absence of dental insurance. Services or supplies received by an insured person before the (4) dental insurance starts for that person. Treatment or services received outside of the United States and (5) Canada. Services which are primarily cosmetic, except for services (6) covered under the Teeth Whitening Benefit if Teeth Whitening is shown as a covered service in your certificate of coverage. Services which are neither performed nor prescribed by a (7) dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for: • scaling and polishing of teeth; or • fluoride treatments. Services or appliances which restore or alter occlusion or vertical (8) dimension. Restoration of tooth structure damaged by attrition, abrasion or (9) erosion, unless caused by disease or unless TMJ is listed as a covered service in your certificate of coverage. The following services are not covered services: (37) • a connector bar, • a stress breaker, • coping, • pediatric partial dentures For complete plan details, please refer to your Equitable policy documents. This summary is not a guarantee of coverage. This summary is for highlight purposes only and does not include all plan features, limitations, or exclusions. If there is a discrepancy between this summary and the policy, the policy will prevail. Insurance coverage may be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that the insurance would otherwise become effective. The certificate has exclusions and limitations for certain conditions that may affect any benefits payable. For costs and complete details of the coverage, please see the actual policy or contact your benefits representative. Benefits payable are subject to all terms and conditions of the certificate. Plan documents are the final arbiter of coverage. Policy form MOEBP15DEN; AXEBP15DEN; MOEBP18DEN; MOEBP19DEN; AXEBP19DEN; MOEBP19DEN_PPO; and state variations. Availability is subject to state approvals. Legal disclosures: Equitable is the brand name of the retirement and protection subsidiaries of Equitable Holdings, Inc., including Equitable Financial Life Insurance Company (Equitable Financial) (NY, NY), Equitable Financial Life Insurance Company of America (Equitable America), an AZ stock company with an administrative office located in Charlotte, NC, and Equitable Distributors, LLC. Equitable Advisors is the brand name of Equitable Advisors, LLC (member FINRA, SIPC) (Equitable Financial Advisors in MI and TN). All group insurance products are issued either by Equitable Financial or Equitable America, which have sole responsibility for their respective insurance and backed solely by their claims- paying obligations. Some products are not available in all states. ©2023 Equitable Holdings, Inc. All rights reserved. (6/23) | EB360® is a registered mark of Equitable Holdings, Inc., NY, NY. • • • • • •

Page 8 Group name: Betenbough Homes, LLC Policy number: 024883 Form created: 08/28/2025 Regular dental care is one of the best ways to maintain a winning smile and protect your overall health. With Equitable’s dental plan, you can receive the care you need, including routine cleanings and fillings, and potentially major dental procedures, orthodontia and teeth-whitening benefits. Benefit Plan & Features This is only a partial list of covered dental services. Please carefully review your certificate of insurance for a full list of covered services, as well as all limitations and exclusions that apply to your plan. Benefit Plan and Features Class definition: Class 1 – All Active Full Time Employees enrolled in Low Plan Coverage Details Benefit Reimbursement 90th percentile R&C Coinsurance 100/80/50 Annual Individual / Family Deductible (Waived for Preventive Services) $50/3x individual Annual Individual Maximum Benefit (Waived for Preventive Services) $1,750 Alternate Benefit Included Missing Tooth Clause Applies Orthodontia* Individual Deductible/ Lifetime Maximum Child: $0/$1,500 Orthodontia* is eligible if the initial banding or appliance is inserted while you are covered for Orthodontia under Equitable’s policy, or while you were covered for Orthodontia under your immediate prior carrier.

Page 9 Preventive Services Benefit Evaluations • Periodic Oral Evaluation 100% • Limited Oral Evaluation – problem focused 100% • Comprehensive Oral Evaluation 100% Treatments • Routine Dental Prophylaxis 100% • Fluoride Treatment 100% • Sealants – child 100% X-Rays • Periapical X-Rays 100% • Bitewing X-Rays 100% Periodontal Maintenance 100% Basic Services Benefit X-Rays • Complete Series/ Panoramic X-Rays 80% Emergency Palliative Treatment 80% Surgical Extractions and Removal of Impacted Teeth 80% Basic Restorative Services (amalgam, composite resin, acrylic, synthetic or plastic fillings) 80% Simple Extractions 80% Surgical Endodontics 80% Non-Surgical Endodontics 80% Non-Surgical Periodontal 80% Oral Surgery 80% Periodontal Surgery 80% Major Services Benefit Inlays/Onlays/Crowns 50% Dentures – complete, partial, overdenture (upper and lower) 50% Implants 50% Bridges 50% Orthodontic Services Benefit Child Orthodontic Services 50%

