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Basic Option PPO Dental Plan (SMG0) Select Another Plan Annual Maximum Benefits In-Network $1,000 per member; in-network and out-of-network combined Out-of-Network $1,000 per member; in-network and out-of-network combined Annual Deductible In-Network $75 per member; three-member family maximum Out-of-Network $75 per member; three-member family maximum Preventive Services Office visits and cleaning: twice per year Fluoride and sealant applications Space maintainer insertion In-Network No charge after deductible Out-of-Network Member pays 50% of covered expense, plus 100% of charges in excess of covered expense after deductible Diagnostic Services Oral examinations, consultations, office visits and X-rays. Full mouth X-rays: limit of one set or its equivalent in a three-year period In-Network No charge after deductible Out-of-Network Member pays 50% of covered expense, plus 100% of charges in excess of covered expense after deductible Minor Restorative Services Filings Oral surgery: tooth extractions Endodontics: root canal therapy In-Network Member pays 50% of negotiated fee after deductible Out-of-Network Member pays 50% of covered expense, plus 100% of charges in excess of covered expense after deductible Major Restorative Services Periodontics: scaling to cure/prevent gum disease, Prosthodontics: removal (dentures) and fixed (crowns, bridges and inlays) 12 month waiting period for periodontics and prosthodontics In-Network Member pays 50% of negotiated fee after deductible Out-of-Network Member pays 50% of covered expense, plus 100% of charges in excess of covered expense after deductible Orthodontic Services In-Network Not covered Out-of-Network Not covered

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