Return to flip book view

The Lincoln National Life Insurance Company 1 The Lincoln DentalConnect® PPO Program: • Covers many preventive,basic, and major dental careservices• Features group coverage foremployees• Allows you to choose anydentist you wish, though youcan lower your out-of-pocketcosts by selecting a networkprovider• Does not make you and yourloved ones wait six monthsbetween routine cleaningsFull-Time Employees of OrangeBox Enterprises Benefits At-A-Glance In-Network Out-of-Network Calendar (Annual) Deductible Individual: $50 Family: $150 Waived for: Preventive Individual: $50 Family: $150 Waived for: Preventive Deductibles are combined for basic and major In-Network services. Deductibles are combined for basic and major Out-of-Network services. Annual Maximum $1,000 $1,000 MaxRewards® lets you and your covered family members roll a portion of unused dental benefits from one year into the next, so you have extra benefit dollars available when you need them most. ● Eligible Range (claim threshold): $1 - $600● Rollover Amount: $250 per calendar year● Rollover Amount with Preferred Provider: $350 per calendar year● Maximum Rollover Account Balance: $1,000Waiting Period This plan includes an additional waiting period if you do not enroll when it is first offered to you (known as late entrant waiting period). ● 12 months for basic services● 12 months for major services Dental Insurance

Dental Coverage Benefits At-A-Glance GP-DENT-FLI0012 Preventive Services In-Network Out-of-Network Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children Sealants Palliative treatment (including emergency relief of dental pain) 100% No Deductible 100% No Deductible Basic Services In-Network Out-of-Network Problem-focused exams Consultations Injections of antibiotics and other therapeutic medications Fillings Prefabricated stainless steel and resin crowns Simple extractions Surgical extractions Oral surgery Biopsy and examination of oral tissue (including brush biopsy) General anesthesia and I.V. sedation Prosthetic repair and recementation services Endodontics (including root canal treatment) Periodontal maintenance procedures Periodontal surgery 80% After Deductible 80% After Deductible Major Services In-Network Out-of-Network Non-surgical periodontal therapy Bridges Full and partial dentures Denture reline and rebase services Crowns, inlays, onlays and related services Build-ups/post & core Implants & implant related services 50% After Deductible 50% After Deductible

Questions? Call 800-423-2765 and mention Group ID: KWPROPERTY. (If VHA, call 855-818-2883.) This is not intended as a complete description of the coverage offered. Controlling provisions are provided in the policy, and this summary does not modify coverage. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate of coverage for your maximum benefit amounts. Lincoln DentalConnect® health center web content is provided by go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group® company. Coverage is subject to actual policy language. Each independent company is solely responsible for its own obligations. Group insurance products and services described herein are issued by The Lincoln National Life Insurance Company, Fort Wayne, IN, which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products are issued by Lincoln Life & Annuity Company of New York, Syracuse, NY. Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Network access plans for specific states are located on LincolnFinancial.com under the Forms section. Limitations and exclusions apply. ©2022 Lincoln National Corporation LCN-4450134-030222 GP-DENT-FLI001_Z01 Dental Coverage Benefit At-A-Glance 3 With the Lincoln Dental Mobile App •Find a network dentist near you inminutes•Have an ID card on your phone•Customize the app to get details of yourplan•Find out how much your plan covers forcheckups and other services•Keep track of your claimsLincoln DentalConnect® Online Health Center •Determine the average cost of a dentalprocedure•Have your questions answered by alicensed dentist•Learn all about dental health for children,from baby’s first tooth to dentalemergencies•Evaluate your risk for oral cancer,periodontal disease and tooth decayCovered Family Members When you choose coverage for yourself, you can also provide coverage for: •Your spouse.•Dependent children, up to age 26.Benefit ExclusionsLike any coverage, this dental coverage does have some exclusions. • The policy does not cover services started before coverage begins orafter it ends. Benefits are limited to appropriate and necessaryprocedures listed in the policy. Benefits are not payable forduplication of services. Covered expenses will not exceed the policy’susual and customary allowances.• Benefits are not payable for a condition that is covered underWorkers’ Compensation or a similar law; that occurs during thecourse of employment or military service or involvement in an illegaloccupation, felony, or riot; or that results from a self-inflicted injury.• In certain situations, there may be more than one method of treatinga dental condition. The policy includes an alternative benefitsprovision that may reduce benefits to the lowest-cost, generallyeffective, and necessary form of treatment.• Certain conditions, such as age and frequency limitations, mayimpact your coverage. See the policy for details.This is an incomplete list of benefit exclusions. A complete list is included in the policy. State variations apply.

The Lincoln National Life Insurance Company Please see prior page for product information. Dental Coverage Benefit| Rate Calculation DTL-ENRO-BRC001-FL 4 Help reduce paper waste and receive electronic Explanation of Benefits (EOBs)! Starting on your effective date, visit LincolnFinancial.com to register and elect “Go paperless” through the Profile & Settings menu. Dental Rate Here’s how little you pay with group rates.As an employee, you can take advantage of this dental coverage and you can add loved ones to the plan for just a little more. Your estimated cost is itemized below. Coverage Monthly Rate Employee only $27.79 Employee & spouse $57.45 Employee & child/children $60.85 Employee & family $90.52