2024 Employee Benefit Guide - Salaried - Yeled 11.3.23

EXCLUSIVE NETWORK DENTAL PLAN DENTAL DHMO (SNY02)

BENEFIT

IN NETWORK ONLY

Annual Deductible

Not Applicable

Annual Benefit Maximum

Not Applicable

Preventive Services Oral Exams Full Mouth, Panoramic and Bitewing X-rays Cleanings Emergency Care to Relieve Pain Flouride Application Basic Services Fillings Oral Surgery, Simple Extractions Periodontics Root Canal/Therapy Surgical Extraction of Impacted Teeth Relines, Rebases and Adjustments Repairs — Bridges, Crowns and Inlays Repairs — Dentures

See DMO Schedule

See DMO Schedule

Major Services Crowns Dentures Bridges

See DMO Schedule

Orthodontic Services Adults and Children

Subject to Copay

Dependent Age Limit: To age 26; benefits terminate at the end of the month in which the dependent turns 26

PRE-TAX SEMI-MONTHLY CONTRIBUTIONS

Employee

$4.72

Employee & Spouse

$5.68

Employee & Child(ren)

$10.39

Family

$17.44

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.