Dental SDBC

Summary of Dental Benefits and Coverage Disclosure Matrix (SDBC) Part I: GENERAL INFORMATION Insurer Name: Anthem Blue Cross Life and Health Plan Name: Essential Choice Insurance Company Policy Type: PPO Insurer Phone #: 1-844-729-1565 Effective Date: Beginning on or after 04/01/2024 Insurer Website: www.anthem.com/ca THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND WHAT YOU WILL PAY FOR COVERED SERVICES. THIS IS A SUMMARY ONLY AND DOES NOT INCLUDE THE PREMIUM COSTS OF THIS DENTAL BENEFITS PACKAGE. PLEASE CONSULT YOUR EVIDENCE OF COVERAGE AND DENTAL CONTRACT FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. FOR MORE INFORMATION ABOUT YOUR COVERAGE, VISIT THE INSURER WEBSITE AT www.anthem.com/ca OR CALL 1-844-729-1565. THIS MATRIX IS NOT A GUARANTEE OF EXPENSES OR PAYMENT. Part II: DEDUCTIBLES Deductible In-Network Out-of-Network Dental $50 per individual/$150 per family $50 per individual/$150 per family Orthodontia None None • The deductible applies to all services except Preventive & Diagnostic and Orthodontia. • A deductible is the amount you are required to pay for covered dental services each policy year before the insurer begins to pay for the cost of covered dental treatment. • In-network services are dental care services provided by dentists or other licensed dental care providers that contract with your insurer for alternative rates of payment for dental services. • Out-of-network services are dental care services provided by dentists or other licensed dental care providers that have not contracted with your insurer for alternative rates of payment.

Part III: MAXIMUMS POLICY WILL PAY Maximums In-Network Out-of-Network Annual Maximum $2,000 $2,000 Lifetime or Annual Lifetime $1,000 Lifetime $1,000 Maximum for Orthodontia • Annual maximum is the maximum dollar amount your policy will pay toward the cost of dental care within a specific period of time, usually a consecutive 12-month or calendar year period. • Lifetime maximum means the maximum dollar amount your policy providing dental benefits will pay for the life of the enrollee. Lifetime maximums usually apply to specific services, such as orthodontic treatment. Part IV: WAITING PERIODS Waiting Periods: A waiting period is the amount of time that must pass before you are eligible to receive benefits for all or certain dental treatments. 24 month waiting period for replacement of teeth missing prior to member's effective date Part V: WHAT YOU WILL PAY All copayments and coinsurance costs shown in this chart apply after your deductible has been met, if a deductible applies. The Common Dental Procedures fit into one of the following applicable categories: Preventive & Diagnostic, Basic or Major. The Benefit Limitations and Exclusions column includes common limitations and exclusions only. For a full list, see the full disclosure document referenced in the Benefit Limitations and Exclusions column. Common Dental Category In- Out-of- Benefit Limitations and Exclusions Procedures Network Network Oral Exam Preventive & 0% 0% 2 per 12 months Diagnostic Deductible Deductible For Limitations and Exclusions, refer does not does not to the Covered Services; Preventive apply apply Care section of your Certificate of Coverage. Bitewing X-ray Preventive & 0% 0% 1 set per 12 months Diagnostic Deductible Deductible For Limitations and Exclusions, refer does not does not to the Covered Services; Preventive apply apply Care section of your Certificate of Coverage. Cleaning Preventive & 0% 0% 2 per 12 months Diagnostic Deductible Deductible For Limitations and Exclusions, refer does not does not to the Covered Services; Preventive apply apply Care section of your Certificate of Coverage.

Common Dental Category In- Out-of- Benefit Limitations and Exclusions Procedures Network Network Filling Basic 10% 20% 1 per tooth per surface per 24 months For Limitations and Exclusions, refer to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Extraction, Erupted Basic 10% 20% 1 per tooth per lifetime Tooth or Exposed For Limitations and Exclusions, refer Root to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Root Canal Basic 10% 20% 1 per tooth per lifetime For Limitations and Exclusions, refer to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Scaling and Root Basic 10% 20% 1 per quadrant per 24 months Planing For Limitations and Exclusions, refer to the Covered Services; Basic Restorative Services section of your Certificate of Coverage. Ceramic Crown Major 40% 50% 1 per tooth per 60 months For Limitations and Exclusions, refer to the Covered Services; Major Restorative Services section of your Certificate of Coverage. Removable Partial Major 40% 50% 1 per tooth per 60 months Denture For Limitations and Exclusions, refer to the Covered Services; Prosthodontic Services section of your Certificate of Coverage. 24 month waiting period for replacement of teeth missing prior to member's effective date Extraction, Erupted Basic 10% 20% 1 per tooth per lifetime Tooth with Bone For Limitations and Exclusions, refer Removal to the Covered Services; Basic Restorative Services section of your Certificate of Coverage.

Common Dental Category In- Out-of- Benefit Limitations and Exclusions Procedures Network Network Orthodontia Orthodontia 50% 50% Adult & Dependent children: Deductible Deductible For Limitations and Exclusions, refer does not does not to the Covered Services; Orthodontics apply apply section of your Certificate of Coverage.

Part VI: COVERAGE EXAMPLES THESE EXAMPLES DO NOT REPRESENT A COST ESTIMATOR OR GUARANTEE OF PAYMENT. The examples provided represent commonly used services in the categories of Diagnostic and Preventive, Basic and Major Services for illustrative purposes and to compare this product to other dental products you may be considering. Your actual costs will likely be different from those shown in the chart below depending on the actual care you receive, the prices your providers charge and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and the summary of excluded services under the plan. Dana Has a Dental Appointment Sam Needs a Tooth Filled Maria Needs a Crown with a New Dentist New patient exam, x-rays (FMX) Resin-based composite – one Crown – porcelain/ceramic and cleaning surface, posterior substrate Dana’s Visit Dana's Cost Sam's Visit Sam's Cost Maria's Visit Maria's Cost Total Cost of In-network: $400 Total Cost of In-network: $150 Total Cost of In-network: $1,300 Care Out-of-network: Care Out-of-network: Care Out-of-network: $550 $200 $1,750 Deductible In-network: Deductible In-network: Deductible In-network: Not applicable $50 $50 Out-of-network: Out-of-network: Out-of-network: Not applicable $50 $50 Annual In-network: Annual In-network: Annual In-network: Maximum $2,000 Maximum $2,000 Maximum $2,000 (Plan Will Pay) (Plan Will Pay) (Plan Will Pay) Out-of-network: Out-of-network: Out-of-network: $2,000 $2,000 $2,000 Patient Cost In-network: Patient Cost In-network: Patient Cost In-network: (copayment or 0% (copayment or 10% (copayment or 40% coinsurance) coinsurance) coinsurance) Out-of-network: Out-of-network: Out-of-network: 0% 20% 50%

Dana’s Visit Dana's Cost Sam's Visit Sam's Cost Maria's Visit Maria's Cost In this In-network: In this In-network: In this In-network: example, $0 example, Sam $60 example, $550 Dana would would pay Maria would pay (includes (includes pay (includes copays/ Out-of-network: copays/ Out-of-network: copays/ Out-of-network: coinsurance $0 coinsurance $80 coinsurance $900 and and and deductible, if deductible, if deductible, if applicable): applicable): applicable): Summary of Exam covered 2 Summary of Covered 1 per Summary of Covered 1 per what is not per 12 months; X- what is not tooth per surface what is not tooth per 60 covered or ray covered 1 per covered or per 24 months covered or months subject to a 60 months; subject to a subject to a limitation: Cleaning covered limitation: limitation: 2 per 12 months;