Page 10 Provider network You can choose from one of the 132,000 credentialed providers at any of the 600,000 access points nationwide in the Equitable Dental Network. You can locate an in-network provider by visiting: . Using a www.equitable.com/finddentist network dentist will significantly lower your out-of-pocket expense because these dental professionals have agreed to provide covered services at discounted fees. Equitable does not contract directly with dentists. Equitable’s dental network is supported by several partner companies which may vary by state. This information is provided on our website at . www.equitable.com/dentalprovider Please reference the following network names when confirming in-network participation with your provider. • Careington • Dental Benefit Providers (DBP) • Dentemax Plus • HealthSmart • PPO USA Connection Dental Network (GEHA) • Total Dental Administrators (TDA) • Zelis Dental Network • United Concordia AdvantagePlus Out-of-network dentists have the right to balance bill members for the difference between the provider charge and our maximum allowable charge. Out-of-network dentists are not obligated by contractual agreement to submit claims on behalf of members. Claim forms may be requested by contacting the telephone number or email address indicated on your ID card or above. Understanding your benefits Commonly Used Terms Standard Benefit Waiting Period A dental insurance waiting period is a set period before you receive coverage for some specific dental procedures. Waiting periods vary based on your plan. Please refer to your certificate of insurance for any associated waiting periods (e.g., 6 months). In-Network Provider Dentists who have agreed to provide dental services at discounted rates for participants. Because your plan has a Passive PPO ,you can save up to 34% on average off of provider change by visiting an in network provider. You will not be liable for the difference between the discounted rate and the provider charge if you visit an in-network provider. Out-of-Network Provider Dentists who have not agreed to provide dental services at discounted rates for participants. You are free to visit out-of-network providers, but you may be balance billed for the difference between our allowed amount and the provider charge. Annual Individual Maximum Annual maximum for each individual covered under the plan for procedures other than orthodontia. Lifetime Orthodontia Maximum Maximum for orthodontia procedures which pays up to the maximum over a lifetime including treatment covered under other dental plans. Frequently Asked Questions When can I enroll? You can enroll when you are initially eligible for benefits and during any subsequent annual enrollment period defined by your employer or if there is a life status change, such as involuntary termination under another policy. • • • • • • • •

Page 11 Are my dependents eligible for coverage? Your spouse or domestic partner, and your dependent children up to the end of the month they reach age 19, are eligible. Who is eligible for Orthodontic Services? Covered members to age 19 Can I see a provider outside of the network? Yes, you can see a provider outside of the network, but your out-of-pocket cost will likely be higher as out-of-network providers have not agreed to discounted rates on their services. How do I learn more about my benefits? Go to www.equitable.com/employeebenefits and log on to EB360® to view your account details. If I have additional questions, who can I talk to? Please don’t hesitate to contact us at 1-866-274-9887. Do I need a dental ID card in order to receive benefits? ID cards are not needed in order to receive treatment from a dentist, but can help to simplify your office experience so we encourage that they are printed and brought with you to your dental visit. ID cards can be printed from www.equitable.com/employeebenefits . Is there a late entrant penalty? A late entrant waiting period of 12 months is applicable for all but Preventive services if you do not enroll within your enrollment eligibility period. Am I required to have a pre-treatment estimate submitted in order to be eligible for coverage? No, a pre-treatment estimate is not required in order to receive benefits for covered services, but it will allow you to know what your out-of-pocket expenses are prior to services being performed. We recommend that a pre-treatment estimate be submitted for all anticipated work that you consider to be expensive. A pre-treatment estimate is not a pre- authorization or guarantee of payment or eligibility; rather it is an indication of the estimated benefits available if the described procedures are performed based on eligible services and subject to benefits availability at the time that the pre-treatment is processed. What if I started dental work under a different plan (i.e., treatment in progress)? These special provisions apply only to those persons who were insured under a given benefit section of a prior carrier, and become insured under a similar benefit section of our policy on the effective date of the policy. Benefits for covered charges which are a part of a course of treatment which began while you were insured by a prior carrier will be paid as follows if such benefits are covered under your policy with us and are not eligible under the prior carrier based on their definition of incurred date: Non-Orthodontic Services: • For Cast Restorations (Crowns, Inlays, Onlays) and Bridges, if the tooth was prepared while you were covered under the prior carrier’s policy. • For any other Prosthetics or modification of Prosthetics, if the master impression was made while you were covered under the prior carrier’s policy. • For Root Canal Therapy, if the pulp chamber was opened while you were covered under the prior carrier’s policy. • For all other non-orthodontic services, the charge is considered incurred on the date the services are performed. If performed while covered under the prior carrier, they are not eligible for payment by us. Orthodontic Services: • If you were covered for Orthodontia under your prior carrier, we will pay for active work in progress if the initial banding or appliance insertion occurred while covered under the prior carrier, up to our maximum benefit per individual per lifetime considering any amounts already paid under the prior carrier. We will require a copy of the last Orthodontic Explanation of Benefits paid by the prior carrier showing total amount paid toward the Orthodontic maximum in order to determine remaining benefits. If the insurance ends during the course of the treatment plan, the monthly benefits will end. • If you were not covered for Orthodontia under your prior carrier and become covered for Orthodontia under this policy, we will not pay for work in progress. Services must begin while this policy is in force in order to be eligible. Services are considered to have begun when the initial banding or appliance is inserted. Waiting periods, if, any, must be satisfied before payment begins, and then only treatment rendered after the waiting period has been met will be eligible for payment. If the insurance ends during the course of the treatment plan, the monthly benefits will end. • • • • • •

