Exhibit A-2 - 2026 Dental Summary of Benefit Coverages.pdf

Central Health Effective Date: 01-01-2026

Dental Benefits Summary Passive PDN

With PDNII and Extend SM Networks Participating Non-participating

Annual Deductible*

Individual $50 $50

Family $150 $150

Preventive Services 100% 100%

Basic Services 80% 80%

Major Services 50% 50%

Annual Benefit Maximum $1500 $1500

Office Visit Copay N/A N/A

Orthodontic Services** 50% 50%

Orthodontic Deductible None None

Orthodontic Lifetime Maximum $1000 $1000

*The deductible applies to: Basic & Major services only

**Orthodontia is covered only for children (appliance must be placed prior to age 20).

Partial List of Services

Preventive

Passive PDN With PDNII and Extend SM Networks

Participating Non-participating

Oral examinations (a) 100% 100%

Cleanings (a) Adult/Child 100% 100%

Fluoride (a) 100% 100%

Sealants (permanent molars only) (a) 100% 100%

Bitewing Images (a) 100% 100%

Full mouth series Images (a) 100% 100%

Space Maintainers 100% 100%

Basic

Root canal therapy, anterior teeth and bicuspid teeth 80% 80%

Root canal therapy, molar teeth 80% 80%

Scaling and root planing (a) 80% 80%

Exhibit A-2 (Basic PPO PLAN) Summary

Effective Date: 01-01-2026

Dental Benefits Summary

Gingivectomy (a)* 80% 80%

Amalgam (silver) fillings 80% 80%

Composite fillings (anterior teeth only) 80% 80%

Stainless steel crowns 80% 80%

Incision and drainage of abscess* 80% 80%

Uncomplicated extractions 80% 80%

Surgical removal of erupted tooth* 80% 80%

Surgical removal of impacted tooth (soft tissue)* 80% 80%

Osseous surgery (a)* 80% 80%

Surgical removal of impacted tooth (partial bony/ full bony)*

80% 80%

General anesthesia/intravenous sedation* 80% 80%

Crown Lengthening 80% 80%

Major

Inlays 50% 50%

Onlays 50% 50%

Crowns 50% 50%

Full & partial dentures 50% 50%

Pontics 50% 50%

Denture repairs 50% 50%

Crown Build-Ups 50% 50%

Implants 50% 50%

*Certain services may be covered under the Medical Plan. Contact Member Services for more details.

(a) Frequency and/or age limitations may apply. Limits are described in the booklet/certificate.

Other Important Information This Aetna Dental® Participating Dental Network (PDN) benefits summary is provided by Aetna Life Insurance Company for some of the more frequently performed dental procedures.

Under the Dental Participating Dental Network (PDN) plan, you may choose at the time of service a PDN participating dentist. With the PDN plan, savings are possible because the participating dentists have agreed to provide care for covered services at negotiated rates.

Effective Date: 01-01-2026

Dental Benefits Summary

Out-of-Network plan payments are based on the 90th percentile of billed charges for the geographic area.

Emergency Dental Care If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week.

When emergency services are provided by a participating PDN dentist, your co-payment/coinsurance amount will be based on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be responsible for the difference between the plan payment and the dentist's usual charge. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.

Partial List of Exclusions and Limitations* - Coverage is not provided for the following (unless otherwise noted in the member booklet):

1. Charges for services or supplies

· Provided by a network provider in excess of the negotiated charge.

· Provided by an out-of-network provider in excess of the recognized charge.

· Provided for your personal comfort or convenience, or the convenience of any other person, including a dental provider

· Provided in connection with treatment or care that is not covered under the plan

· Cancelled or missed appointment charges or charges to complete claim forms

· Charges for which you have no legal obligation to pay

· Charges that would not be made if you did not have coverage, including:

- Care in charitable institutions

- Care for conditions related to current or previous military service

- Care while in the custody of a governmental authority

2. Any charge in excess of any benefit, dollar, visit, or frequency limit stated in the schedule of benefits.(Does not apply to New Hampshire contract state)

3. Cosmetic services and supplies.

4. Court-ordered services and supplies - Includes those court-ordered services and supplies, or those required as a condition of parole, probation, release or as a result of any legal proceeding.

