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