Dental & Vision Benefit Summary Dental Plan In-Network Base Plan Buy Up Plan Calendar year Deductible (EEO/Family) $0,00 $0,00 Annual Maximum per Person $0,00 $0,00 Dental Maximum Rollover $0,00 $0,00 Preventive Dental Services Covered 100%, no deductible Covered 100%, no deductible Basic Dental Services 80% after deductible is satisfied 80% after deductible is satisfied Major Dental Services 50% after deductible is satisfied 50% after deductible is satisfied Covered 50% with lifetime max of Orthodontia Services Not covered $0 per person; this service is not subject to the deductible Network = Delta Dental PPO and Delta Dental Premier. You will pay the least amount out of your pocket, and your annual maximum dollars will stretch further when you see a Dental Dental PPO provider. The primary difference in benefits between the Base Plan and Buy-Up Plan is the annual maximum available under the plan and orthodontic services (only available under the Buy-Up plan). With the Maximum Carryover Provision, you may carryover a portion of maximum to the next calendar maximum payment. You will qualify if you have at least one covered service paid in a calendar year and the benefit paid does not exceed $500 in the calendar year. If you use Delta Dental PPO providers, the amount you are eligible to carryover increases to $350 in a calendar year. If you use Premier or Non-participating providers, the amount you are eligible to carryover is reduced to $250 in a calendar year. This amount automatically accumulates from one calendar year to the next but will not exceed $1,000. *Note: if no covered services are paid in a calendar year all carryover dollars from previous years will be forfeited. Please review your certificate of coverage for a complete list of services covered by the plan. Vision Plan In-Network Frequency Base (Davis) Plan Buy Up (VSP) Plan Vision Exam Services Once per calendar year $0 copay $0 copay Glasses Lenses Once per calendar year $0 copay $0 copay (Single/Bifocal/Trifocal/Lenticular) $0 retail frame $0 retail frame Glasses Frames Once per calendar year allowance +20% off allowance +20% off remaining balance remaining balance Contact Lenses (Medically $0 copay/$25 $0 copay/$0 retail Necessary/Elective) Once per calendar year copay with $0 allowance retail allowance Page 11 | ACME | Plan Year 2024 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.