Dental & Vision Benefit Summary Delta Dental VSP Vision Standard Premier VSP Choice Network Low Plan High Plan Annual Deductible Routine Eye Exam - (once every 12 months) Individual $25 $25 $10 copay Family $75 $75 Annual Plan Maximum $1,500 $2,000 Materials - (once every 24 months) $25 Copay Orthodontia Lifetime N/A $1,500 $150-$200 allowance then 20% off any remaining balance Maximum Standard Plastic Lenses - (once every 12 months) Plan Coinsurance Levels Single vision (1 pair) $25 copay Preventive 100% 100% Bifocal lenses (1 pair) $25 copay Basic Services 50% 80% Trifocal lenses (1 pair) $25 copay Major Services 25% 50% Contact Lenses - (once every 12 months in lieu of glasses) Orthodontia (Child N/A 50% Elective $150 allowance or Adult) Non-Elective Covered in full Lens Enhancements (Progressive, Anti-Glare, Scratch Provider Directory: www.deltadentalin.com Resistant) $0 Provider Directory: www.VSP.com Delta Dental has three levels of benefit Members can visit vsp.com to find VSP in- coverage available; you can choose from any network doctor, discover special offers and of these networks. savings, and find the eye care and eyewear information they need. PPO Coverage - Offers significant discounts; When members create an account on vsp.com, no balance billing; acceptance of processing they can: policies; and 108,000 dentist locations. • View personalized benefit information . Premier Coverage - Negotiated fees; no • Print a member ID card, if they prefer to have balance billing; acceptance of processing one. policies; and 186,000 dentist locations. • Customize their email preferences. Utilize the Premier Program to maximize your Non-Participating Coverage - Balance billing savings. and does not offer discounts. Page 9 | Inotiv | Plan Year 2025 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.