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. • • • • • •