Common use of BENEFIT PAYMENT PROCEDURES Clause in Contracts

BENEFIT PAYMENT PROCEDURES. 1. After Subscriber or eligible Dependent has met any applicable Class I deductible requirement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class I services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment. 2. After Subscriber or eligible Dependent has met any applicable Class II deductible requirement, payment for covered Class II services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of eighty percent (80%) of the balance of the Dentist’s submitted fee or eighty percent (80%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class II services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of eighty percent (80%) of the balance of the Dentist’s submitted fee or eighty percent (80%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class II services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of eighty percent (80%) of the balance of the Dentist’s submitted fee or eighty percent (80%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment. 3. After Subscriber or eligible Dependent has met any applicable Class III deductible requirement, payment for covered Class III services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of fifty percent (50%) of the balance of the Dentist’s submitted fee or fifty percent (50%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class III services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of fifty percent (50%) of the balance of the Dentist’s submitted fee or fifty percent (50%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class III services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of fifty percent (50%) of the balance of the Dentist’s submitted fee or fifty percent (50%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment. 4. After eligible dependent child has met any applicable Class IV deductible requirement, payment for covered Class IV services received by such eligible person shall be made by DDPOK as follows: (Applicable only if benefits for Class IV services are included in this Plan. Refer to section B. above.)

BENEFIT PAYMENT PROCEDURES. 1. After Subscriber or eligible Dependent has met any applicable Class I deductible requirement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. Form No. 1000.3 8 of 13 CONFIDENTIAL Appendix B Revised January 2022 In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class I services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment. 2. After Subscriber or eligible Dependent has met any applicable Class II deductible requirement, payment for covered Class II services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of eighty percent (80%) of the balance of the Dentist’s submitted fee or eighty percent (80%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class II services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of eighty percent (80%) of the balance of the Dentist’s submitted fee or eighty percent (80%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class II services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of eighty percent (80%) of the balance of the Dentist’s submitted fee or eighty percent (80%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment. 3. After Subscriber or eligible Dependent has met any applicable Class III deductible requirement, payment for covered Class III services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of fifty percent (50%) of the balance of the Dentist’s submitted fee or fifty percent (50%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class III services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of fifty percent (50%) of the balance of the Dentist’s submitted fee or fifty percent (50%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. Form No. 1000.3 9 of 13 CONFIDENTIAL Appendix B Revised January 2022 In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class III services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of fifty percent (50%) of the balance of the Dentist’s submitted fee or fifty percent (50%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment. 4. After eligible dependent child has met any applicable Class IV deductible requirement, payment for covered Class IV services received by such eligible person shall be made by DDPOK as follows: (Applicable only if benefits for Class IV services are included in this Plan. Refer to section B. above.) a. New Orthodontic Treatment Plan: New Orthodontic Treatment Plan shall mean an orthodontic treatment plan which initially commences on or after such eligible person’s effective date of orthodontic coverage under this Plan. (1) Orthodontic Treatment Plan Down Payment – If orthodontic treatment is provided by a Delta Dental PPO Participating Dentist, payment shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of fifty percent (50%) of the amount equal to one-third (1/3) of the Delta Dental PPO Participating Dentist’s estimated total treatment plan fee or fifty percent (50%) of the amount equal to one-third (1/3) of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to the maximum orthodontic benefit payment and treatment plan. The Subscriber shall be responsible for paying the Delta Dental PPO Participating Dentist any amount of the orthodontic treatment plan down payment that is not discharged by the DDPOK payment. In the event the Dentist providing orthodontic treatment has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of fifty percent (50%) of the amount equal to one-third (1/3) of the Delta Dental Premier Participating Dentist’s estimated total treatment plan fee or fifty percent (50%) of the amount equal to one-third (1/3) of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to the maximum orthodontic benefit payment and treatment plan. The Subscriber shall be responsible for paying the Delta Dental Premier Participating Dentist any amount of the orthodontic treatment plan down payment that is not discharged by the DDPOK payment. In the event the Dentist providing orthodontic treatment has not signed a Participating Dentist Agreement, payment shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of fifty percent (50%) of the amount equal to one-third (1/3) of the Nonparticipating Form No. 1000.3 10 of 13 CONFIDENTIAL Appendix B Revised January 2022 Dentist’s estimated total treatment plan fee or fifty percent (50%) of the amount equal to one-third (1/3) of the prevailing fee, whichever is less, subject to the maximum orthodontic benefit payment and treatment plan. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK for the orthodontic treatment plan down payment and any amount of the Nonparticipating Dentist’s required down payment that is not discharged by the DDPOK payment.