Dental Summary

Summary of Benefits Anthem Dental Essential Choice Total Education Solutions Anthem Blue Cross Dental Complete Network WELCOME TO YOUR DENTAL PLAN! Regular dental checkups can help find early warning signs of certain health problems, which means you can get the care you need to get healthy. So, don't skimp on your dental care, good oral care can mean better overall health! Powerful and easily accessible member tools. Dentists in your plan network. ● Ask a Hygienist: Dental members can simply email their dental ● You'll save money when you visit a dentist in your plan questions to a team of licensed dental professionals who in turn will network because Anthem Blue Cross (Anthem) respond in about 24 hours. and the dentist have agreed on pricing for covered services. ● Dental Health Risk Assessment: We want our dental members Dentists who are not in your plan network have not agreed to better understand their oral health and their risk factors for tooth to pricing, and may bill you for the difference between what decay, gum disease and oral cancer. This easy to use online tool can Anthem pays them and what the dentist usually help them do this. charges. ● Dental Care Cost Estimator: In order to help our dental member ● To find a dentist by name or location, go to better understand the cost of their dental care, we offer access to a anthem.com/ca or call dental customer service at the user-friendly, web-based tool that provides estimates on common number listed on the back of your ID card. dental procedures and treatments when using a network dentist. ● More Capabilities: With our latest mobile application, members can find Ready to use your dental benefits? a network dentist as well as view their claims. Our application is available ● Choose a dentist from the network for both Android and Apple phones. ● Make an appointment ● Show the office staff your member ID card ● Pay any deductible or copay that is part of your plan Need to contact us? See the back of your ID card for who to call, write or email us. Your dental benefits at a glance The following benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your policy. In-Network Out-of-Network Coverage Year Calendar Year Annual Benefit Maximum ● Per insured person $2,000 $2,000 ● Diagnostic & Preventive Services are applied to the Annual Maximum Annual Maximum Carryover No No Orthodontic Lifetime Benefit Maximum ● Per eligible person $1,000 $1,000 Annual Deductible ● Per insured person $50 $50 ● Family maximum 3x single member 3x single member deductible deductible Deductible Waived for Diagnostic/Preventive Services Yes Yes Out-of-Network Reimbursement: 90th percentile Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. QuoteID: 00942573 Page 1 of 3

Dental Services In-Network Out-of-Network Waiting Period Anthem Pays: Anthem Pays: Diagnostic and Preventive Services 100% Coinsurance 100% Coinsurance No Waiting Period ● Periodic oral exam ○ Limited to 2 per 12 months ● Teeth cleaning (prophylaxis) ○ Limited to two per 12 months combined with periodontal maintenance ● Bitewing X-rays ○ Limited to one set per 12 months ● Full-Mouth or Panoramic X-rays ○ Limited to one per 60 months ● Fluoride application ○ 1 per 12 months through age 18 ● Sealant application ○ 1 per 60 months; through age 18 ● Space maintainer insertion ○ Limited to one per tooth space per lifetime through age 18 Basic (Restorative) Services 90% Coinsurance 80% Coinsurance No Waiting Period ● Consultation (second opinion); only with X-rays and no other services ○ Limited to one per 12 months ● Amalgam (silver-colored) filling ○ Limited to one per tooth surface per 24 months ● Composite (tooth-colored) filling ○ Limited to one per tooth surface per 24 months posterior (back) fillings paid as an amalgam (silver-colored filling) ● Brush Biopsy (cancer test) ○ Limited to one per 12 months; all ages Endodontics (Non-Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Root Canal (permanent teeth only) ○ Limited to 1 per tooth per lifetime; permanent teeth only Endodontics (Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Apicoectomy and apexification ○ Limited to 1 per tooth per lifetime; permanent teeth only Periodontics (Non-Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Periodontal maintenance ○ Limited to two per 12 months combined with teeth cleanings ● Scaling and root planning; when the tooth pocket has a depth of four millimeters or greater ○ Limited to one per quadrant per 24 months Periodontics (Surgical) 90% Coinsurance 80% Coinsurance No Waiting Period ● Periodontal surgery (osseous, gingivectomy, graft procedures) ○ Limited to one per quadrant per 36 months Oral Surgery (Simple) 90% Coinsurance 80% Coinsurance No Waiting Period ● Simple extraction ○ Limited to one per tooth per lifetime Oral Surgery (Complex) 90% Coinsurance 80% Coinsurance No Waiting Period ● Surgical extraction ○ Limited to one per tooth per lifetime Major (Restorative) Services 60% Coinsurance 50% Coinsurance No Waiting Period ● Crowns, onlays, veneers ○ Limited to one per tooth/arch per 60 months Prosthodontics 60% Coinsurance 50% Coinsurance No Waiting Period ● Dentures and bridges ○ Limited to one per tooth/arch per 60 months ● Implant placement ○ Limited to one per tooth/arch per 60 months ● Implant prosthodontics ○ Limited to one per tooth/arch per 60 months as a non-implant crown, bridge, and/or denture Repairs/Adjustments 60% Coinsurance 50% Coinsurance No Waiting Period ● Crown, denture, bridge repairs ○ Limited to one per 12 months; 6 months after placement ● Denture and bridge adjustments: ○ 2 per 12 months; 6 months after placement Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. QuoteID: 00942573 Page 2 of 3

