Common use of Co-Payments Clause in Contracts

Co-Payments. Effective January 1, 20082012, the State Dental Plan will cover 26 allowable charges for the following services subject to the co-payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 60% after deductible 50% after deductible Endodontics 60% after deductible 50% after deductible Periodontics 60% after deductible 50% after deductible Oral Surgery 60% after deductible 50% after deductible Crowns 60% after deductible 50% after deductible Prosthetics 50% after deductible 50% after deductible Prosthetic Repairs 50% after deductible 50% after deductible Orthodontics* 50% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations for 3 dependent orthodontic care.

Co-Payments. Effective January 1, 200820122016, the State Dental Plan will cover 26 allowable charges for the following services subject to the co-co- payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service InSERVICE IN-Network OutNETWORK OUT-ofOF-Network NETWORK Diagnostic/Preventive 100% 50% after deductible Fillings 6080% After Deductible after deductible deducible 50% after deductible Endodontics 6080% After Deductible after deductible deductibel 50% after deductible Periodontics 6080% After Deductible after deductible 50% after deductible Oral Surgery 6080% After Deductible after deductible 50% after deductible Crowns 6080% After Deductible after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 505080% after deductible 50% after deductible Prosthetic Repairs 505080% after deductible 50% after deductible Orthodontics* 505080% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations Limitations for 3 dependent orthodontic care.

Co-Payments. Effective January 1, 200820122006 2008, the State Dental Plan will cover 26 allowable charges for the following services allowable charges for the following services subject to the co-payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 60% after deductible After Deductible 50% after deductible Endodontics 60% after deductible After Deductible 50% after deductible Periodontics 60% after deductible After Deductible 50% after deductible Oral Surgery 60% after deductible After Deductible 50% after deductible Crowns 60% after deductible After Deductible 50% after deductible Prosthetics 50% after deductible 50% after deductible Prosthetic Repairs 50% after deductible 50% after deductible Orthodontics* 50% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations Limitations for 3 dependent orthodontic care.

Co-Payments. Effective January 1, 2008201220122014, the State Dental Plan will cover 26 allowable charges for the following services subject to the co-payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 60% after deductible 50% after deductible Endodontics 60% after deductible 50% after deductible Periodontics 60% after deductible 50% after deductible Oral Surgery 60% after deductible 50% after deductible Crowns 60% after deductible 50% after deductible Prosthetics 50% after deductible 50% after deductible Prosthetic Repairs 50% after deductible 50% after deductible Orthodontics* 50% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations for 3 dependent orthodontic care.

Co-Payments. Effective January 1, 200820122006, the State Dental Plan will cover 26 allowable charges for the following services subject to the co-payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 60% after deductible 50% after deductible Endodontics 60% after deductible 50% after deductible Periodontics 60% after deductible 50% after deductible Oral Surgery 60% after deductible 50% after deductible Crowns 60% after deductible 50% after deductible Prosthetics 50% after deductible 50% after deductible Prosthetic Repairs 50% after deductible 50% after deductible Orthodontics* 50% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations for 3 dependent orthodontic care.

Co-Payments. Effective January 1, 200820122012, the State Dental Plan will cover 26 allowable charges for the following services allowable charges for the following services subject to the co-payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service InSERVICE IN-Network OutNETWORK OUT-ofOF-Network NETWORK Diagnostic/Preventive 100% 50% after deductible Fillings 60% after deductible After Deductible 50% after deductible Endodontics 60% after deductible After Deductible 50% after deductible Periodontics 60% after deductible After Deductible 50% after deductible Oral Surgery 60% after deductible After Deductible 50% after deductible Crowns 60% after deductible After Deductible 50% after deductible Prosthetics 50% after deductible 50% after deductible Prosthetic Repairs 50% after deductible 50% after deductible Orthodontics* 50% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations Limitations for 3 dependent orthodontic care.

Co-Payments. Effective January 1, 200820122010, the State Dental Plan will cover 26 allowable charges for the following services allowable charges for the following services subject to the co-payments and coverage 27 limits stated. Higher out-of-pocket costs apply to services obtained from dental care 28 providers not in the State Dental Plan network. Services provided through the State 29 Dental Plan are subject to the State Dental Plan's managed care procedures and 30 principles, including standards of dental necessity and appropriate practice. The plan 31 shall cover general cleaning two (2) times per plan year and special cleanings (root or 32 deep cleaning) as prescribed by the dentist. Service InSERVICE IN-Network OutNETWORK OUT-ofOF-Network NETWORK Diagnostic/Preventive 100% 50% after deductible Fillings 60% after deductible After Deductible 50% after deductible Endodontics 60% after deductible After Deductible 50% after deductible Periodontics 60% after deductible After Deductible 50% after deductible Oral Surgery 60% after deductible After Deductible 50% after deductible Crowns 60% after deductible After Deductible 50% after deductible Prosthetics 50% after deductible 50% after deductible Prosthetic Repairs 50% after deductible 50% after deductible Orthodontics* 50% after deductible 50% after deductible 1 2 *Please refer to your certificate of coverage for information regarding age limitations Limitations for 3 dependent orthodontic care.