Dental Plan DELTA DENTAL PLAN In-Network Out-of-Network* Deductible $50 member / $150 family $50 member / $150 family Calendar Year Max $1,500 / year $1,500 / year Preventive Care 100% covered; deductible does not 100% covered; deductible does not apply apply Basic Care 80% covered after deductible 80% covered after deductible Major Care 50% covered after deductible 50% covered after deductible Orthodontia (All ages) 50% covered up to the separate 50% covered up to the separate lifetime max of $1,500 lifetime max of $1,500 *Services from out-of-network providers may be subject to balance billing (member would be responsible for any difference between the allowance and the provider’s actual charge). 15