Dental Services (continued) In-Network Out-of-Network Waiting Period Anthem Pays: Anthem Pays: Adult/Child Orthodontic Services 50% coinsurance 50% coinsurance No waiting periods ○ No age limits apply Temporomandibular Joint Disorder (TMJ) ● X-rays, splints, and surgical procedures including arthroscopy and orthotic devices Not Covered Not Covered N/A ○ Not Covered Cosmetic Teeth Whitening Not Covered Not Covered N/A ○ Not covered NOTE: Cosmetic benefits, such as teeth bleaching, in an insurance policy may have income tax implications for both employer groups and plan members. For example, the dollar value of the cosmetic benefit may be considered part of an individual’s taxable income. For more information concerning the tax ramifications of cosmetic insurance benefits, please consult a legal or tax advisor. Additional Services and Programs In-Network Out-of-Network Waiting Period Anthem Pays: Anthem Pays: Anthem Whole Health Connection® - Dental ● For members with certain health conditions, additional dental benefits are available without a Included Included No waiting period deductible, office visit copay, nor waiting periods. Eligible services are paid at 100% and won’t reduce your coverage year annual maximum (if applicable). Accidental Dental Injury Benefit ● Provides members 100% coverage for accidental injuries to teeth up to the coverage year annual Included Included No waiting period maximum (if applicable). No deductibles, office visit copay, member coinsurance, nor waiting periods apply. Extension of Benefits ● Following termination of coverage, members are provided up to 60 days to complete treatment Included Included No waiting period started prior to their termination of coverage under the plan and eligible services will be covered. International Emergency Dental Program ● Provides emergency dental benefits while working or traveling abroad from licensed, English- speaking dentists. Eligible covered services will be paid 100% with no deductibles, office visit copay, Included Included No waiting period member coinsurance, nor waiting periods and won’t reduce the member coverage year annual maximum (if applicable). Additional Limitations & Exclusions Below is a partial listing of non-covered services under your dental plan. Please see your policy for a full list. Services provided before or after the term of this coverage - Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate Orthodontics (unless included as part of your dental plan benefits) including orthodontic braces, appliances and all related services Cosmetic dentistry (unless included as part of you dental plan benefits) provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist Drugs and medications including intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care Analgesia, analgesic agents, and anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There is a 24 month waiting period for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan. This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your policy. In the event of a discrepancy between the information in this summary and the policy, your policy will prevail. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. QuoteID: 00942573 Page 3 of 3