Benefits for 2022 Dental Coverage SUMMARY OF COVERAGE Plan Features IN NETWORK Annual Deductible (Individual / Family) $50 / $150 Preventive Care 100% Covered – deductible is waived Basic Procedures (Extractions, fillings, etc.) 80% Covered Major Procedures (Crowns, dentures, etc.) 50% Covered Child Orthodontia 50% Covered up to lifetime max of $1,250 Calendar Year Maximum Benefit $1,250 per person OUT OF NETWORK Annual Deductible (Individual / Family) $50 / $150 Preventive Care 100% Covered – deductible is waived Basic Procedures (Extractions, fillings, etc.) 80% Covered Major Procedures (Crowns, dentures, etc.) 50% Covered Child Orthodontia 50% Covered up to lifetime max of $1,250 Calendar Year Maximum Benefit $1,250 per person 2022 Employee Benefit Guide 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 11 carrier or provider’s contract.