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NYE COUNTY Dental Highlight Sheet Plan 1: Dental Plan Summary Plan Benefit In Network Out of Network Type 1 100% 100% Type 2 80% 80% Type 3 50% 50% Deductible $50/Calendar Year Type 2 & 3 $50/Calendar Year Type 2 & 3 Waived Type 1 Waived Type 1 3 Family Maximum 3 Family Maximum Maximum (per person) $2,250 per calendar year $1,500 per calendar year Allowance Discounted Fee 85th U&C Waiting Period None None Annual Eye Exam None None LASIK Advantage® None None Annual Open Enrollment Included Included Orthodontia Summary - Adult and Child Coverage In Network Out of Network Allowance Discounted Fee U&C Plan Benefit 50% 50% Lifetime Maximum (per person) $1,500 $1,500 Waiting Period None None Sample Procedure Listing (Current Dental Terminology © American Dental Association.) In Network Type 1 Type 2 Type 3 Routine Exam (1 in 6 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (4 in 12 months) Fluoride for Children 13 and under (1 in 12 months) Sealants (age 13 and under) Space Maintainers Restorative Amalgams Restorative Composites Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 5 years) Out of Network Type 1 Type 2 Type 3 Routine Exam (1 in 6 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (4 in 12 months) Fluoride for Children 13 and under (1 in 12 months) Sealants (age 13 and under) Space Maintainers Restorative Amalgams Restorative Composites Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Denture Repair Simple Extractions Complex Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 5 years) ---PAGE BREAK--- NYE COUNTY Dental Highlight Sheet Ameritas Information We're Here to Help This plan was designed specifically for the associates of NYE COUNTY. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: [PHONE REDACTED]. For plan information any time, access our automated voice response system or go online to ameritas.com. Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card. Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount. Dental Rewards® This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. In addition, a person earning dental rewards who submits a claim for services received through the dental network earns an extra reward, called the PPO Bonus. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. Benefit Threshold $750 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount $250 Dental Rewards amount is added to the following year's maximum Annual PPO Bonus $150 Additional bonus is earned if the member sees a network provider Maximum Carryover $1,000 Maximum possible accumulation for Dental Rewards and PPO Bonus combined Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at [PHONE REDACTED]. Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed. Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on July 1.