Common use of Coverage Examples Clause in Contracts

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 Copayments $10 Coinsurance $1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 Cost Sharing Deductibles $250 Copayments $800 Coinsurance $70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 Cost Sharing Deductibles $250 Copayments $70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 0 ◼ Primary care physician coinsurance 0% Specialist copayment $50 ◼ Hospital (facility) coinsurance 10% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Primary care physician Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 0 ◼ Specialist copayment $20 50 ◼ Hospital (facility) coinsurance 10% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 0 ◼ Specialist copayment $20 50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 0 Copayments $10 300 Coinsurance $1,200 0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 360 Cost Sharing Deductibles $250 0 Copayments $800 1,000 Coinsurance $70 0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,020 Cost Sharing Deductibles $250 0 Copayments $70 500 Coinsurance $100 0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO 500 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 000-000-0000. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 000-000-0000 (Pointvoicemail) 000 X. Xxxxxxxx St. TTY/TDD: 000-of000-Service) 0000 35th Floor Fax: 000-000-0000 Xxxxxxx, Xxxxxxxx 00000 Email: XxxxxXxxxxxXxxxxxxxxxx@xxxx.xxx You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 000-000-0000 000 Xxxxxxxxxxxx Xxxxxx XX TTY/TDD: 000-000-0000 Xxxx 000X, XXX Xxxxxxxx 0000 Xxxxxxxxx Xxxxxx: xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf Xxxxxxxxxx, XX 00000 Complaint Forms: xxxx://xxx.xxx.xxx/ocr/office/file/index.html Summary of Dental Benefits and Coverage: What this Plan Benefits Covers & What You Pay For Group# 7280 Township of Clinton This Covered Services Coverage Period: 01/01/2022 – 12/31/2022 Xxxx County: Union HMOI Plan Coverage for: ALL | Plan Type: HMO The Summary of Dental Plan Benefits should and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be read along with your Certificateprovided separately. Your Certificate provides additional This is only a summary. For more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, call 0-000-000-0000 or at xxx.xxxxxx.xxx. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx/ or call 0-000-000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing XxxJoe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $250 Copayments $10 0 Coinsurance $1,200 500 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 810 Cost Sharing Deductibles $250 Copayments $800 500 Coinsurance $70 30 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 770 Cost Sharing Deductibles $250 Copayments $70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "FH" Delta Dental PPO PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton 7280-0016, 0000 Xxxxxxxx xx Xxxxxxx This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO PPO™ Dentist Delta Dental Premier Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Pays* Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 8565% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 8565% 65% Brush Biopsy – to detect oral cancer 100% 8565% 65% Radiographs – X-rays 100% 8565% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up treatment must begin prior to age 19 up and coverage will continue to age 19 up to age 19 the end of treatment or until the maximum has been reached Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Sealants are not a Covered Service.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Page 77 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care to Agpeptedndeinx t"aHl" care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 1,500 per person total per Benefit Year on all services except orthodontic services. $2,000 1,500 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to Delta Dental. Deductible – None.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing XxxJoe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $250 Copayments $10 Coinsurance $1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 Cost Sharing Deductibles $250 Copayments $800 Coinsurance $70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 Cost Sharing Deductibles $250 Copayments $70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) The Summary of Dental Plan Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx- glossary or call Care Coordinators at (000) 000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 0 ◼ Primary care physician coinsurance 0% Specialist copayment $50 ◼ Hospital (facility) coinsurance 10% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Primary care physician Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 0 ◼ Specialist copayment $20 50 ◼ Hospital (facility) coinsurance 10% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 0 ◼ Specialist copayment $20 50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 0 Copayments $10 300 Coinsurance $1,200 0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 360 Cost Sharing Deductibles $250 0 Copayments $800 1,000 Coinsurance $70 0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,020 Cost Sharing Deductibles $250 0 Copayments $70 600 Coinsurance $100 0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO 600 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 000-000-0000. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 000-000-0000 (Pointvoicemail) 000 X. Xxxxxxxx St. TTY/TDD: 000-of000-Service) 0000 35th Floor Fax: 000-000-0000 Xxxxxxx, Xxxxxxxx 00000 Email: XxxxxXxxxxxXxxxxxxxxxx@xxxx.xxx You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 000-000-0000 000 Xxxxxxxxxxxx Xxxxxx XX TTY/TDD: 000-000-0000 Xxxx 000X, XXX Xxxxxxxx 0000 Xxxxxxxxx Xxxxxx: xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf Xxxxxxxxxx, XX 00000 Complaint Forms: xxxx://xxx.xxx.xxx/ocr/office/file/index.html Summary of Dental Benefits and Coverage: What this Plan Benefits Covers & What You Pay For Group# 7280 Township of Clinton This Covered Services Coverage Period: 01/01/2022 – 12/31/2022 Xxxx County: Union BA HMO Plan Coverage for: ALL | Plan Type: HMO The Summary of Dental Plan Benefits should and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be read along with your Certificateprovided separately. Your Certificate provides additional This is only a summary. For more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, call 0-000-000-0000 or at xxx.xxxxxx.xxx. