ESBD_521004_1780003853623_Exhibit A-2. -Comprehensive Dental Basic Plan - Multi Plans.PDF

AL HSOB-G-PPODental 01 1 TX GE-01

Schedule of benefits

Comprehensive dental expense insurance plan

Prepared for:

Policyholder: Travis County Healthcare District d/b/a Central Health Policyholder number: GP-0285663 Schedule of benefits: 1A Group policy effective date: March 1, 2021 Plan name: Comprehensive Dental - Basic Plan Plan effective date: March 1, 2021 Plan issue date: April 3, 2023 Plan revision effective date: March 1, 2023

Underwritten by Aetna Life Insurance Company in the state of Texas

AL HSOB-G-PPODental 01 2 TX GE-01

Schedule of benefits

This schedule of benefits lists the eligible dental services, deductibles, coinsurance, maximums, and other limits that apply to the services you get under this plan.

How to read your schedule of benefits When we say:

- “Contracting dental provider coverage” we mean that you get care from contracting dental providers.

- “Non-contracting dental provider coverage” we mean that you can get care from non-contracting dental providers.

The deductibles and coinsurance listed in the schedule of benefits below reflects the deductibles and coinsurance amounts under your plan.

You must pay any deductibles and your part of the coinsurance.

The coinsurance listed in the schedule of benefits reflects the plan coinsurance percentage. This is the coinsurance amount the plan pays. You are responsible for paying any remaining coinsurance.

You must pay the full amount of any dental care services you get that are not a covered benefit or that exceed your Calendar Year maximums or lifetime maximums.

This plan also has limits for some covered benefits. For example, these could be visit limits. They may be combined limits between or separate limits for contracting dental providers and non-contracting dental providers unless we state otherwise. See later in this schedule of benefits for information about limits.

Important note:

All covered benefits are subject to a Calendar Year deductible and coinsurance unless otherwise noted in the schedule of benefits below.

How to contact us for help We are here to answer your questions:

Register and log onto our self-service website available 24/7 at https://www.aetna.com/ Call us at 1-877-238-6200

The coverage described in this schedule of benefits will be provided under Aetna Life Insurance Company’s group policy. This schedule of benefits replaces any schedule of benefits previously in effect under the group policy. Keep this schedule of benefits with your booklet-certificate.

https://www.aetna.com/

AL HSOB-G-PPODental 01 3 TX GE-01

General coverage provisions This section explains the:

Deductibles Maximums

Calendar Year deductible Eligible dental services applied to the non-contracting dental provider deductibles will be applied to satisfy the contracting dental provider deductibles. Eligible dental services applied to the contracting dental provider deductibles will be applied to satisfy the non-contracting dental provider deductibles.

Individual deductible You pay for eligible dental services each Calendar Year before this plan begins to pay. This individual deductible applies separately to you and each covered dependent. After the amount paid reaches the individual deductible, this plan starts to pay for eligible dental services for the rest of the Calendar Year.

Family deductible You pay for eligible dental services each Calendar Year before this plan begins to pay. After the amount paid for eligible dental services reaches this family deductible, this plan starts to pay for eligible dental services for the rest of the Calendar Year. To satisfy this family deductible for the rest of the Calendar Year, the combined eligible dental services that you and each of your covered dependents incur toward the individual deductible must reach this family deductible in a Calendar Year. When this happens in a Calendar Year, the individual deductibles for you and your covered dependents are met for the rest of the Calendar Year.

Calendar Year maximum The most the plan will pay for eligible dental services incurred by any one covered person in a Calendar Year is called the Calendar Year maximum.

This Calendar Year maximum applies to eligible dental services provided by contracting dental providers and non-contracting dental providers combined.

Specific dental care lifetime maximum This is the most this plan will pay, after you have paid any deductible, for specific dental care treatment expenses incurred by any one covered person during their lifetime for eligible dental services.

These specific dental care lifetime maximums apply to eligible dental services provided by contracting dental providers and non-contracting dental providers combined.

Any expenses applied to satisfy a specific dental care lifetime maximum will not be applied to satisfy any lifetime maximum.

Your financial responsibility and determination of benefits provisions Your financial responsibility for the cost of services is based on when the service or supply is provided, not when payment is made. Benefits will be pro-rated to account for treatment that occurs in more than one Calendar Year. Determinations regarding when benefits are covered are subject to the terms and conditions of the booklet-certificate.

AL HSOB-G-PPODental 01 4 TX GE-01

Plan features

Calendar Year deductible You have to meet your Calendar Year deductible before this plan pays for benefits.

Deductibles Contracting dental provider coverage Amounts

Non-contracting dental provider coverage Amounts

Calendar Year deductible* Individual $50 Family $150

Individual $50 Family $150

*Important note: The Calendar Year deductible applies to all eligible dental services except Type A expenses.

