A Sample of Services Covered by Your Plan: Your dental coverage GUARDIAN® is a registered trademark of The Guardian Life Insurance Company of America Aesop IntermediateLLC Kit created 12/05/22 ALL ELIGIBLE EMPLOYEES Groupnumber:00554984 Option 1: HIGH Option 2: LOW Plan pays (on average) Plan pays (on average) Tier 1 Tier 2 Tier 1 Tier 2 Preventive Care Cleaning (prophylaxis) 100% 100% 100% 100% Frequency: 2 in 12 Months (applies to all levels) 2 in 12 Months (applies to all levels) Fluoride Treatments 100% 100% 100% 100% Limits: Under Age 19 (applies to all levels) Under Age 19 (applies to all levels) Oral Exams 100% 100% 100% 100% Sealants (per tooth) 100% 100% 100% 100% X-rays 100% 100% 100% 100% Basic Care Anesthesia* 80% 80% 50% 50% Fillings‡ 80% 80% 50% 50% Perio Surgery 80% 80% 50% 50% Periodontal Maintenance 80% 80% 50% 50% Frequency: 2 in 12 months (applies to all levels) 2 in 12 months (applies to all levels) Root Canal 80% 80% 50% 50% Scaling & Root Planing (per quadrant) 80% 80% 50% 50% Simple Extractions 80% 80% 50% 50% Surgical Extractions 80% 80% 50% 50% Major Care Bridges and Dentures 50% 50% 50% 50% Inlays, Onlays, Veneers** 50% 50% 50% 50% Repair & Maintenance of Crowns, Bridges & Dentures 50% 50% 50% 50% Single Crowns 50% 50% 50% 50% Orthodontia Orthodontia 50% 50% Not Covered Limits: Child(ren) (applies to all levels) (applies to all levels) Guardian’s Preferred Provider Organization consists of Dentists in the DentalGuard Preferred (“DGP”) network. These tiers represent specific benefit levels as described in Your Schedule of Benefits. Network access varies by geographic location and zip code. Please visit www.Guardianlife.com to confirm your Dentist’s tiered participation. This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required by your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. *General Anesthesia – restrictions apply. ‡For PPO and or Indemnity members, Fillings – restrictions may apply to composite fillings. 5