Common use of Copayments Clause in Contracts

Copayments. Effective with the 2022 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2023, 2024, 2025 insurance contract yearyears, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan plan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2020 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2014 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2018 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2008 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2010 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2023, 2024, 2025 insurance contract yearyears, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan plan are subject to the managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall must cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2012 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 2016 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the 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. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.

Copayments. Effective with the 2022 insurance contract year, the Base Dental Plan will cover allowable charges for the following services subject to the copayments and coverage limits stated. Services provided through the UPlan are subject to the managed care procedures and principles, including standards of dental necessity and appropriate practice. The plan shall must cover general cleaning two (2) times per plan year and special cleanings (root or deep cleaning) as prescribed by the dentist. Services In-Network Out-of-Network Diagnostic/Preventive 100% None Fillings 80% None Endodontics 80% None Periodontics 80% None Oral Surgery 80% None Crowns 80% None Prosthetics 50% None Prosthetic Repairs 50% None Orthodontics* 80% None *Please refer to your certificate of coverage for information regarding age limitations for dependent orthodontic care.