The Calendar Year deductible applies to all eligible dental services except Type A expenses.

Coinsurance The coinsurance listed below reflects the plan coinsurance percentage. This is the coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.

About contracting and non-contracting providers Your benefits, cost-sharing, and maximums are the same for contracting dental providers and non-contracting dental providers. However, you might pay more when you use a non-contracting dental provider. Non-contracting dental providers do not have to accept the negotiated charge that the contracting dental providers have agreed to be paid. We pay non-contracting dental providers based on the recognized charge, and they may balance bill you for charges over our recognized charge.

Coinsurance Expenses Contracting dental provider coverage Coinsurance

Non-contracting dental provider coverage Coinsurance

Type A expenses 100% of the negotiated charge 100% of the recognized charge

Type B expenses 80% of the negotiated charge 80% of the recognized charge

Type C expenses 50% of the negotiated charge 50% of the recognized charge

Orthodontic treatment coinsurance Expense Contracting dental provider coverage Coinsurance

Non-contracting dental provider coverage Coinsurance

Orthodontic treatment 50% of the negotiated charge 50% of the recognized charge

Calendar Year maximum Maximums Contracting dental provider coverage Amounts

Non-contracting dental provider coverage Amounts

Calendar Year maximum $1,500 $1,500

AL HSOB-G-PPODental 01 5 TX GE-01

Specific dental care lifetime maximum Eligible dental service Contracting dental provider coverage Amounts Non-contracting dental provider coverage Amounts

Orthodontic treatment $1,000 $1,000

AL HSOB-G-PPODental 01 6 TX GE-01

Eligible dental services

Type A expenses: Diagnostic & preventive care Visits and exams Oral evaluations, (2 visits per year or 2 routine visits and 2 problem focused visits per year) Prophylaxis (cleaning), (2 treatments per year) Topical application of fluoride if you are under age 16, (1 application per year) Sealants, per tooth (1 application every 3 years for permanent molars only and if you are under age

16) Sealant repair - per tooth (for permanent molars only and if you are under age 16) Scaling – moderate/severe inflammation, full mouth (2 treatments per year, frequency combined with prophylaxis)

Space maintainers - Only when needed to preserve space resulting from premature loss of deciduous teeth. (Includes all adjustments within 6 months after installation.)

Fixed or removable (unilateral or bilateral) Recementation or removal

Images and pathology Bitewing images (1 set per year) Entire dental series, including bitewings or panoramic film (1 set every 3 years) Vertical bitewing images (1 set every 3 years) Periapical images

Type B expenses: Basic restorative care Visits and exams Office visit after hours (we will pay either for the office visit charge or for the eligible dental services performed, whichever is more) Emergency palliative treatment, per visit

Images and pathology Intra-oral, occlusal view Extra-oral Accession of tissue

Restorative - Excluding inlays, onlays and crowns. Multiple restorations in 1 surface will be considered as a single restoration.

Amalgam restorations Resin-based composite restorations, (other than for molars) Protective restoration Reattachment of tooth fragment, incisal edge or cusp Interim therapeutic restoration – primary dentition Pin retention, per tooth, in addition to restoration Prefabricated crowns (primary teeth only, excludes temporary crowns) Recementation

AL HSOB-G-PPODental 01 7 TX GE-01

Oral surgery Extractions – coronal remnants – deciduous tooth Extractions erupted tooth or exposed root Surgical removal of erupted tooth Removal of impacted tooth - Soft tissue Removal of impacted tooth – Partially bony Removal of impacted tooth – Completely bony Surgical removal of residual tooth roots Primary closure of a sinus perforation Oroantral fistula closure Tooth transplantation Surgical access of unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Placement of device to facilitate eruption of impacted tooth Biopsy of oral tissue Exfoliative cytological sample collection Alveoloplasty Removal of odontogenic cysts or tumors Removal of exostosis Removal of torus Surgical reduction of osseous tuberosity Incision and drainage of abscess Removal of foreign body Sequestrectomy Suture of wounds Frenectomy/frenuloplasty Excision of hyperplastic tissue per arch Excision of pericoronal gingiva Surgical reduction of fibrous tuberosity Sialolithotomy Closure of salivary fistula Coronectomy

Periodontics Periodontal maintenance (following active therapy, 2 per year) Occlusal adjustment, (other than with an appliance or by restoration) Root planing and scaling, 1 to 3 teeth per quadrant, (1 per site every 2 years) Root planing and scaling, 4 or more teeth per quadrant, (4 separate quadrants every 2 years) Surgical revision procedure, per tooth Gingivectomy/gingivoplasty, 1 to 3 teeth per quadrant, (1 per site every 3 years) Gingivectomy/gingivoplasty, 4 or more teeth per quadrant, (1 per quadrant every 3 years) Gingival flap procedure, 1 to 3 teeth per quadrant, (1 per site every 3 years) Gingival flap procedure, 4 or more teeth per quadrant, (1 per quadrant every 3 years)