5. Acupuncture, acupressure and acupuncture therapy

6. Crown, inlays and onlays, and veneers unless for one of the following:

· It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material

· The tooth is an abutment to a covered partial denture or fixed bridge.

7. Dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants.

Effective Date: 01-01-2026

Dental Benefits Summary

8. Dentures, crowns, inlays, onlays, bridges, or other prosthetic appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion.

9. Dental work that began before you were covered by the plan.(Does not apply to California contract state)

10. First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to replace congenitally missing teeth or to replace teeth, all of which were lost while you were not covered.(Does not apply to California contract state)

11. General anesthesia and intravenous sedation, unless specifically covered and done in connection with another eligible dental service. Medically necessary services, such as anesthesia, may be covered for neurodiverse patients as needed.

12. Instruction for diet, tobacco counseling and oral hygiene.

13. Orthodontic treatment except as covered in the Eligible Dental Services section of the schedule of benefits.

14. Dental services and supplies made with high noble metals (gold or titanium) except as covered in the Eligible Dental Services section of the schedule of benefits.

15. Services and supplies provided in connection with treatment or care that is not covered under the plan.

16. Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances that have been damaged due to abuse, misuse or neglect and for an extra set of dentures.

17. Replacement of teeth beyond the normal complement of 32.

18. Services and supplies provided where there is no evidence of pathology, dysfunction or disease, other than covered preventive services.

19. Space maintainers except when needed to preserve space resulting from the premature loss of deciduous teeth.

20. Surgical removal of impacted wisdom teeth when removed only for orthodontic reasons.

21. Temporomandibular joint dysfunction/disorder

Effective Date: 01-01-2026

Dental Benefits Summary

22. Dental services and supplies that are covered in whole or in part:

· Under any other part of this plan

· Under any other plan of group benefits provided by the policyholder

23. Experimental or investigational drugs, devices, treatments or procedures.

24. Services, including but not limited to, treatments, services, prescription drugs and supplies which are not medically necessary (as determined by Aetna)

25. Payment for a portion of the charge that another party is responsible for as the primary payer.

26. Prescribed drugs, pre-medication or analgesia.

27. Treatment by other than a dentist. However, the plan will cover some services provided by a licensed dental hygienist under the supervision and guidance of a dentist. These are:

· Scaling of teeth

· Cleaning of teeth

· Topical application of fluoride.

28. Work related illness or injuries.

Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage.

*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.

Your Dental Care Plan Coverage Is Subject to the Following Rules:

Alternate treatment rule : Sometimes there are several ways to treat a dental problem, all of which provide acceptable results.

· If a charge is made for a non-eligible dental service or supply and an eligible dental service that would provide an acceptable result, then your plan will pay a benefit for the eligible dental service or supply.

· If a charge is made for an eligible dental service but another eligible dental service that would provide an acceptable result is less expensive, the benefit will be for the least expensive eligible dental service.(Does not apply to New Hampshire contract state)

Effective Date: 01-01-2026

Dental Benefits Summary

· You should review the differences in the cost of alternate treatment with your dental provider. Of course, you and your dental provider can still choose the more costly treatment method. You are responsible for any charges in excess of what your plan will cover.

Replacement rule : Some eligible dental services are subject to your plan’s replacement rule. The replacement rule applies to replacements of, or additions to existing:

· Crowns

· Inlays

· Onlays

· Veneers

· Complete dentures

· Removable partial dentures

· Fixed partial dentures (bridges)

· Other prosthetic services

These eligible dental services are covered only when you give us proof that:

· While you were covered by the plan (Does not apply to California contract state):

- You had a tooth (or teeth) extracted after the existing denture or bridge was installed.