Page 12 Center for Disease Control and Prevention. (2020). Adult Oral 1 Restorations or appliances used for the purpose of periodontal (10)

Page 13 Center for Disease Control and Prevention. (2020). Adult Oral 1 Health. Retrieved from: Https://www.cdc.gov Center for Disease Control and Prevention. (2020). Children’s Oral 2 Health. Retrieved from: Https://www.cdc.gov Important Information Limitations and Exclusions Payment of benefits is limited under this certificate as Limitations: shown below. Refer to certificate of coverage for full limitations and exclusions. Orthodontic services must begin while this insurance is in force. (1) If the insurance ends during the course of the treatment plan, the monthly benefits will end. Services are considered to have begun when the initial banding or appliance is inserted. Services must begin after the end of any applicable waiting (2) period. Waiting periods for each category of service shown in your certificate of coverage. When multiple dental services of similar types are provided, the (3) frequency limit under the plan will combine all the similar types of services under the stated frequency limit in combination. Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes under this plan, these separate steps of one service are considered to be part of the more comprehensive service. Even if the dentist submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the pulp chamber, additional x-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, we will only pay benefits for the root canal therapy. Alternate Benefit: If We determine that a service, less costly than (4) the covered service the dentist performed, could have been performed to treat a dental condition, We will pay benefits based upon the less costly service if such service: • would produce an equivalent therapeutic or diagnostic result as to the diagnosis or treatment of the individual’s dental condition; and • would qualify as a covered service. For example, if a high noble metal crown and a predominantly base metal crown are both professionally acceptable methods for restoring a tooth, we may base our determination on the less costly predominantly base metal material. If we pay benefits based upon a less costly service in accordance with this subsection, the dentist may charge for the difference between the service that was performed and the less costly service. This is the case even if the service is performed by an in-network dentist. Basic restorative services are limited as follows: (5) a. Amalgam, composite resin, acrylic, synthetic or plastic restorations for treatment of caries. If the tooth can be restored with such materials, any other restoration such as a crown or jacket is not a covered service. b. Micro filled resin restorations which are non-cosmetic. c. Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as recurrent caries or fracture, and replacement is medically necessary. We will not pay benefits under this certificate for any of Exclusions: the following: Any procedures not specifically listed as a covered service in (1) your certificate of coverage. Services which are not deemed to be necessary care or (2) Restorations or appliances used for the purpose of periodontal (10) splinting. Counseling or instruction about oral hygiene, plaque control, (11) nutrition and tobacco. Personal supplies or devices including, but not limited to: water (12) piks, toothbrushes, or dental floss. Decoration or inscription of any tooth, device, appliance, crown (13) or other dental work. Charges for missed appointments. (14) Services: (15) • covered under any workers’ compensation or occupational disease law; • covered under any employer liability law; • for which the employer of the person receiving such services is required to pay; or • received at a facility maintained by your employer, labor union, mutual benefit association, or VA hospital. Services covered under other coverage provided by your (16) employer. Temporary or provisional restorations. (17) Temporary or provisional appliances. (18) Prescription drugs. (19) Services for which the submitted documentation indicates a (20) poor prognosis. Fixed and removable appliances for correction of harmful (21) habits unless Orthodontics is listed as a covered service in your certificate of coverage. Application of desensitizing agents. (22) Repair or replacement of an orthodontic device. (23) The following, when charged by the dentist on a separate (24) basis: • claim form completion; • infection control, such as gloves, masks, and sterilization of supplies; or • local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide. Caries susceptibility tests. (25) Appliances or treatment for bruxism (grinding teeth), including (26) but not limited to occlusal guards and night guards, unless Occlusal Guards is listed as a covered service in your certificate of coverage, then only the occlusal guard is covered. Precision attachments associated with fixed and removable (27) prostheses. Adjustment of a denture made within 6 months after (28) installation by the same dentist who installed it. Duplicate prosthetic devices or appliances. (29) Replacement of a lost or stolen appliance, cast restoration or (30) denture. Intra and extra-oral photographic images, unless Orthodontics (31) is listed as a covered service in your certificate of coverage. Cone beam imaging. (32) Diagnostic casts, unless part of overall treatment plan (33) allowance for orthodontia if Orthodontia is shown as a covered service in your certificate of coverage. Labial veneers. (34) Modification of removable prosthodontic and other removable (35) prosthetic services. Occlusal adjustments (36) The following services are not covered services: (37) • • • • • • • • •

