Dental & Vision Benefit Summary Annual Deductible In-Network Out-Of- Individual $50 Network Family $150 Routine Eye Exam - (once every 12 months) Annual Plan Maximum $1,250 $10 copay $42 allowance Orthodontia Lifetime $1,000 Frames - (once every 24 months) Maximum Plan Coinsurance Levels $130 $45 allowance Preventive Services 100% allowance Basic Services 80% then 20% off Major Services 50% any remaining Orthodontia 50% balance Provider Directory: www.deltadentalin.com Standard Plastic Lenses - (once every 12 months) Single vision (1 pair) $10 copay $40 allowance Bifocal lenses (1 pair) $10 copay $60 allowance Trifocal lenses (1 pair) $10 copay $80 allowance Retiree Monthly Premiums Retiree DePauw Contact Lenses - (once every 12 months in lieu of Retiree Only $16.57 $17.25 glasses) Retiree + Spouse $32.32 $29.97 Elective/ $130 $105 Non-Elective allowance/ allowance/ Retiree + Child(ren) $44.09 $36.30 Covered in $210 full allowance Family $64.02 $59.22 https://www.anthem.com/find-care/ Provider Directory: Allowances must be used on transaction Delta Dental offers three levels of benefit coverage: Retiree Monthly Premiums PPO Dentist, Premier Dentist and Non-Participating Retiree Only $6.08 Dentist. Review summary of benefits for more details. PPO Coverage - Offers significant discounts; no Retiree + Spouse $10.66 balance billing; acceptance of processing policies; Retiree + Child(ren) $11.57 and 108,000 dentist locations Family $17.67 Premier Coverage - Negotiated fees; no balance billing; acceptance of processing policies; and Anthem Blue Cross and Blue Shield vision members 186,000 dentist locations have access to one of the nation’s largest vision Non-Participating Coverage - Balance billing and network. Blue View Vision is the only network that gives does not offer discounts you the ability to use in-network benefits at 1-800- CONTACTS, or choose a private eye doctor, or go to retail vendors such as LensCrafters®, Sears Optical, Target Optical®, and most Pearle Vision locations. This benefit guide only highlights the benefits available. For a more complete description, see the Plan Certificate. 15 If any conflict should arise between this summary and the Plan, the Plan's Certificate will govern in all cases.