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Cigna Dental Benefit SummaryEpiscopal Church Medical Trust01/01/2022 (DD25: Dental & Orthodontia)Administered by: Cigna Health and Life Insurance CompanyThis material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plandocuments to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusionsand limitations. Your DPPO plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-of-pocketexpenses.Benefit Plan FeaturesNetwork OptionsReimbursement LevelsCalendar Year Benefits MaximumApplies to: Class II, III & IX expensesCalendar Year DeductibleIndividualFamilyBenefit HighlightsTotal Cigna DPPO NetworkNon-NetworkSee Non-NetworkReimbursementCigna DPPO AdvantageCigna DPPOFee ScheduleDiscount on FeesMaximum ReimbursableCharge 2,000 2000 2000 0 0 25 75 25 75Plan PaysPlan PaysPlan PaysClass I: Diagnostic & Preventive100%No Deductible100%No Deductible100%No DeductibleClass II: Basic Restorative85%No Deductible85%After Deductible85%After DeductibleClass III: Major Restorative85%No Deductible85%After Deductible85%After DeductibleClass IV: Orthodontia50%No Deductible50%After Deductible50%After Deductible85%No Deductible85%After Deductible85%After DeductibleOral EvaluationsProphylaxis: routine cleaningsX-rays: routineX-rays: non-routineFluoride ApplicationSealants: per toothSpace Maintainers: non-orthodonticEmergency Care to Relieve PainRestorative: fillingsEndodontics: minor and majorPeriodontics: minor and majorOral Surgery: minor and majorRepairs: bridges, crowns and inlaysRepairs: denturesDenture Relines, Rebases and AdjustmentsOsseous SurgeryInlays and OnlaysProsthesis Over ImplantCrowns: prefabricated stainless steel / resinCrowns: permanent cast and porcelainBridges and DenturesAnesthesia: general and IV sedationAnesthesia: ExparelCoverage for Subscriber and All DependentsLifetime Benefits Maximum: 1,500Class IX: ImplantsBenefit Plan Provisions:In-Network ReimbursementFor services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse thedentist according to a Fee Schedule or Discount Schedule.5

Non-Network ReimbursementCross AccumulationCalendar Year Benefits MaximumCalendar Year DeductibleCarryover ProvisionPretreatment ReviewAlternate Benefit ProvisionOral Health Integration Program(OHIP)For services provided by a non-network dentist, Cigna Dental will reimburse according to theMaximum Reimbursable Charge. The MRC is calculated at the 80th percentile of all provideramounts in the geographic area. The dentist may balance bill up to their usual fees.All deductibles, plan maximums, and service specific maximums cross accumulate between in andout of network. Benefit frequency limitations are based on the date of service and cross accumulatebetween in and out of network.The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable.Benefit-specific Maximums may also apply.This is the amount you must pay before the plan begins to pay for covered charges, whenapplicable. Benefit-specific deductibles may also apply.Certain Dental Expenses incurred and applied toward the Individual or Family Deductible duringthe last 3 months of the calendar year will be applied toward the next year’s Deductible.Pretreatment review is available on a voluntary basis when dental work in excess of 200 isproposed.When more than one covered Dental Service could provide suitable treatment based on commondental standards, Cigna will determine the covered Dental Service on which payment will be basedand the expenses that will be included as Covered Expenses.Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers withthe following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancerradiation, organ transplants and chronic kidney disease. There’s no additional charge for theprogram, and those who qualify are eligible to receive reimbursement of their coinsurance forcertain related dental procedures. Eligible customers can also receive guidance on behavioralissues related to oral health. Reimbursements under this program are not subject to the annualdeductible, but will be applied to and are subject to the plan annual maximum. For moreinformation including how to enroll in this program and a complete list of program terms andeligible medical conditions, go to www.mycigna.com or call customer service 24/7 at1.800.CIGNA24.Out of network claims submitted to Cigna after 365 days from date of service will be denied.Timely FilingBenefit Limitations: Benefit frequency limitations are based on date of service and cross accumulate between in and out of network.Oral Evaluations/ExamsX-rays (routine)Diagnostic CastsCleaningsFluoride Application3 per calendar yearBitewings: 2 per calendar yearComplete series of radiographic images and panoramic radiographic images: Limited to a combinedtotal of 1 per 36 months.Payable only in conjunction with orthodontic workup.3 per calendar year, including periodontal maintenance procedures following active therapy.2 per calendar year for children under age 19.Sealants (per tooth)Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14.Space MaintainersLimited to non-orthodontic treatment for children under age 19.Inlays, Crowns, Bridges, Dentures and PartialsReplacement every 60 months if unserviceable and cannot be repaired. Benefits are based on theamount payable for non-precious metals. No porcelain or white/tooth-colored material on molarcrowns or bridges.X-rays (non-routine)Denture and Bridge RepairsReviewed if more than once.Denture Relines, Rebases and AdjustmentsProsthesis Over ImplantCovered if more than 6 months after installation. 1 per 36 months1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amountpayable for non-precious metals. No porcelain or white/tooth colored material on molar crowns orBenefit Exclusions:Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: ceramic, resin, or acrylic materials on crowns or bridges on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments; Procedures, appliances or restorations, except full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions ofdysfunction of the temporomandibular joint (TMJ), stabilize periodontally involved teeth or restore occlusion; Athletic mouth guards; Services performed primarily for cosmetic reasons; Personalization or decoration of any dental device or dental work; Replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature;6