AL HSOB-G-PPODental 01 8 TX GE-01

Apically positioned flap Unscheduled dressing change (by someone other than treating dentist or their staff) Clinical Crown Lengthening – Hard Tissue Full mouth debridement (1 per lifetime) Osseous surgery, (including flap and closure), 1 to 3 teeth per quadrant (1 per site every 3 years) Osseous surgery, (including flap and closure), 4 or more per teeth per quadrant (1 per quadrant every 3 years) Soft tissue graft procedures

Endodontics Pulp cap Pulpal debridement Pulpal therapy Pulpotomy Apexification/recalcification Apicoectomy Root canal therapy and retreatment

- Anterior

- Bicuspid

- Molar

Pulpal regeneration Hemisection Retrograde filling Root amputation

General anesthesia and intravenous sedation General anesthesia and intravenous sedation are covered when provided as part of a covered surgical procedure Evaluation by anesthesiologist for deep sedation or general anesthesia

Infiltration of a sustained release therapeutic when provided as part of an eligible dental service - Only for impacted wisdom teeth procedure

Type C expenses: Major restorative care Restorative – Inlays, onlays, labial veneers and crowns (excludes temporary crowns) are covered only as treatment for decay or acute traumatic injury, and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge. Coverage is limited to 1 per tooth every 8 years. (See the Replacement rule.)

Inlays Onlays Labial veneers Crowns Post and core Repairs - inlay, onlay, veneer, crown Core Build Up

AL HSOB-G-PPODental 01 9 TX GE-01

Prosthodontics - The first installation of dentures and bridges is covered only if needed to replace teeth extracted while coverage was in force and which were not abutments to a denture or bridge less than 8 years old. (See the Tooth missing but not replaced rule.) Replacement of existing bridges or dentures is limited to 1 every 8 years. (See the Replacement rule.)

Bridge abutments Pontics Dentures and partials (fees for dentures and partial dentures include relines, rebases and adjustments within 6 months after installation. Fees for relines and rebases include adjustments within 6 months after installation. Specialized techniques and characterizations are not eligible).

- Complete upper and lower denture

- Partial upper and lower (including any conventional clasps, rests and teeth)

- Removable unilateral partial denture

Stress breakers Interim partial denture (stayplate), anterior only Reline (partial or complete) Rebase, per denture Special tissue conditioning, per denture Repairs, full and partial denture Adding teeth and clasps to existing partial denture Repairs, bridges Occlusal guard for bruxism (1 every 3 years) Adjustments, repair or reline of occlusal guard Cleaning and inspection of a removable appliance Implant

Dental care services and anesthesia in a hospital or surgery center Eligible dental services include dental care and anesthesia in a hospital or surgery center only if your provider tells us you:

Have a physical, mental, or medical condition that requires you be treated in a hospital or surgery center

Are developmentally disabled Are in poor health and have a medical need for general anesthesia

Type: Orthodontics treatment expenses Interceptive orthodontic treatment Limited orthodontic treatment Comprehensive orthodontic treatment of adolescent dentition Comprehensive orthodontic treatment of adult dentition Fixed appliance therapy Removable appliance therapy Orthodontic retention Repair of orthodontic appliance

AL HSOB-G-PPODental 01 10 TX GE-01

Important note:

The following apply:

Inlays, onlays, labial veneers and crowns (excludes temporary crowns) are covered only:

- As treatment for decay or acute traumatic injury

- When teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge.

There is an extra charge for eligible dental services that use high noble metals (ex. Gold or titanium).

General anesthesia and sedation are covered benefits when part of a covered surgical procedure.

AL HSOB-G-PPODental 01 11 TX GE-01

Additional eligible dental services We will provide additional eligible dental services if you have at least one of the following conditions:

Pregnancy Coronary artery disease/cardiovascular disease Cerebrovascular disease Diabetes

The additional eligible dental services are:

Prophylaxis (cleaning) (one additional per Calendar Year) Scaling and root planing, (4 or more teeth), per quadrant Scaling and root planing (limited to 1 to 3 teeth), per quadrant Full mouth debridement Periodontal maintenance

Payment of benefits We will waive the Calendar Year deductible and coinsurance for the additional eligible dental services above.

The plan coinsurance applied to the additional eligible dental services will be:

Expense Contracting dental provider coverage Coinsurance Non-contracting dental provider coverage Coinsurance

Additional eligible dental services 100% 100%