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx/ or call 0-000-000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 0 ◼ Primary care physician coinsurance 0% Specialist copayment $50 ◼ Hospital (facility) coinsurance 10% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Primary care physician Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 0 ◼ Specialist copayment $20 50 ◼ Hospital (facility) coinsurance 10% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 0 ◼ Specialist copayment $20 50 ◼ Hospital (facility) coinsurance 0% copayment $250 ◼ Other coinsurance 10% $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 0 Copayments $10 300 Coinsurance $1,200 0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 360 Cost Sharing Deductibles $250 0 Copayments $800 1,000 Coinsurance $70 0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,020 Cost Sharing Deductibles $250 0 Copayments $70 500 Coinsurance $100 0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO 500 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 000-000-0000. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 000-000-0000 (Pointvoicemail) 000 X. Xxxxxxxx St. TTY/TDD: 000-of000-Service) 0000 35th Floor Fax: 000-000-0000 Xxxxxxx, Xxxxxxxx 00000 Email: XxxxxXxxxxxXxxxxxxxxxx@xxxx.xxx You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 000-000-0000 000 Xxxxxxxxxxxx Xxxxxx XX TTY/TDD: 000-000-0000 Xxxx 000X, XXX Xxxxxxxx 0000 Xxxxxxxxx Xxxxxx: xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf Xxxxxxxxxx, XX 00000 Complaint Forms: xxxx://xxx.xxx.xxx/ocr/office/file/index.html Summary of Dental Benefits and Coverage: What this Plan Benefits Covers & What You Pay For Group# 7280 Township of Clinton This Covered Services Coverage Period: 01/01/2022 – 12/31/2022 Xxxx County: Non-Union HMOI Plan Coverage for: ALL | Plan Type: HMO The Summary of Dental Plan Benefits should and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be read along with your Certificateprovided separately. Your Certificate provides additional This is only a summary. For more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, call 0-000-000-0000 or at xxx.xxxxxx.xxx. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx/ or call 0-000-000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing XxxJoe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $250 500 Copayments $10 Coinsurance $1,200 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 2,970 Cost Sharing Deductibles $250 500 Copayments $800 700 Coinsurance $70 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,300 Cost Sharing Deductibles $250 500 Copayments $70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) 770 The Summary of Dental Plan Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Peg is Having a Baby baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type Joe's type 2 Diabetes diabetes (a year of routine in-network care of a well- well-controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s 's overall deductible $250 ◼ Primary care physician coinsurance 0% ◼ Specialist copayment Hospital (facility) coinsurance 10% ◼ copayment Other coinsurance 10% copayment $0.00 $40.00 $350.00 $0.00 The plan's overall deductible Specialist copayment Hospital (facility) copayment Other copayment $0.00 $40.00 $125.00 $5.00 The plan's overall deductible Specialist copayment Hospital (facility) copayment Other copayment $0.00 $40.00 $125.00 $5.00 This EXAMPLE event includes services like: Primary care physician Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) $12,700.00 Total Example Cost Specialist visit (anesthesia) Total Example Cost Sharing Deductibles $12,700 0.00 Copayments $900.00 Coinsurance $100.00 What isn't covered Limits or exclusions $0.00 The total Peg would pay is $1,000.00 In this example, Peg would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs $7,400.00 Total Example Cost Cost Sharing Deductibles $0.00 Copayments $2,000.00 Coinsurance $0.00 What isn't covered Limits or exclusions $0.00 The total Xxx would pay is $2,000.00 Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) $1,900.00 Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 0.00 Copayments $10 600.00 Coinsurance $1,200 0.00 What isn’t n't covered Limits or exclusions $60 The total Peg would pay is $1,520 Cost Sharing Deductibles $250 Copayments $800 Coinsurance $70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 Cost Sharing Deductibles $250 Copayments $70 Coinsurance $100 What isn’t covered Limits or exclusions $0 0.00 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan600.00 In this example, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services.Mia would pay:

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing XxxJoe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 1,000 ◼ Specialist copayment $20 30 ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 1,000 ◼ Specialist copayment $20 30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx Mia would pay: Cost Sharing Deductibles $250 1,000 Copayments $10 Coinsurance $1,200 2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 3,370 Cost Sharing Deductibles $250 900 Copayments $800 Coinsurance $70 0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,720 Cost Sharing Deductibles $250 1,000 Copayments $70 100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) 1,200 The Summary of Dental Plan Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 750 ◼ Primary care physician coinsurance 0% Specialist copayment $50 ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% ◼ The plan’s overall deductible $750 ◼ Specialist copayment $50 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% ◼ The plan’s overall deductible $750 ◼ Specialist copayment $50 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Specialist Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 750 Copayments $10 30 Coinsurance $1,200 2,000 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 2,810 Cost Sharing Deductibles $250 750 Copayments $800 1,000 Coinsurance $70 30 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,800 Cost Sharing Deductibles $250 750 Copayments $70 400 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO 1,350 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 000-000-0000. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 000-000-0000 (Pointvoicemail) 000 X. Xxxxxxxx St. TTY/TDD: 000-of000-Service) 0000 35th Floor Fax: 000-000-0000 Xxxxxxx, Xxxxxxxx 00000 Email: XxxxxXxxxxxXxxxxxxxxxx@xxxx.xxx You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 000-000-0000 000 Xxxxxxxxxxxx Xxxxxx XX TTY/TDD: 000-000-0000 Xxxx 000X, XXX Xxxxxxxx 0000 Xxxxxxxxx Xxxxxx: xxxxx://xxxxxxxxx.xxx.xxx/ocr/portal/lobby.jsf Xxxxxxxxxx, XX 00000 Complaint Forms: xxxx://xxx.xxx.xxx/ocr/office/file/index.html Summary of Dental Benefits and Coverage: What this Plan Benefits Covers & What You Pay For Group# 7280 Township of Clinton This Covered Services Coverage Period: 01/01/2022 – 12/31/2022 Xxxx County: Non-Union BA HMO Plan Coverage for: ALL | Plan Type: HMO The Summary of Dental Plan Benefits should and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be read along with your Certificateprovided separately. Your Certificate provides additional This is only a summary. For more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, call 0-000-000-0000 or at xxx.xxxxxx.xxx. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx/ or call 0-000-000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 1,000 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 1,000 ◼ Specialist copayment $20 30 ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 1,000 ◼ Specialist copayment $20 30 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 1,000 Copayments $10 Coinsurance $1,200 2,300 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 3,370 Cost Sharing Deductibles $250 900 Copayments $800 Coinsurance $70 0 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,720 Cost Sharing Deductibles $250 1,000 Copayments $70 100 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) 1,200 Summary of Dental Benefits and Coverage: What this Plan Benefits Covers & What You Pay For Group# 7280 Covered Services Coverage Period: 01/01/2021 – 12/31/2021 Charter Township of Clinton This Employee and Retiree Benefit Plan: MICHIGAN 050 Coverage for: Single + Family | Plan Type: POS The Summary of Dental Plan Benefits should and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be read along with your Certificateprovided separately. Your Certificate provides additional This is only a summary. For more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.

Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 500 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 1020% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 1020% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 500 Copayments $10 Coinsurance $1,200 2,400 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 2,970 Cost Sharing Deductibles $250 500 Copayments $800 700 Coinsurance $70 80 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 1,300 Cost Sharing Deductibles $250 500 Copayments $70 Coinsurance $100 200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 770 Appendix "FC" Delta Dental PPO (Point-of-Service) 29 The Summary of Dental Plan Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For Group# 7280 Township of Clinton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional more information about your Delta Dental plancoverage, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Delta Dental PPO Dentist Delta Dental Premier Dentist Plan Pays Plan Pays Control Plan – Delta Dental of Michigan Benefit Year – January 1 through December 31 Covered Services – Nonparticipating Diagnostic & Preventive Dentist Plan Pays* Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 85% 65% Emergency Palliative Treatment – to temporarily relieve pain 100% 85% 65% Brush Biopsy – to detect oral cancer 100% 85% 65% Radiographs – X-rays 100% 85% 65% Basic Services Minor Restorative Services – fillings and crown repair 80% 65% 65% Endodontic Services – root canals 80% 65% 65% Periodontic Services – to treat gum disease 80% 65% 65% Oral Surgery Services – extractions and dental surgery 80% 65% 65% Other Basic Services – misc. services 80% 65% 65% Relines and Repairs – to prosthetic appliances 80% 65% 65% Major Restorative Services – crowns 75% 60% 60% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 60% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – up to age 19 up to age 19 up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice in any period of 12 consecutive months.  Prophylaxes (cleanings) are payable twice in any period of 12 consecutive months.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice in any period of 12 consecutive months for people age 18 and under.  Bitewing X-rays are payable once in any period of 12 consecutive months and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.  Composite resin (white) restorations are optional treatment on posterior teeth.  Porcelain and resin facings on crowns are optional treatment on posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services. 44 Having Delta Dental coverage makes it easy for you toApgpeet nddeixnt"aFl"care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheetthe complete terms of coverage, go to xxxxx://xxxxxxxxxxxxxxxxxxxxxxxx.xxxxxxxx.xxx or call (000) 000-0000. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic servicesFor general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. $2,000 per person total per lifetime on orthodontic servicesYou can view the Glossary at xxx.xxxxxxxxxx.xxx/xxx-xxxxxxxx or call Care Coordinators at (000) 000-0000 to request a copy.