Dental Insurance Plan Summary

This document provides a summary of dental insurance coverage and benefits including in-network and out-of-network services, deductibles, annual maximum benefits, and a list of primary covered services and limitations.

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 L0325047071[exp0327][xNM] © 2025 MetLife Services and Solutions, LLC DN-ANY-PPO-DUAL PLAN SUMMARY Dental Insurance Coverage that can help make it easier to visit a dentist and can help lower your dental costs. The service categories and plan limitations shown above represent an overview of your plan benefits. This document presents the majority of services within each category, but is not a complete description of the plan. Exclusions This plan does not cover the following services, treatments and supplies: • Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature; • Services for which you would not be required to pay in the absence of Dental Insurance; • Services or supplies received by you or your Dependent before the Dental Insurance starts for that person; • Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate); • Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for: o Scaling and polishing of teeth; or o Fluoride treatments; • Services or appliances which restore or alter occlusion or vertical dimension; • Restoration of tooth structure damaged by attrition, abrasion or erosion; • Restorations or appliances used for the purpose of periodontal splinting; • Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco; • Personal supplies or devices including, but not limited to: water picks, toothbrushes, or dental floss; • Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work; • Missed appointments; • Services: o Covered under any workers’ compensation or occupational disease law; o Covered under any employer liability law; o For which the employer of the person receiving such services is not required to pay; or o Received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital; • Services covered under other coverage provided by the Employer; • Temporary or provisional restorations; • Temporary or provisional appliances; • Prescription drugs; • Services for which the submitted documentation indicates a poor prognosis; • The following when charged by the Dentist on a separate basis: o Claim form completion; o Infection control such as gloves, masks, and sterilization of supplies; or o Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide. • Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food; • Caries susceptibility tests; • Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth; • Other fixed Denture prosthetic services not described elsewhere in the certificate; • Precision attachments, except when the precision attachment is related to implant prosthetics; • Initial installation of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth; • Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth; • Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 L0325047071[exp0327][xNM] © 2025 MetLife Services and Solutions, LLC DN-ANY-PPO-DUAL PLAN SUMMARY Dental Insurance Coverage that can help make it easier to visit a dentist and can help lower your dental costs. • Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth; • Fixed and removable appliances for correction of harmful habits; • Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards; • Diagnosis and treatment of temporomandibular joint (TMJ) disorders. • Repair or replacement of an orthodontic device; • Duplicate prosthetic devices or appliances; • Replacement of a lost or stolen appliance, Cast Restoration, or Denture; and Limitations Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pre- treatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment. Cancellation/Termination of Benefits: Coverage is provided under a group insurance policy (Policy form GPNP99 / G.2130-S) issued by Metropolitan Life Insurance Company (MetLife). Coverage terminates when your participation ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. The group policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: Completion of a prosthetic device, crown or root canal therapy. Group dental plans featuring the Preferred Dentist Program are provided by Metropolitan Life Insurance Company, New York, NY 10166. Like most group benefits programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. You may be financially responsible for copayments, deductibles, or any other amounts in excess of those MetLife is required to pay for covered services as described in your dental certificate and/or policy. Ask your MetLife representative for costs and complete details. Questions & Answers Q. Who is a participating dentist? A. A participating dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for covered services provided to plan members. Negotiated fees typically range from 30% – 45% below the average fees charged in a dentist’s community for the same or substantially similar services.† Q. How do I find a participating dentist? A. There are thousands of general dentists and specialists to choose from nationwide --so you are sure to find one that meets your needs. You can receive a list of these participating dentists online at www.metlife.com/mybenefits or call to have a list faxed or mailed to you. Q. What services are covered under this plan? A. The Plan documents set forth the services covered by your plan. The List of Primary Covered Services & Limitations herein contains a summary of covered services. In the event of a conflict between the Plan documents and this summary, the terms of the Plan documents shall govern. Please review the enclosed plan benefits to learn more. Q. May I choose a non-participating dentist? A. Yes. You are always free to select the dentist of your choice. However, if you choose a non-participating dentist your out-of- pocket costs may be higher.