- As a result, you need to replace or add teeth to your denture or bridge.

· The present item cannot be made serviceable, and is:

- A crown installed at least 8 years before its replacement.

- An inlay, onlay, veneer, complete denture, removable partial denture, fixed partial denture (bridge), or other prosthetic item installed at least 8 years before its replacement.

· While you were covered by the plan:

- You had a tooth (or teeth) extracted.

- Your present denture is an immediate temporary one that replaces that tooth (or teeth).

- A permanent denture is needed, and the temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months from the date that the temporary denture was installed.

Tooth missing but not replaced rule (Does not apply to California contract state) :

The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic services will be covered if:

· The dentures, bridges or other prosthetic items are needed to replace one or more natural teeth that were removed while you were covered by the plan. (The extraction of a third molar tooth does not qualify.)

· The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 8 years

Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.

Effective Date: 01-01-2026

Dental Benefits Summary

Late entrant rule (Does not apply to California and Maine contract states and Maine residents): The plan does not cover services and supplies given to a person age 5 or older if that person did not enroll in the plan during one of the following:

· The first 31 days the person is eligible for this coverage or

· Any period of open enrollment agreed to by the employer and us

This does not apply to charges incurred for any of the following:

· After the person has been covered by the plan for 12 months

· As a result of injuries sustained while covered by the plan

· Diagnostic and preventive services such as exams, cleanings, fluoride, and images (excludes services related to orthodontia).

Finding Participating Providers

Consult Aetna Dentals online provider search for the most current provider listings. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. For the most current information, please contact the selected provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider search available at www.aetna.com.

Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without notice. In case of a conflict between your plan documents and this information, the plan documents will govern.

In the event of a problem with coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the grievance procedure when appropriate.

All member care and related decisions are the sole responsibility of participating providers. Aetna Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes.

Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna Health Inc.

Telehealth Services: the plan will reimburse the treating or consulting provider for the diagnosis, consultation, or treatment of an enrollee via telehealth on the same basis and to the same extent that the plan would reimburse the same covered in-person service.

Members have access to virtual dental care. Log in to www.aetna.com to access virtual dental providers.

In Texas, the Dental Preferred Provider Organization (PPO) is known as the Participating Dental Network (PDN), and is administered by Aetna Life Insurance Company.

This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. The availability of a plan or program may vary by geographic service area. Certain dental plans are available only for groups of a certain size in accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan http://www.aetna.com

Effective Date: 01-01-2026

Dental Benefits Summary documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan.

Aetna Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with 45 CFR § 92.101(a)(2)). Aetna Inc. does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

Aetna Inc.:

· Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats).

· Provides free language assistance services to people whose primary language is not English, which may include:

o Qualified interpreters o Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, call 1-800-872-3862 (TTY: 711) or the number on the back of your ID card.

If you believe that Aetna Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Civil Rights Coordinator Attn: 1557 Coordinator CVS Pharmacy, Inc.

1 CVS Drive, MC 2332, Woonsocket, RI 02895

Phone: 1-800-648-7817 , TTY: 711 Email: CRCoordinator@aetna.com

You can file a grievance in person, by mail, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW file:///C:\Users\CE1264313\Downloads\Notices%20of%20Non-Discrimination%20for%20Accessibility%20Review\1-800-648-7817 file:///C:\Users\CE1264313\Downloads\Notices%20of%20Non-Discrimination%20for%20Accessibility%20Review\711 mailto:CRCoordinator@aetna.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Effective Date: 01-01-2026

Dental Benefits Summary

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html .

