Dental

Lincoln Financial Group

ABOUT DENTAL

Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease.

For full plan details, please visit your benefit website: www.mybenefitshub.com/goosecreekcisd

EMPLOYEE BENEFITS

Our dental plan helps you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work. Premium contributions are deducted from your paycheck on a pretax basis. Coverage is provided through Lincoln Financial Group.

DPPO Plan Two levels of benefits are available with the DPPO plan: in-network and out-of-network. You may select the dental provider of your choice, but your level of coverage may vary based on the provider you see for services. You could pay more if you use an out-of-network provider. Schedule of Benefits

Plan

Deductible (Annually on a Plan Year Basis) Individual

Family Deductible applies to: Benefit Levels Type 1 – Diagnostic & Preventative Type 2 – Basic Services Type 3 – Major Services Type 4 – Orthodontic Services Benefits Based On Maximum Benefit (per covered person): Types 1, 2 & 3 combined Type 4, while covered by the plan Benefit Waiting Period Type 2 Expenses Type 3 Expenses Type 4 Expenses Late Entrant Limitation Type 2 Expenses Type 3 Expenses Type 4 Expenses Low Plan

High Plan Contracted Dentist Non Contracted Dentist Contracted Dentist Non Contracted Dentist $50

$150 Type 2 & 3 $50

$150 Type 2 & 3 $50

$150 Type 2 & 3 $50

$150 Type 2 & 3

100% 50% 50% Negotiated Fees 100% 50% 50% U&C 100% 80% 50% 50% Negotiated Fees 100% 80% 50% 50% U&C

$750 Per Plan Year $750 Per Plan Year $1,500 Per Plan Year $1,500 Per Plan Year - - $1,000 Lifetime $1,000 Lifetime

None None None None None None

None None None None None None

DHMO Plan If you enroll in the DHMO plan, you must select a Primary Care Dentist (PCD) from the DHMO network directory to manage your care. Each eligible dependent may choose their own PCD. Dental services are unlimited, you pay fixed copays, there are no deductibles and there are no claim forms to file. There is no coverage for services provided without a referral from your PCD or if you seek care from out-of -network providers. Dental LOW HIGH DHMO Employee Only $19.70 $28.30 $12.60 Employee and Spouse $36.76 $54.12 $24.60 Employee and Child(ren) $42.90 $69.48 $26.60 Employee and Family $50.32 $80.90 $38.44

Questions about your plan or claims? Call or email us. 800-423-2765 Monday –Thursday, 8 a.m. – 8 p.m. ET; Friday, 8 a.m. – 6 p.m. ET Claims@LFG.com