Common use of Benefits, Limitations and Exclusions Clause in Contracts

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or her services or the maximum allowable amount for participating dentists. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered charges, deductible and co−payment amounts, and any charges over the plan maximum. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix A. Appendix A defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber or other participant obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant if required by law, and will be based on the dentist’s submitted fee for his or her service or the Prevailing Fee, whichever is less. Each Subscriber or participant is responsible for paying the dentist and for filing their own claims. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. All claims shall be evaluated, reviewed and paid in accordance with this Plan Agreement and Appendix A, subject to Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case basis, in Plan Administrator’s sole discretion in its role as fiduciary. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or her hisƒher services or the maximum allowable amount heƒshe has agreed to accept as payment for participating dentistscovered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered charges, deductible and co−payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix A. Appendix A the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber Subscriber, participant, or other participant beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by law, and will be based on the dentist’s submitted fee for his or her service or Benefit Payment provisions set forth in the Prevailing Fee, whichever is lessappendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber Subscriber, participant, or participant beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed reviewed, and paid in accordance with this Plan Agreement and Appendix A, subject to the appendix(ices) attached and forming a part of this Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case basis, in Plan Administrator’s sole discretion in its role as fiduciaryAgreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or her services or the maximum allowable amount for participating dentists. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered non-covered charges, deductible and co−payment co-payment amounts, and any charges over the plan maximum. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix A. Appendix A defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber or other participant obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant if required by law, and will be based on the dentist’s submitted fee for his or her service or the Prevailing Fee, whichever is less. Each Subscriber or participant is responsible for paying the dentist and for filing their own claims. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. All claims shall be evaluated, reviewed and paid in accordance with this Plan Agreement and Appendix A, subject to Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case case- by-case basis, in Plan Administrator’s sole discretion in its role as fiduciary. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or her services or the maximum allowable amount for participating dentists. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered non-covered charges, deductible and co−payment co-payment amounts, and any charges over the plan maximum. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in AppendixAppendix Tulsa County CONFIDENTIAL Self-insured Administrative Services Agreement July 2023 A. Appendix A defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber or other participant obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant if required by law, and will be based on the dentist’s submitted fee for his or her service or the Prevailing Fee, whichever is less. Each Subscriber or participant is responsible for paying the dentist and for filing their own claims. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. All claims shall be evaluated, reviewed and paid in accordance with this Plan Agreement and Appendix A, subject to Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case case- by-case basis, in Plan Administrator’s sole discretion in its role as fiduciary. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or his/her services or the maximum allowable amount he/she has agreed to accept as payment for participating dentistscovered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered non-covered charges, deductible and co−payment co-payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix A. Appendix A the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber Subscriber, participant, or other participant beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by applicable law, and will be based on the dentist’s submitted fee for his or her service or Benefit Payment provisions set forth in the Prevailing Fee, whichever is lessappendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber Subscriber, participant, or participant beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed reviewed, and paid in accordance with this Plan Agreement and Appendix A, subject to the appendix(ices) attached and forming a part of this Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case basis, in Plan Administrator’s sole discretion in its role as fiduciaryAgreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Form No. 1000.1 Page 14 of 18 Confidential Fully-Insured Plan Agreement Revised January 2022

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or his/her services or the maximum allowable amount he/she has agreed to accept as payment for participating dentistscovered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered non-covered charges, deductible and co−payment co-payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix A. Appendix A the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber Subscriber, participant, or other participant beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by law, and will be based on the dentist’s submitted fee for his or her service or Benefit Payment provisions set forth in the Prevailing Fee, whichever is lessappendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber Subscriber, participant, or participant beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed reviewed, and paid in accordance with this Plan Agreement and Appendix A, subject to the appendix(ices) attached and forming a part of this Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case basis, in Plan Administrator’s sole discretion in its role as fiduciaryAgreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or his/her services or the maximum allowable amount he/she has agreed to accept as payment for participating dentistscovered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered charges, deductible and co−payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix A. Appendix A the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber Subscriber, participant, or other participant beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by applicable law, and will be based on the dentist’s submitted fee for his or her service or Benefit Payment provisions set forth in the Prevailing Fee, whichever is lessappendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber Subscriber, participant, or participant beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed reviewed, and paid in accordance with this Plan Agreement and Appendix A, subject to the appendix(ices) attached and forming a part of this Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case basis, in Plan Administrator’s sole discretion in its role as fiduciaryAgreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.