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Dental

Please see the Benefits at a Glance chart for specifics on plan options, coverage basics,
province-specific default coverage, and plan costs.
Eligible Dependents

Children are covered up to age 21, or up to their 26th birthday if they are in post-
secondary school. Over-age dependents must re-certify every summer, or the
benefits will be terminated on August 31.

Default Coverage
In Quebec: Associates will receive the CORE PLAN if you do not enrol during
open enrolment. In all other Provinces: Associates will receive OPT-OUT / HCSA-
ONLY PLAN if you do not enroll during open enrolment. Termination age for dental
coverage is the earliest of age 70 or retirement.

OPT-OUT /
DENTAL HCSA ONLY CORE PREMIUM
Deductible None None
No
Dental Fee Guide Current province of treatment Current province of treatment
Coverage *
Recall Examination Frequency Once every 9 months Once every 6 months
COVERED EXPENSES
Basic / Preventative 75% 100%
Endodontic / Periodontic No Coverage * 100%
No
Dentures / Bridges / Crowns No Coverage * 60%
Coverage *
Maximum $750 / year $2,000 / year (excluding orthodontic)
Orthodontic No Coverage * 50% (maximum $2,000 / lifetime)
OPT-OUT /
COST HCSA ONLY CORE PREMIUM

Single $0 / per pay $0 / per pay $6.77 / per pay
Single +1 $0 / per pay $0 / per pay $11.97 / per pay
Family (Single + more than 1) $0 / per pay $0 / per pay $17.02 / per pay
* Expense eligible for reimbursement through HCSA

HEALTH CARE OPT-OUT /
SPENDING ACCOUT HCSA ONLY CORE PREMIUM
Amount $750 / year $500 / year $250 / year

Health Care Spending Account

The HCSA allows you to get reimbursement for your out-of-pocket expenses. When your
coverage starts, you get all of your HCSA money for the year in one deposit.

You can use this money to help pay for:
• If your plan doesn’t cover the entire amount of your claim, you can submit a
claim to your HCSA to get the rest back.
• If you’ve opted out of regular health and dental coverage or reached your yearly
limit, you can submit remaining expenses to your HCSA.

12 AMERICAN EAGLE OUTFITTERS, INC.

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