This notice is available at Aetna Inc.’s website: https://www.aetna.com/

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

http://www.hhs.gov/ocr/office/file/index.html https://www.aetna.com/

Effective Date: 01-01-2026

Dental Benefits Summary

Effective Date: 01-01-2026

Dental Benefits Summary Passive PDN

With PDNII and Extend SM Networks Participating Non-participating

Annual Deductible*

Individual $50 $50

Family $150 $150

Preventive Services 100% 100%

Basic Services 80% 80%

Major Services 50% 50%

Annual Benefit Maximum $2000 $2000

Office Visit Copay N/A N/A

Orthodontic Services** 50% 50%

Orthodontic Deductible None None

Orthodontic Lifetime Maximum $1500 $1500

*The deductible applies to: Basic & Major services only

**Orthodontia is covered only for children (appliance must be placed prior to age 20).

Partial List of Services

Preventive

Passive PDN With PDNII and Extend SM Networks

Participating Non-participating

Oral examinations (a) 100% 100%

Cleanings (a) Adult/Child 100% 100%

Fluoride (a) 100% 100%

Sealants (permanent molars only) (a) 100% 100%

Bitewing Images (a) 100% 100%

Full mouth series Images (a) 100% 100%

Space Maintainers 100% 100%

Basic

Root canal therapy, anterior teeth and bicuspid teeth 80% 80%

Root canal therapy, molar teeth 80% 80%

Scaling and root planing (a) 80% 80%

Exhibit A-2 (PPREMIUM PPO PLAN) Summary

Effective Date: 01-01-2026

Dental Benefits Summary

Gingivectomy (a)* 80% 80%

Amalgam (silver) fillings 80% 80%

Composite fillings (anterior teeth only) 80% 80%

Stainless steel crowns 80% 80%

Incision and drainage of abscess* 80% 80%

Uncomplicated extractions 80% 80%

Surgical removal of erupted tooth* 80% 80%

Surgical removal of impacted tooth (soft tissue)* 80% 80%

Osseous surgery (a)* 80% 80%

Surgical removal of impacted tooth (partial bony/ full bony)*

80% 80%

General anesthesia/intravenous sedation* 80% 80%

Crown Lengthening 80% 80%

Major

Inlays 50% 50%

Onlays 50% 50%

Crowns 50% 50%

Full & partial dentures 50% 50%

Pontics 50% 50%

Denture repairs 50% 50%

Crown Build-Ups 50% 50%

Implants 50% 50%

*Certain services may be covered under the Medical Plan. Contact Member Services for more details.

(a) Frequency and/or age limitations may apply. Limits are described in the booklet/certificate.

Other Important Information This Aetna Dental® Participating Dental Network (PDN) benefits summary is provided by Aetna Life Insurance Company for some of the more frequently performed dental procedures.

Under the Dental Participating Dental Network (PDN) plan, you may choose at the time of service a PDN participating dentist. With the PDN plan, savings are possible because the participating dentists have agreed to provide care for covered services at negotiated rates.

Effective Date: 01-01-2026

Dental Benefits Summary

Out-of-Network plan payments are based on the 90th percentile of billed charges for the geographic area.

Emergency Dental Care If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week.

When emergency services are provided by a participating PDN dentist, your co-payment/coinsurance amount will be based on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be responsible for the difference between the plan payment and the dentist's usual charge. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.

Partial List of Exclusions and Limitations* - Coverage is not provided for the following (unless otherwise noted in the member booklet):

1. Charges for services or supplies

· Provided by a network provider in excess of the negotiated charge.

· Provided by an out-of-network provider in excess of the recognized charge.

· Provided for your personal comfort or convenience, or the convenience of any other person, including a dental provider

· Provided in connection with treatment or care that is not covered under the plan

· Cancelled or missed appointment charges or charges to complete claim forms

· Charges for which you have no legal obligation to pay

· Charges that would not be made if you did not have coverage, including:

- Care in charitable institutions

- Care for conditions related to current or previous military service

- Care while in the custody of a governmental authority

2. Any charge in excess of any benefit, dollar, visit, or frequency limit stated in the schedule of benefits.(Does not apply to New Hampshire contract state)

3. Cosmetic services and supplies.

4. Court-ordered services and supplies - Includes those court-ordered services and supplies, or those required as a condition of parole, probation, release or as a result of any legal proceeding.

