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YOUR DENTAL BENEFITS Prepared for the employees of Two Rivers Public Schools The summary below does not cover all plan details. Further information can be found in the Summary Plan Description or dental benefit handbook. That document provides a thorough explanation of your dental plan, including any limitations or exclusions that might apply. If there are any discrepancies between information found here and the group contract, the group contract shall govern. ™ Delta Dental PPO™ Delta Dental Premier® or Out-of-Network Individual Annual Maximum $1,500 $1,500 Deductible $0 $0 Diagnostic & Preventive Exams, cleanings, fluoride treatments, X-rays, space maintainers, sealants 80% 80% Basic & Major Services Emergency treatment to relieve pain, fillings, root canals, treatment of gum disease, repairs and adjustments to bridges and dentures, extractions, crowns, and other oral surgery 80% 80% Bridges, dentures, and implants 50% 50% Orthodontic Services Coverage copayment Individual lifetime maximum Dependents eligible to Adult orthodontics 60% $1,500 Age 26 Yes 60% $1,500 Age 26 Yes EBICP Yes Yes Dependent Eligibility Dependents are covered to the end of the month they turn 26 Evidence-Based Integrated Care Plan (EBICP) provides additional cleaning(s) and/or fluoride treatments to individuals with specific medical conditions that have oral implications. Need assistance? Contact Customer Service at 800-236-3712 or claims@deltadentalwi.com. Learn more at www.deltadentalwi.com.

YOUR VISION BENEFITS Prepared for the employees of Two Rivers Public Schools The summary below does not cover all plan details. Further information can be found in the vision benefit handbook, which provides a thorough explanation of your vision plan, including any limitations or exclusions that might apply. If there are any discrepancies between information found here and the group contract, the group contract shall govern. DeltaVision® Full Plan Network Insight Frame/Contact Allowance $150/$150 Copay (exams/standard plastic lenses) $10/$10 Frequency (exams/lenses or contact/frames) Based on calendar year 12 months/12 months/24 months Dependent Age Limit To age 26 Benefit Details Network Benefit Out-of-Network Reimbursement Comprehensive Glasses Exam Member pays $10, plan pays balance $35 Retinal Imaging Member pays up to $39 None Standard Contact Lens* Fit and Follow-Up Member pays up to $40 None Premium Contact Lens** Fit and Follow-Up 10% discount off retail None Frames (any available frame at provider location) $150 allowance, then 20% off balance $75 Laser Vision Correction (Lasik or PRK) 15% off retail price or 5% off promotional price None Includes Diabetic Eye Care Benefits that provide an additional office visit and diagnostic testing for those who have diabetes. Standard Plastic Lenses Single Vision Member pays $10, plan pays balance $25 Bifocal Member pays $10, plan pays balance $40 Trifocal Member pays $10, plan pays balance $55 Standard Progressive Member pays $75 $40 Premium Progressive See next page for benefit details Lens Options UV Coating Member pays $15 None Tint (solid and gradient) Member pays $15 None Standard Scratch Resistance Member pays $15 None Standard Polycarbonate Member pays $40 None Standard Anti-Reflective Coating Member pays $45 None Premium Anti-Reflective Coating See next page for benefit details Other Add-Ons and Services 20% off retail None *Lenses that are spherical power only, soft lens materials, including planned replacement and conventional lenses. Lenses are to be used in a daily wear (removed prior to sleep) mode only. **Includes all lens powers and designs other than spherical powers (i.e. toric, multifocal, etc.), modes of wear that are extended or overnight schedules, and rigid or gas-permeable materials.

Premium Progressive Lens Tier 1 $95 copay $60 Tier 2 $105 copay $60 Tier 3 $120 copay $60 Tier 4 $75 copay, 80% of charge less $120 allowance $60 Premium Anti-Reflective Coating Tier 1 $57 None Tier 2 $68 None Tier 3 80% of charge None Additional In-Network Discounts • 20% discount on items not covered by the plan at network providers. This discount may not be combined with any other discounts or promotional offers. This discount does not apply to an EyeMed® provider’s professional services (i.e. exams) or contact lenses. Retail prices may vary by location. • 40% discount on complete eyeglass purchases after your plan benefits have been fully used (includes prescription sunglasses). • 15% discount on conventional contact lenses after your plan benefits have been fully used. • Members can purchase eyeglasses online and apply their in-network eyeglass benefits at www.glasses.com, lenscrafters.com, targetoptical.com, or rayban.com. • Members can purchase contact lenses online and apply their in-network contact lenses benefits at www.contactsdirect.com. • Discounts do not apply for benefits provided by other group benefit plans. How to Maximize Your DeltaVision Plan • Use providers participating in your vision plan network; your benefit dollars will go farther at participating providers. For an up-to-date listing of EyeMed providers in your area, visit our website at https://www.deltadentalwi.com/vision or call EyeMed's Customer Care Center at 844-848-7090. • For laser vision correction, LASIKPlus is the network provider offering members additional benefits. Additional information can be obtained by calling 1-800-988-4221 or visiting eyemedlasik.com. • Use your full benefit allowance. Frames and lenses (plastic or contact) each have an annual benefit allowance. The benefit allowance must be used on a single day purchase; there is no remaining balance if entire allowance is not used after initial purchase. • Frequency of benefits: your benefit frequency is based on calendar year. For example, you’ll be covered for another pair of glasses as of January 1 of the next calendar year. • Participating providers may offer promotional pricing on vision materials. You can partake in either the DeltaVision Network Benefit or the promotional price available, but not both. Your provider can help you to determine which is best for you. If you select the promotional pricing you can submit your expenses for Out-of-Network Reimbursement. • Prescription sunglasses can be purchased with your benefit allowance for frames and plastic lenses. • A 20% discount may be available on selected brands of non-prescription sunglasses from participating providers ----- ask your vision provider. • Premium progressive lenses are more costly than standard progressive lenses. Please discuss your costs for progressive lenses with your vision provider. ***Medically necessary contacts require authorization from a vision doctor when some conditions are present. Please contact the plan for more information. Benefit Details (continued) Network Benefit Out-of-Network Reimbursement Contact Lenses – In lieu of glasses (Contact lens allowance covers materials only) Conventional $150 allowance, then 15% off balance $120 Disposable $150 allowance $120 Medically Necessary*** Paid in full $200

Plan Limitations/Exclusions • Orthoptic or vision training, subnormal vision aids, and associated supplemental testing. • Medical and/or surgical treatment of the eye, eyes, or supporting structures. • Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under the plan. • Services provided as a result of any worker’s compensation law. • Plano nonprescription lenses and nonprescription sunglasses (except for 20% discount). • Aniseikonic lenses. • Services or materials provided by any other group benefit providing vision care. • Two pairs of glasses in lieu of bifocals. • Lost or broken materials are not covered. DeltaVision is underwritten by Wyssta Insurance Company.