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Voluntary PPO Dental Plan (G890) Select Another Plan This is an overview of coverage. Please refer to the Universal Exclusions and Limitations reference sheet for additional plan provisions. A comprehensive description of coverage, benefits and limitations is contained in the Combined Evidence of Coverage and Disclosure Form. Initial oral evaluation—problem focused Participating 100% Non-Participating $16 Bitewing X-rays — single film Participating 100% Non-Participating $12 Bitewing X-rays — two films Participating 100% Non-Participating $15 Single (periapical) X-rays — first film Participating 100% Non-Participating $9 Single X-rays — additional films Participating 100% Non-Participating $9 Bitewing X-rays — four films Participating 100% Non-Participating $21 Full mouth X-rays (limited to one set every 3 years) Participating 100% Non-Participating $45 Routine cleaning — adult (limited to two per year per adult per year) Participating 100% Non-Participating $35 Routine cleaning — child (limited to two per child per year) Participating 100% Non-Participating $22 Cleaning with fluoride (limited to two per child per year) Participating 100% Non-Participating $35 Available for groups with 10 or more eligible employees enrolled in Blue Cross Medical Coverage, a minimum of 25% participation by eligible employees and employee and dependent premiums collected through payroll deduction. Topical fluoride only (limited to two per child per year) Participating 100% Non-Participating $15 BASIC DENTAL CARE: COVERAGE BEGINS AFTER THE POLICY HAS BEEN IN EFFECT FOR SIX CONTINUOUS MONTHS. Filling — one surface, primary Participating $26 Non-Participating $26 Filling — one surface, permanent Participating $28 Non-Participating $28 Filling — two surfaces, primary Participating $34 Non-Participating $34 Filling — two surfaces, permanent Participating $37 Non-Participating $37 Filling — three surfaces, primary Participating $40 Non-Participating $40 Filling — three surfaces, permanent Participating $42 Non-Participating $42 Filling — four or more surfaces, primary Participating $47 Non-Participating $47 Filling — four or more surfaces, permanent Participating $50 Non-Participating $50 AMOUNTS LISTED ARE WHAT THE PLAN PAYS. The plan pays either the specified amount, or the actual amount charged by your dentist, whichever is lower. You pay any charges in excess of the stated benefit. Extraction — single tooth (simple) Participating $32 Non-Participating $32 Extraction — each additional tooth (simple) Participating $32 Non-Participating $32 Surgical extraction Participating $60 Non-Participating $60 Removal of impacted tooth — soft tissue/partial bony/complete bony Participating $80/$95/$120 Non-Participating $80/$95/$120 MAJOR DENTAL CARE: COVERAGE BEGINS AFTER THE POLICY HAS BEEN IN EFFECT FOR 12 CONTINUOUS MONTHS. Scaling/root planning per quadrant Participating $36 Non-Participating $36 Gingivectomy — per tooth/per quadrant Participating $32/$115 Non-Participating $32/$115 Root canal — one canal Participating $120 Non-Participating $120 Root canal — two canals Participating $145 Non-Participating $145 Root canal — three canals Participating $185 Non-Participating $185 DENTAL NETWORK AVAILABILITY: The Blue Cross Small Group Voluntary PPO Dental Plan, provided by BC Life & Health Insurance Company, is available throughout the state of California. However, please note that eligible benefits are only payable at the non-participating provider level for the following Crown (except stainless steel) Participating $200 Non-Participating $200 Stainless steel crown Participating $50 Non-Participating $50 Pontic Participating $200 Non-Participating $200 Complete denture (upper or lower) Participating $260 Non-Participating $260 Partial denture (upper or lower) Participating $240 Non-Participating $240 Denture reline (chair side) Participating $60 Non-Participating $60 Denture reline (lab) Participating $80 Non-Participating $80 Annual Maximum Benefit per calendar year Participating $1,000/member (benefits paid after the deductible and applicable waiting periods are met) Non-Participating $1,000/member (benefits paid after the deductible and applicable waiting periods are met) Annual Deductible per calendar year Participating $50/person (3-member maximum) Non-Participating $50/person (3-member maximum) PREVENTIVE and DIAGNOSTIC CARE: COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION. Comprehensive oral evaluation Participating 100% Non-Participating $16 Periodic oral exam (limited to two per member per year) Participating 100% Non-Participating $16

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