Services and supplies received from a hospital; Drugs: prescription drugs; Charges in excess of the Maximum Reimbursable ChargeThis document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, theterms of the official plan documents will prevail.Product availability may vary by location and plan type and is subject to change. All group dental insurance policies and dental benefit plans containexclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representativeAll Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and LifeInsurance Company (CHLIC), Connecticut General Life Insurance Company, and Cigna Dental Health, Inc. 2021 Cigna / version 010420217

Cigna Dental Benefit SummaryEpiscopal Church Medical Trust01/01/2022 (DDPV: Preventive Dental)Administered by: Cigna Health and Life Insurance CompanyThis material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plandocuments to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusionsand limitations. Your DPPO plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-of-pocketexpenses.Cigna Dental PPONetwork OptionsIn-Network:Total Cigna DPPO NetworkNon-Network:See Non-Network ReimbursementReimbursement LevelsBased on Contracted FeesMaximum Reimbursable ChargeCalendar Year Benefits MaximumApplies to: Class II, III & IX expensesCalendar Year DeductibleIndividualFamilyBenefit HighlightsClass I: Diagnostic & PreventivePlan Pays 1,500 1,500 0 0 0 0You PayPlan PaysYou Pay100%No DeductibleNo Charge100%No DeductibleNo ChargeClass II: Basic Restorative80%No Deductible20%No Deductible80%No Deductible20%No DeductibleClass III: Major Restorative1%No Deductible99%No Deductible1%No Deductible99%No DeductibleOral EvaluationsProphylaxis: routine cleaningsX-rays: routineX-rays: non-routineFluoride ApplicationSealants: per toothSpace Maintainers: non-orthodonticEmergency Care to Relieve PainRestorative: fillingsEndodontics: minor and majorPeriodontics: minor and majorOral Surgery: minor and majorAnesthesia: general and IV sedationAnesthesia: ExparelRepairs: bridges, crowns and inlaysRepairs: denturesDenture Relines, Rebases and AdjustmentsOsseous SurgeryInlays and OnlaysProsthesis Over ImplantCrowns: prefabricated stainless steel / resinCrowns: permanent cast and porcelainBridges and DenturesBenefit Plan Provisions:8

In-Network ReimbursementNon-Network ReimbursementCross AccumulationCalendar Year Benefits MaximumCalendar Year DeductiblePretreatment ReviewAlternate Benefit ProvisionFor services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse thedentist according to a Fee Schedule or Discount Schedule.For services provided by a non-network dentist, Cigna Dental will reimburse according to theMaximum Reimbursable Charge. The MRC is calculated at the 80th percentile of all provideramounts in the geographic area. The dentist may balance bill up to their usual fees.All deductibles, plan maximums, and service specific maximums cross accumulate between in andout of network. Benefit frequency limitations are based on the date of service and cross accumulatebetween in and out of network.The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable.Benefit-specific Maximums may also apply.This is the amount you must pay before the plan begins to pay for covered charges, whenapplicable. Benefit-specific deductibles may also apply.Pretreatment review is available on a voluntary basis when dental work in excess of 200 isproposed.When more than one covered Dental Service could provide suitable treatment based on commondental standards, Cigna will determine the covered Dental Service on which payment will be basedand the expenses that will be included as Covered Expenses.Oral Health Integration Program (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers withthe following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancerradiation, organ transplants and chronic kidney disease. There’s no additional charge for theprogram, and those who qualify are eligible to receive reimbursement of their coinsurance forcertain related dental procedures. Eligible customers can also receive guidance on behavioralissues related to oral health. Reimbursements under this program are not subject to the annualdeductible, but will be applied to and are subject to the plan annual maximum. For moreinformation including how to enroll in this program and a complete list of program terms andeligible medical conditions, go to www.mycigna.com or call customer service 24/7 at1.800.CIGNA24.Timely FilingOut of network claims submitted to Cigna after 365 days from date of service will be denied.Benefit Limitations: Benefit frequency limitations are based on date of service and cross accumulate between in and out of network.Oral Evaluations/ExamsX-rays (routine)X-rays (non-routine)3 per calendar yearBitewings: 2 per calendar yearComplete series of radiographic images and panoramic radiographic images: Limited to a combinedtotal of 1 per 36 months.Cleanings3 per calendar year, including periodontal maintenance procedures following active therapy.Fluoride Application2 per calendar year for children under age 19.Sealants (per tooth)Space MaintainersLimited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14.Limited to non-orthodontic treatment for children under age 19.Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on theamount payable for non-precious metals. No porcelain or white/tooth-colored material on molarcrowns or bridges.Reviewed if more than once.Covered if more than 6 months after installation. 1 per 36 months.Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on theamount payable for non-precious metals. No porcelain or white/tooth-colored material on molarcrowns or bridges.Inlays, Crowns, Bridges, Dentures and PartialsDenture and Bridge RepairsDenture Relines, Rebases and AdjustmentsProsthesis Over ImplantBenefit Exclusions:Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: ceramic, resin, or acrylic materials on crowns or bridges on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting;Prosthodontic: precision or semi-precision attachments;Implants: implants or implant related services;Orthodontics: orthodontic treatment;Procedures, appliances or restorations, except full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions ofdysfunction of the temporomandibular joint (TMJ), stabilize periodontally involved teeth or restore occlusion; Athletic mouth guards; 9

