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CIS Dental Plan II Effective January 1, 2026 How to use this dental plan - Examination/X-rays - Prophylaxis - Fissure Sealants - Restorative Dentistry (treatment of tooth decay with amalgam or composite) - Oral Surgery (surgical extractions & certain minor surgical procedures) - Endodontic (pulp therapy & root canal filling) - Periodontics (treatment of tissues supporting the teeth) - Space Maintainers - Repair or reline of dentures and bridges - Crowns - Implants - Denture and Bridge Work (construction of fixed bridges, partials and complete dentures) * Annual dental maximum does not apply to members under age 16. ¹ Any amount paid by the plan for Preventive services does not apply towards the calendar year maximum. ² Page 1 1st year - 70% 2nd year - 80% 3rd year - 90% 4th year - 100% 1st year - 70% 2nd year - 80% 3rd year - 90% 4th year - 100% When you visit your dental provider, tell them you are a Delta Dental member. CLASS I - PREVENTIVE ¹ Benefit Amount Service Calendar year maximum, per member* $1,500 Calendar year deductible, per member $0 CLASS II - BASIC 2 CLASS III - MAJOR 2 50% There is a 12 month waiting period for Late Enrollees. A Late Enrollee is anyone not enrolled when initially eligible. Delta Dental provides dental claims payment services only and does not assume financial risk or obligation with respect to payment of claims. Dental Tools is a free resource the Member Dashboard that enables you to assess your risk level for oral health concerns and use that assessment to learn about reducing your risks and treatment costs. MEMBER SERVICES Under this plan, benefits start at 70% your first calendar year of coverage. Thereafter, payments increase by 10% each calendar year (up to a maximum benefit of 100%) provided the individual has visited the dentist at least once during the previous calendar year. If in any calendar year the individual fails to receive covered dental services, the percentage for Class I and II services will decrease by 10% the next calendar year, but it will never be reduced below 70%. Through the Member Dashboard you can download your member handbook, view claims status and payment information, search for participating providers, order ID cards, view personal information, and email dental customer service. You can access the Member Dashboard at DeltaDentalOR.com, or the CIS website at www.cisbenefits.org. This is a benefit summary only; any errors or omissions are unintentional. For a more detailed description of benefits, including limitations and exclusions, refer to your member handbook. It can be accessed through your Member Dashboard or by calling Customer Service to request a copy. Delta Dental Customer Service [PHONE REDACTED] - Delta Dental's website DeltaDentalOR.com ---PAGE BREAK--- ADVANTAGES * * * * Page 2 Delta Dental provides dental claims payment services only and does not assume financial risk or obligation with respect to payment of claims. This is a benefit summary only; any errors or omissions are unintentional. For a more detailed description of benefits, including limitations and exclusions, refer to your member handbook. It can be accessed through your Member Dashboard or by calling Customer Service to request a copy. Delta Dental Customer Service [PHONE REDACTED] - Delta Dental's website DeltaDentalOR.com Health through Oral Wellness® program: Your plan includes access to the Health through Oral Wellness program. This patient-centered program provides enhanced benefits designed to help you maintain better oral health through risk assessment, education and additional evidence-based preventive care. Freedom to choose your dentist: Delta Dental is unique in that we have contracts with nearly 2,400 licensed Premier providers in Oregon and 154,000 nationwide. More than 1,300 are also PPO providers in Oregon and 116,000 nationwide. Professional Arrangements: The Delta Dental Passive PPO plan utilizes a select group of dentists who have contracted with us at a preferred rate. This helps ensure that members who utilize the services of a preferred dentist have lower out- of-pocket costs. While receiving treatment from a Preferred Provider is still the most cost-effective option, your plan allows for services to be rendered by a non-preferred dentist, while still maintaining the same percentage of coverage. Members who utilize Premier and PPO providers will not be balanced billed. Members who utilize non-participating providers will be responsible for charges above the maximum plan allowance. Pre-determination: As a service to our customers, your dental office can submit a pre-treatment plan to Delta Dental on your behalf, and we will return it to your dentist, indicating the dollar allowance that will be covered by your plan before you go forward with treatment.