Comprehensive Dental Plans:

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1 PLAN NETWORK Is this a smaller network? Is there out-of-network coverage? Annual deductible one enrollee* Annual deductible family* Maximum annual out-of-pocket child under 19 yrs. Maximum annual out-of-pocket 2 or more children under 19 yrs. Maximum annual benefit adults 19 and over only Altus Dental Participating Dentists Family MetLife Preferred Program DentalGuard Preferred Yes No No Yes No No Yes $50 $150 $350 $700 $1,250 *Waived for diagnostic and preventive services and for some plans, medically necessary orthodontia. Page 1 of 10

2 Family Type I services: Preventive & Diagnostic Dental Co-insurance percentage (what you pay) All ages in-network 0% out-of-network 20% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. 2 Procedures per Comprehensive 1 per patient per location per Evaluation lifetime Periodic Oral Exams Oral Evaluation under 3 Years of Age 2 Procedures per patient per Teeth Cleaning 12 Limited Oral Evaluation 2 Procedures per patient per 12 * Full Mouth X-Rays Panoramic X-Rays Single Tooth X-Rays Bitewing X-Rays Fluoride Treatments patient per 36 2 Procedures per patient per 12 3 Space Maintainers tooth per 36 Sealants *Not combined with other covered exam procedures. 4 Procedures per 12 patient per lifetime Page 2 of 10

3 Family For enrollees 19 yrs. and over Benefit Standard Limits means that the limits are the standard limits or the equivalent. 2 Procedures per Comprehensive Evaluation 1 per patient per 60 Periodic Oral Exams 2 Procedures per patient per Teeth Cleaning 12 Limited Oral Evaluation 2 Procedure/s per patient per 12 * Full Mouth X-Rays Panoramic X-Rays Single Tooth X-Rays Bitewing X-Rays Periodontal Cleaning patient per 60 2 Procedures per patient per 12 patient per 3 patient per 36 patient per 36 patient per 6 (some restrictions Palliative Care may apply) *Not combined with other covered exam procedures. **Less the number of teeth cleanings [prophylaxis] received during that 12 month period. patient per 6 patient per 6 as Type I, see Type II for coverage details 4 Procedures per ** as Type II Service 2 Procedures per 12 Page 3 of 10

4 Family Type II services: Basic Restorative Co-insurance percent (what you pay) All ages: in-network 25% out-of-network 45% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. 4 Procedures per Periodontal Cleaning patient per 3 ** Silver Fillings tooth per surface per White Fillings 12 * * Temporary Fillings Prefabricated Stainless Steel tooth per lifetime Crowns Periodontal Scaling and Root ing Root canals on permanent teeth Apicoectomy* quadrant per 36 quadrant per 24 tooth per lifetime Vital Pulpotomy tooth per lifetime Simple Extractions Surgical Extractions (prior authorization may be required) Anesthesia (some restrictions may apply) Palliative Care (some restrictions may apply) Page 4 of 10

5 Periodontal Surgery Bridge or Denture Repair quadrant per 36 *** *** Rebase or Reline Dentures patient per 24 month Recement Crowns *** patient per and Onlays lifetime*** *No limitation for this procedure, MetLife only. *For white fillings, paid as an alternate benefit on multi- surface restorations on posterior teeth. **Less the number of teeth cleanings [prophylaxis] received during that 12 month period. ***6 after initial placement. tooth per patient per lifetime*** 12 patient per 24 *** tooth per 12 arch per 24 Page 5 of 10

6 For enrollees 19 yrs. And over Family Benefit Standard Limits means that the limits are the standard limits or the equivalent. Silver Fillings tooth per * White Fillings surface per 24 Temporary Fillings Prefabricated Stainless Steel Crowns (pre-authorization may be required) tooth per 60 tooth per lifetime tooth per lifetime quadrant per 24 (Periodontal) Scaling and Root ning quadrant per 24 Root canals on permanent teeth tooth per lifetime Apicoectomy Vital Pulpotomy tooth per Simple Extractions lifetime (pre-authorization Surgical Extractions may be required) Anesthesia (some restrictions may apply) Page 6 of 10

7 Palliative Care Periodontal Surgery Bridge or Denture Repair Rebase or Reline Dentures (some restrictions may apply) quadrant per 36 1 Procedure/s per patient per Procedures per 12 For enrollees 19 yrs. And over Family as Type I Service ** arch per 36 ** Recement Crowns and Onlays tooth per lifetime ** *For white fillings, paid as an alternate benefit on restorations on molar teeth. **6 after initial placement. arch per 24 Page 7 of 10

8 Family Type III services: Major Restorative Co-insurance percent (what you pay) All ages: in-network 50% out-of-network 70% For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. Waiting period None Crown, resin tooth per 60 Porcelain/ceramic crowns tooth per 60 Porcelain fused to metal/noble/high noble crowns tooth per 60 Partial & complete dentures arch per 84 Fixed Bridges and Crowns (when part of a bridge) tooth per 60 * only if no other less expensive adequate dental service is available * * * Page 8 of 10

9 Family Type III services: Major Restorative Co-insurance percent (what you pay) All ages: in-network 50% out-of-network 70% For enrollees 19 yrs. And over Benefit Standard Limits means that the limits are the standard limits or the equivalent. Waiting period 6 Prefabricated Stainless Steel Crowns tooth per lifetime Crown, resin patient per tooth per 60 tooth per Porcelain/ceramic crowns Porcelain fused to metal/noble/high noble crowns Partial & complete dentures Fixed Bridges and Crowns (when part of a bridge) tooth per 60 tooth per 60 patient per 84 tooth per 60 * only when teeth cannot be restored with regular fillings. patient per 60 ** only if no other less expensive adequate dental service is available. tooth per 84 tooth per 84 tooth per 60 * * * * arch per 84 ** arch per 84 ** Page 9 of 10

10 Family Type IV services: Orthodontia Co-insurance percent (what you pay) Under 19: in-network 50% out-of-network 70% 19 and over: For enrollees under 19 yrs. Benefit Standard Limits means that the limits are the standard limits or the equivalent. patient per Medically necessary orthodontia lifetime (pre-authorization is required) Page 10 of 10

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