Page 14 Services which are not deemed to be necessary care or (2) treatment and/or medically necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature. Services for which the insured person would not be required to (3) pay in the absence of dental insurance. Services or supplies received by an insured person before the (4) dental insurance starts for that person. Treatment or services received outside of the United States and (5) Canada. Services which are primarily cosmetic, except for services (6) covered under the Teeth Whitening Benefit if Teeth Whitening is shown as a covered service in your certificate of coverage. Services which are neither performed nor prescribed by a (7) dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for: • scaling and polishing of teeth; or • fluoride treatments. Services or appliances which restore or alter occlusion or vertical (8) dimension. Restoration of tooth structure damaged by attrition, abrasion or (9) erosion, unless caused by disease or unless TMJ is listed as a covered service in your certificate of coverage. The following services are not covered services: (37) • a connector bar, • a stress breaker, • coping, • pediatric partial dentures For complete plan details, please refer to your Equitable policy documents. This summary is not a guarantee of coverage. This summary is for highlight purposes only and does not include all plan features, limitations, or exclusions. If there is a discrepancy between this summary and the policy, the policy will prevail. Insurance coverage may be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that the insurance would otherwise become effective. The certificate has exclusions and limitations for certain conditions that may affect any benefits payable. For costs and complete details of the coverage, please see the actual policy or contact your benefits representative. Benefits payable are subject to all terms and conditions of the certificate. Plan documents are the final arbiter of coverage. Policy form MOEBP15DEN; AXEBP15DEN; MOEBP18DEN; MOEBP19DEN; AXEBP19DEN; MOEBP19DEN_PPO; and state variations. Availability is subject to state approvals. Legal disclosures: Equitable is the brand name of the retirement and protection subsidiaries of Equitable Holdings, Inc., including Equitable Financial Life Insurance Company (Equitable Financial) (NY, NY), Equitable Financial Life Insurance Company of America (Equitable America), an AZ stock company with an administrative office located in Charlotte, NC, and Equitable Distributors, LLC. Equitable Advisors is the brand name of Equitable Advisors, LLC (member FINRA, SIPC) (Equitable Financial Advisors in MI and TN). All group insurance products are issued either by Equitable Financial or Equitable America, which have sole responsibility for their respective insurance and backed solely by their claims- paying obligations. Some products are not available in all states. ©2023 Equitable Holdings, Inc. All rights reserved. (6/23) | EB360® is a registered mark of Equitable Holdings, Inc., NY, NY. • • • • • •