Retiree Dental Summary

INPPOSUM123 KR#84407221 Delta Dental PPO™ (Standard) Summary of Dental Plan Benefits For Group #0414-0001 DePauw University Retirees 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% Palliative Treatment – to temporarily relieve pain 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 Minor Restorative Services – fillings and crown repair 50% 50% 50% Endodontic Services – root canals 50% 50% 50% Periodontic Services – to treat gum disease 50% 50% 50% Oral Surgery Services – extractions and dental surgery 50% 50% 50% Major Restorative Services – crowns 50% 50% 50% Other Basic Services – misc. services 50% 50% 50% Relines and Repairs – to prosthetic appliances 50% 50% 50% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 50% 50% 50% * When you receive services from a Delta Dental Premier or Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's PPO Dentist Schedule that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Three oral exams (including evaluations by a specialist) are payable per calendar year.  Prophylaxes (cleanings) are payable twice 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 once per calendar year for people age 18 and under.  Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any three-year period.  Sealants are payable once per tooth per three-year period for first and second permanent molars for people age 13 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.

INPPOSUM123 KR#84407221  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 – $1,500 per Member total per Benefit Year on all services. Deductible – $100 Deductible per Member total per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, and sealants. Waiting Period – Enrollees who are eligible for Benefits are covered on the first day of the month following the qualification for DePauw University retirement benefits. Eligible People – All qualified retirees of DePauw University and their eligible dependents who choose the dental plan during an election period and COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees, if applicable. Also eligible are your Spouse and your Children to the end of the calendar year in which they attain the age of 19 or to the end of the calendar year in which they no longer qualify as a Dependent, whichever occurs sooner. Also eligible are your Dependent unmarried Children to the end of the calendar year in which they turn 25 if a full-time student and are eligible to be claimed by you as a dependent under the U.S. Internal Revenue Code during the current calendar year. 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. 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 in which your employment is terminated. Customer Service Toll-Free Number: 800-524-0149 (TTY users call 711) https://www.DeltaDentalIN.com Document Creation Date: October 3, 2025