5. Acupuncture, acupressure and acupuncture therapy

6. Crown, inlays and onlays, and veneers unless for one of the following:

· It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material

· The tooth is an abutment to a covered partial denture or fixed bridge.

7. Dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants.

Effective Date: 01-01-2026

Dental Benefits Summary

8. Dentures, crowns, inlays, onlays, bridges, or other prosthetic appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion.

9. Dental work that began before you were covered by the plan.(Does not apply to California contract state)

10. First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to replace congenitally missing teeth or to replace teeth, all of which were lost while you were not covered.(Does not apply to California contract state)

11. General anesthesia and intravenous sedation, unless specifically covered and done in connection with another eligible dental service. Medically necessary services, such as anesthesia, may be covered for neurodiverse patients as needed.

12. Instruction for diet, tobacco counseling and oral hygiene.

13. Orthodontic treatment except as covered in the Eligible Dental Services section of the schedule of benefits.

14. Dental services and supplies made with high noble metals (gold or titanium) except as covered in the Eligible Dental Services section of the schedule of benefits.

15. Services and supplies provided in connection with treatment or care that is not covered under the plan.

16. Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances that have been damaged due to abuse, misuse or neglect and for an extra set of dentures.

17. Replacement of teeth beyond the normal complement of 32.

18. Services and supplies provided where there is no evidence of pathology, dysfunction or disease, other than covered preventive services.

19. Space maintainers except when needed to preserve space resulting from the premature loss of deciduous teeth.

20. Surgical removal of impacted wisdom teeth when removed only for orthodontic reasons.

21. Temporomandibular joint dysfunction/disorder

Effective Date: 01-01-2026

Dental Benefits Summary

22. Dental services and supplies that are covered in whole or in part:

· Under any other part of this plan

· Under any other plan of group benefits provided by the policyholder

23. Experimental or investigational drugs, devices, treatments or procedures.

24. Services, including but not limited to, treatments, services, prescription drugs and supplies which are not medically necessary (as determined by Aetna)

25. Payment for a portion of the charge that another party is responsible for as the primary payer.

26. Prescribed drugs, pre-medication or analgesia.

27. Treatment by other than a dentist. However, the plan will cover some services provided by a licensed dental hygienist under the supervision and guidance of a dentist. These are:

· Scaling of teeth

· Cleaning of teeth

· Topical application of fluoride.

28. Work related illness or injuries.

Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage.

*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.

Your Dental Care Plan Coverage Is Subject to the Following Rules:

Alternate treatment rule : Sometimes there are several ways to treat a dental problem, all of which provide acceptable results.

· If a charge is made for a non-eligible dental service or supply and an eligible dental service that would provide an acceptable result, then your plan will pay a benefit for the eligible dental service or supply.

· If a charge is made for an eligible dental service but another eligible dental service that would provide an acceptable result is less expensive, the benefit will be for the least expensive eligible dental service.(Does not apply to New Hampshire contract state)

Effective Date: 01-01-2026

Dental Benefits Summary

· You should review the differences in the cost of alternate treatment with your dental provider. Of course, you and your dental provider can still choose the more costly treatment method. You are responsible for any charges in excess of what your plan will cover.

Replacement rule : Some eligible dental services are subject to your plan’s replacement rule. The replacement rule applies to replacements of, or additions to existing:

· Crowns

· Inlays

· Onlays

· Veneers

· Complete dentures

· Removable partial dentures

· Fixed partial dentures (bridges)

· Other prosthetic services

These eligible dental services are covered only when you give us proof that:

· While you were covered by the plan (Does not apply to California contract state):

- You had a tooth (or teeth) extracted after the existing denture or bridge was installed.

