Dental & Vision Benefit Summary Dental Plan Vision Plan Annual Deductible IN-Network/Out-of-Network In-Network Out-Of- Network Individual $50 Routine Eye Exam - (once every 12 months) Family $150 $10 copay $42 allowance (once every 24 months) Annual Plan Maximum $1,000 Frames - Orthodontia Lifetime $1,000 $130 allowance Maximum then 20% off any $45 allowance Preventive/ Diagnostic Care remaining Includes: routine oral exams, balance cleanings, fluoride treatment You Pay 0% / 0% Standard Plastic Lenses - (once every 12 months) sealants (through 18), x-rays Basic Dental Services Single vision (1 pair) $25 copay $40 allowance Includes: fillings, consultations, You Pay 10% / 20% Bifocal lenses (1 pair) $25 copay $60 allowance space maintainers, brush biopsy, Trifocal lenses (1 pair) $25 copay $80 allowance endodontics, extractions Major Dental Services Contact Lenses - (once every 12 months instead of eye glass lenses) Includes:, dentures, bridges, You Pay 40% / 50% implants, periodontics (surgical & Elective (disposable) $130 allowance $105 allowance non-surgical) Orthodontia for Children up Elective (non- $130 allowance $105 allowance to age 19 You Pay 50% / 50% disposable) plus 15% off remaining Provider Directory: www.anthem.com balance Anthem Dental benefits listed above are shown In- Non-Elective Covered in full $210 allowance Network. See full plan details for Provider Directory: www.anthem.com description and Out-of-Network Coverage details. Allowances must be used on transaction Network –Anthem Dental offers network Network – Anthem Blue View Vision coverage with balance billing. You may provides you with the option to go to any go to any dentist however, if you go to eye doctor. However, if you go to an an Anthem Dental in-network provider Anthem blue View Vision network provider you will usually pay less. To search for you will usually pay less. To search for in- in-network vision providers, visit network vision providers, visit www.anthem.com or search for www.anthem.com or search for providers providers using the Sydney Health app. using the Sydney Health app. Page 17 | Duncan Supply Company, Inc.| Plan Year 2025 Open Enrollment This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.