Common use of Copayments Clause in Contracts

Copayments. Effective January 1, 2019, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 2019, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants Prosthetics 80% after deductible 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192020, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 2019, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics Orthodontics* 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192016, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible Prosthetics 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192018, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-out- of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants Prosthetics 80% after deductible 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192020, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics Orthodontics* 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192018, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Service In-Network Out-of-Network Crowns 80% after deductible 50% after deductible Implants Prosthetics 80% after deductible 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192014, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192012, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192020, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductible

Copayments. Effective January 1, 2019, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants Prosthetics 80% after deductible 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192018, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns Implants 80% after deductible 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192018, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192006, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192010 2012, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's ’s managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible * Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192010, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192008, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192020, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics 80% after deductible 50% after deductible

Copayments. Effective January 1, 20192014, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-of- pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Service In-Network Out-of-Network Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192014, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-of- pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192010, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192006, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192008, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 20192014, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Service In-Network Out-of-Network Diagnostic/Preventive 100% 50% after deductible Fillings 8060% after deductible 50% after deductible Endodontics 8060% after deductible 50% after deductible Periodontics 8060% after deductible 50% after deductible Oral Surgery 8060% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 8060% after deductible 50% after deductible Prosthetics 8050% after deductible 50% after deductible Prosthetic Repairs 8050% after deductible 50% after deductible Orthodontics 80Orthodontics* 50% after deductible 50% after deductibledeductible *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective January 1, 2019, the State Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Higher out-of-pocket out‐of‐pocket costs apply to services obtained from dental care providers not in the State Dental Plan network. Services provided through the State Dental Plan are subject to the State Dental Plan's managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Diagnostic/Preventive 100% 50% after deductible Fillings 80% after deductible 50% after deductible Endodontics 80% after deductible 50% after deductible Periodontics 80% after deductible 50% after deductible Oral Surgery 80% after deductible 50% after deductible Crowns 80% after deductible 50% after deductible Implants 80% after deductible 50% after deductible Prosthetics 80% after deductible 50% after deductible Prosthetic Repairs 80% after deductible 50% after deductible Orthodontics Orthodontics* 80% after deductible 50% after deductible