Delta Dental PPO Plan Benefits Summary for Elkhart Community Schools

Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 1300-0001, 0002, 0099 Elkhart Community Schools This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Control Plan – Delta Dental of Indiana Benefit Year – January 1 through December 31 Covered Services – Delta Dental Delta Dental Nonparticipating PPO™ Dentist Premier® Dentist Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, 80% 80% 80% cleanings, fluoride, and space maintainers Emergency Palliative Treatment – to temporarily 80% 80% 80% relieve pain Sealants – to prevent decay of permanent teeth 80% 80% 80% Brush Biopsy – to detect oral cancer 80% 80% 80% Radiographs – X-rays 80% 80% 80% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Major Restorative Services – crowns 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to prosthetic appliances 80% 80% 80% TMD Treatment – treatment of the disorder of the 80% 80% 80% temporomandibular joint, including related films Major Services Prosthodontic Services – bridges, implants, dentures, 80% 80% 80% and crowns over implants Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – Dependent Dependent Dependent Children up to Children up to Children up to age 19 age 19 age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice per calendar year. Screening and assessment of a patient are payable twice per calendar year.  Prophylaxes (cleanings) are payable twice per calendar year. Two additional prophylaxes are payable per calendar year for individuals with a documented history of periodontal disease. Full mouth debridement is payable once in any three-year period.  Fluoride treatments are payable once per calendar year for people age 23 and under.  Space maintainers are payable once per area per lifetime for people age 15 and under.  Bitewing X-rays are payable twice per calendar year. Full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period.  TMD films are Covered Services. Cone beam imaging are payable once every five years. KR#64690433

 Sealants are payable once per tooth per three-year period for first and second permanent molars for people age 15 and under. The surface must be free from decay and restorations. Interim caries arresting medicament application is payable for bicuspids and first and second permanent molars once every three years for people age 15 and under.  Veneers are payable on incisors, cuspids, and bicuspids once per tooth in any five-year period for people age 12 and older when necessary due to fracture or decay.  Composite resin (white) restorations are payable on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Pulpal regeneration is a Covered Service once per lifetime.  TMD treatment, biopsy of oral tissue, sinus augmentation, and bone replacement graft for ridge preservation are Covered Services.  Benefits for Temporomandibular Disorders (TMD) are limited to those services normally provided by a dentist to relieve oral symptoms associated with malfunctioning of the temporomandibular joint. This does not include services that would normally be provided under medical care.  Tissue conditioning is payable once in any 12-month period.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services.  Office visits for observation and therapeutic parenteral drug administration are payable without limitation. Cleaning and inspection of dentures is payable twice per calendar year. Complete occlusal adjustments are payable twice per lifetime.  A removable or fixed harmful habit appliance is payable without limitation up to age 14. Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,250 per person total per Benefit Year on all services, except orthodontic services. $1,200 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to Delta Dental. Deductible – $25 Deductible per person total per Benefit Year limited to a maximum Deductible of $50 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, sealants, office visits for observation, and orthodontic services. Waiting Period – Certified Employees are eligible for coverage on the 1st of the month following date of hire. Classified Employees are eligible for coverage on the 1st day of the month after meeting the 60 day waiting period for employment. Eligible People – All active full-time & part-time Certified and Classified employees who work 30 or more hours per week (0001), retired teachers who have at least 15 years of service and are at least 55 years of age, retired teachers who have at least 10 years of service and are at least 60 years of age, retired administrators who have at least 10 years of service and are at least 55 years of age, retired classified employees who have at least 15 years of service and are at least 55 years of age, retired classified employees who have at least 10 years of service and are at least 60 years of age (0002) and (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees (0099), if applicable, who choose the Dental Plan. Also eligible are your Spouse and your Children to the end of the calendar year in which they turn 26, including your Children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. The medical and Delta Dental plans are offered as a package. Employees enrolled in either plan are automatically enrolled in both plans with the same type of coverage. For example, employees enrolled with single coverage under the medical plan must also be enrolled with single coverage under the Delta Dental plan. KR#64690433

Coordination of Benefits – If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease at the end of the month of your date of termination. Customer Service Toll-Free Number: 800-524-0149 (TTY users call 711) https://www.DeltaDentalIN.com Contract Start Date: January 1, 2022 Document Creation Date: August 26, 2021 KR#64690433