- As a result, you need to replace or add teeth to your denture or bridge.

· The present item cannot be made serviceable, and is:

- A crown installed at least 8 years before its replacement.

- An inlay, onlay, veneer, complete denture, removable partial denture, fixed partial denture (bridge), or other prosthetic item installed at least 8 years before its replacement.

· While you were covered by the plan:

- You had a tooth (or teeth) extracted.

- Your present denture is an immediate temporary one that replaces that tooth (or teeth).

- A permanent denture is needed, and the temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months from the date that the temporary denture was installed.

Tooth missing but not replaced rule (Does not apply to California contract state) :

The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic services will be covered if:

· The dentures, bridges or other prosthetic items are needed to replace one or more natural teeth that were removed while you were covered by the plan. (The extraction of a third molar tooth does not qualify.)

· The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 8 years

Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.

Effective Date: 01-01-2026

Dental Benefits Summary

Late entrant rule (Does not apply to California and Maine contract states and Maine residents): The plan does not cover services and supplies given to a person age 5 or older if that person did not enroll in the plan during one of the following:

· The first 31 days the person is eligible for this coverage or

· Any period of open enrollment agreed to by the employer and us

This does not apply to charges incurred for any of the following:

· After the person has been covered by the plan for 12 months

· As a result of injuries sustained while covered by the plan

· Diagnostic and preventive services such as exams, cleanings, fluoride, and images (excludes services related to orthodontia).

Finding Participating Providers

Consult Aetna Dentals online provider search for the most current provider listings. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. For the most current information, please contact the selected provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider search available at www.aetna.com.

Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without notice. In case of a conflict between your plan documents and this information, the plan documents will govern.

In the event of a problem with coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the grievance procedure when appropriate.

All member care and related decisions are the sole responsibility of participating providers. Aetna Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes.

Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna Health Inc.

Telehealth Services: the plan will reimburse the treating or consulting provider for the diagnosis, consultation, or treatment of an enrollee via telehealth on the same basis and to the same extent that the plan would reimburse the same covered in-person service.

Members have access to virtual dental care. Log in to www.aetna.com to access virtual dental providers.

In Texas, the Dental Preferred Provider Organization (PPO) is known as the Participating Dental Network (PDN), and is administered by Aetna Life Insurance Company.

This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. The availability of a plan or program may vary by geographic service area. Certain dental plans are available only for groups of a certain size in accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan http://www.aetna.com

Effective Date: 01-01-2026

Dental Benefits Summary documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan.

Aetna Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with 45 CFR § 92.101(a)(2)). Aetna Inc. does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

Aetna Inc.:

· Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats).

· Provides free language assistance services to people whose primary language is not English, which may include:

o Qualified interpreters o Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, call 1-800-872-3862 (TTY: 711) or the number on the back of your ID card.

If you believe that Aetna Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Civil Rights Coordinator Attn: 1557 Coordinator CVS Pharmacy, Inc.

1 CVS Drive, MC 2332, Woonsocket, RI 02895

Phone: 1-800-648-7817 , TTY: 711 Email: CRCoordinator@aetna.com

You can file a grievance in person, by mail, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW file:///C:\Users\CE1264313\Downloads\Notices%20of%20Non-Discrimination%20for%20Accessibility%20Review\1-800-648-7817 file:///C:\Users\CE1264313\Downloads\Notices%20of%20Non-Discrimination%20for%20Accessibility%20Review\711 mailto:CRCoordinator@aetna.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Effective Date: 01-01-2026

Dental Benefits Summary

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html .

This notice is available at Aetna Inc.’s website: https://www.aetna.com/

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

http://www.hhs.gov/ocr/office/file/index.html

Effective Date: 01-01-2026

Dental Benefits Summary

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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

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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.

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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.

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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

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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

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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

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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)

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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

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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

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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.

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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…