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