Benefit Summary 2024 Client Copy

Coverage Summary for Owl Labs, Inc. 015636 Deductible: $50 per individual / $150 per family. Deductible waived for Diagnostic and Preventive categories. Calendar Year Maximum: $2,000 per person. Co-insurance Category / Procedure Qualifications In Out of Network Network* Diagnostic 100% 100% Comprehensive Evaluation Once every 60 months. Periodic Oral Exam Twice every 12 months. Panoramic or Full Mouth X-rays Once every 60 months. Bitewing X-rays Twice every 12 months. Single Tooth X-rays As needed. Preventive 100% 100% Teeth Cleaning Twice every 12 months. Fluoride Treatments Twice every 12 months for members under age 19. Space Maintainers Required due to the premature loss of teeth. For members under age 14 and not for the replacement of primary or permanent anterior teeth. Sealants Unrestored permanent molars, every 4 years per tooth for members through age 15. Sealants also covered for members age 16 up to age 19 with a recent cavity and are at risk for decay. Restorative 100% 100% Silver Fillings Once every 24 months per surface per tooth. White Fillings Once every 24 months per surface per tooth. Inlays Once every 60 months per tooth, inlays are processed as a silver filling and the patient is responsible for the difference between the silver filling and the Delta Dental negotiated fee for an inlay, where permitted by state law. In other states, the patient may be responsible for paying up to the provider’s full submitted charge for an inlay. Protective Restorations Once per tooth. Stainless Steel Crowns Once every 24 months per tooth (on primary teeth only). Oral Surgery 100% 100% Extractions Once per tooth. General Anesthesia General Anesthesia and IV sedation allowed with covered surgical impacted teeth only (up to one hour). Periodontics (on natural teeth only) 100% 100% Periodontal Surgery One surgical procedure per quadrant in 36 months. Scaling and Root Planing Once in 24 months, per quadrant. No more than 2 quadrants per date of service. Periodontal Cleaning 4 times every 12 months following active periodontal treatment. Not to be combined with preventive 100% 100% cleanings. Bone Grafts/GTR No more than 2 teeth per quadrant per 36 months on natural teeth. Endodontics 100% 100% Root Canal Treatment Once per tooth. Root Canal Retreatment Once per tooth after 24 months have elapsed from initial treatment Vital Pulpotomy Limited to deciduous teeth. Prosthetic Maintenance 100% 100% Bridge or Denture Repair Once per bridge/denture per 12 months, after 24 months of initial insertion. Crown or Onlay Repair Once per tooth per 12 months after 24 months of initial placement Rebase or Reline of Dentures Once per denture within 36 months. Recement of Crowns & Onlays, Bridges Once per crown, onlay or bridge. Emergency Dental Care 100% 100% Palliative Treatment Three occurrences in 12 months. Prosthodontics 80% 80% Dentures Once within 60 months (age 16 and older). Fixed Bridges Once within 60 months (age 16 and older). Implants Once per 60 months per Implant. (Pre-estimate recommended). Implant Abutments Once per implant only when surgical implant is benefitted. Major Restorative 80% 80% Crowns or Onlay When teeth cannot be restored with regular fillings. Once within 60 months per tooth (age 12 and older). Cast Posts/Buildups Once per tooth per 60 months only benefitted to retain a crown. Orthodontics: Covered at 50% of Maximum Plan Allowance charges up to age 19. $1,500 separate LIFETIME maximum. Orthodontic treatment must be administered/supervised by a licensed dentist Dependent Eligibility Eligible dependents up to age 26. *Non-participating dentists may balance bill. Subscribers are responsible for the difference between the non-participating maximum plan allowance and the full fee charged by the dentist.

Additional Benefit Information Deductible waived for periodontal cleanings. Ask your dentist to submit a pre-treatment estimate to Delta Dental for any procedure that exceeds $300. This will help you estimate any out-of-pocket expenses you may incur and will confirm that the services are covered under your dental coverage. This plan is eligible for Rollover Maximum: Rollover Max dollars do not apply to orthodontic services. To qualify for Rollover Max, you must receive at least one cleaning or oral exam in the plan year. You must be enrolled for dental coverage before the 4th quarter of the calendar year and your paid claims must not exceed the maximum “threshold” amount. Your calendar year If your total yearly claims Then you can roll over this Your accumulated rollover total maximum benefit amount. don’t exceed this threshold amount to use next year, is capped at this amount. amount… and beyond. $2,000 $800 $600 $1,500