Services performed primarily for cosmetic reasons; Personalization or decoration of any dental device or dental work; Replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; Services and supplies received from a hospital; Drugs: prescription drugs; Charges in excess of the Maximum Reimbursable ChargeThis document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, theterms of the official plan documents will prevail.Product availability may vary by location and plan type and is subject to change. All group dental insurance policies and dental benefit plans containexclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative.All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and LifeInsurance Company (CHLIC), Connecticut General Life Insurance Company, and Cigna Dental Health, Inc. 2021 Cigna / version 1215202010

CHAPTER 2ELIGIBILITY AND ENROLLMENTEligibility for the Episcopal Health Plan (EHP)The Medical Trust determines the minimum eligibility for the Plans. The employer or Group Administratoris responsible for determining whether the Employee is eligible for any employer contributions towardscoverage, confirming that Members meet the eligibility criteria described below and for maintainingdocumentation related to the Members’ enrollment and elections. The Medical Trust may request acopy of required documentation at any time.Eligible Individuals and their Eligible Dependents described below must be part of a Participating Groupthat is participating in the EHP.Eligible Individuals An Employee normally scheduled to work 1,000 or more compensated hours per planyear or who is treated as a full-time Employee under the Employer Shared ResponsibilityProvisions under the Affordable Care Act (Pay or Play Rules), but only for the applicablestability periodA Seminarian who is a full-time student enrolled at a participating seminary of theAssociation of Episcopal SeminariesA Member of a Religious OrderA Pre-65 Former Employee, not eligible for Medicare, as long as their formeremployer is participating in the EHPA cleric eligible for benefits under The Church Pension Fund Clergy Short-TermDisability Plan, or The Church Pension Fund Clergy Long-Term Disability Plan who waseligible to participate in the EHP prior to their disabilityEligible Dependents A Spouse*A Domestic Partner, if Domestic Partner Benefits are elected by the Participating GroupA Child who is 301 years of age or younger on December 31 of the current year**A Disabled Child, 30 1 years of age or older on December 31 of the current year,provided the disability began before the age of 25**A Pre-65 Dependent, not eligible for Medicare, of a Post-65 Former Employee enrolled inthe Group Medicare Advantage Plan (GMAP)***A Pre-65 Surviving Dependent of a deceased Post-65 Former Employee or Pre-65 FormerEmployee***A Pre-65 Dependent, of a Pre-65 Former Employee enrolled in the GMAP*****For information on the eligibility of a former Spouse refer to the Termination of Individual Coverage, under Divorce**The Dependent must be enrolled under the Subscriber’s Plan.***The Dependent will be enrolled as a Subscriber; however, eligibility is based on the Post-65 Former Employee’s status.****The Dependent will be enrolled as a Subscriber; however, eligibility is based on the Pre-65 Former Employee’s status.1Fully insured plans may not cover children up to age 30; as the eligibility rules of the regional or local plans vary and will apply, please confirmprior to enrollment.11

Ineligible IndividualsIndividuals described below are not eligible to enroll in the EHP. A part-time Employee who is scheduled to work and be compensated for less than 1,000hours per Plan Year unless such Employee is required to be treated as a full-time Employeeunder the Pay or Play RulesA Temporary Employee unless such Employee is required to be treated as a full-timeEmployee unde

Plan Document Handbook Cigna Dental Plans Benefits effective as of January 2022 . Timely Filing Out of network claims submitted to Cigna after 365 days from date of service will be denied. . Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: ceramic, resin, or acrylic materials on crowns or .