[Dental] Delta Dental Plan Summary

INPPOSUM1123 KR#08314644 Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group #1151-1001, 1002, 1099 Noblesville 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 PPO™ Dentist Delta Dental Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Palliative Treatment – to temporarily relieve pain 90% 90% 85% Minor Restorative Services – fillings 90% 90% 85% Endodontic Services – root canals 90% 90% 85% Periodontic Services – to treat gum disease 90% 90% 85% Oral Surgery Services – extractions and dental surgery 90% 90% 85% Other Basic Services – misc. services 90% 90% 85% Major Services Crown Repair – to individual crowns 60% 60% 55% Major Restorative Services – crowns 60% 60% 55% Relines and Repairs – to prosthetic appliances 60% 60% 55% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 55% Orthodontic Services Orthodontic Services – braces 50% 50% 50% Orthodontic Age Limit – through age 18 and under through age 18 and under through age 18 and under * 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 and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice per calendar year.  Six prophylaxes (cleanings) are payable per calendar year.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment.  Fluoride treatments are payable twice per calendar year for people age 18 and under.  Space maintainers are Covered Services without limitation for people age 18 and under.  Bitewing X-rays are payable twice per calendar year and full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any three-year period.

INPPOSUM1123 KR#08314644  Cone beam imaging is not payable.  Sealants are payable once per tooth per three-year period for first and second permanent molars for people age 17 and under. The surface must be free from decay and restorations.  Composite resin (white) restorations are payable on all teeth, including posterior teeth.  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.  People with special health care needs may be eligible for additional services including exams, hygiene visits, dental case management, and sedation/anesthesia. Special health care needs include any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, healthcare intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. 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 website or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – Delta Dental PPO™ Dentist or Delta Dental Premier® Dentist - The plan is designed to encourage yearly visits to your dentist for preventive care. The Maximum Payment for the first Benefit Year is $1,250 per Member total per Benefit Year on all services except orthodontic services. If an Eligible Member obtains preventive services in a Benefit Year, the Maximum Payment will increase in the following Benefit Year by $100 up to a Maximum Payment of $1,550 per Benefit Year. If one of the required services is not received in a Benefit Year, the Maximum Payment in the following Benefit Year will be reduced to $1,250. $1,250 per Member total per lifetime on orthodontic services. Nonparticipating Dentist - The plan is designed to encourage yearly visits to your dentist for preventive care. The Maximum Payment for the first Benefit Year is $1,250 per Member total per Benefit Year on all services except orthodontic services. If an Eligible Member obtains preventive services in a Benefit Year, the Maximum Payment will increase in the following Benefit Year by $100 up to a Maximum Payment of $1,550 per Benefit Year. If one of the required services is not received in a Benefit Year, the Maximum Payment in the following Benefit Year will be reduced to $1,250. $1,000 per Member total per lifetime on orthodontic services. These are not separate maximums by type of dentist. 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 50% of the per month fee charged by your Dentist based upon the agreed upon payment plan provided by Delta Dental to your Dentist. Deductible – Delta Dental PPO™ Dentist or Delta Dental Premier® Dentist - None. Nonparticipating Dentist - $25 Deductible per Member total per Benefit Year limited to a maximum Deductible of $75 per family per Benefit Year. The Deductible does not apply to preventive services, X-rays, brush biopsy, sealants, and orthodontic services. Waiting Period – Enrollees who are eligible for Benefits are covered on the date that is defined by Noblesville Schools. Eligible People – All Active full-time employees and their dependents as defined by Noblesville Schools. 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. Enrollees and Dependents choosing this plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125.

INPPOSUM1123 KR#08314644 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 on the last day of the month that is defined by Noblesville Schools. Customer Service Toll-Free Number: 800-524-0149 (TTY users call 711) https://www.DeltaDentalIN.com Document Creation Date: October 28, 2025