ANTHEM DENTAL PLAN Services Anthem PPO Plan Network In-Network Out-of-Network ▪ Anthem BCBS Deductible $50 / $150 $50 / $150 (Waived for Preventative) (Waived for Preventative) Plan Preventative Services ▪ 7/1/2021 –6/30/2022 Exams Cleanings 100% 100% Flouride Provider Search Space Maintainers X-Rays www.anthem.com Sealants Basic Services Additional Information Filings Endontics 80% 80% ▪ PPO Summary Periodontics Oral Surgery Simple Extractions Major Services Crowns Inlays 50% 50% Onlays Bridges Dentures Annual Maximum $1,500 $1,500 17 17