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Item 4GITEM 4G M E M O R A N D U M May 29, 2019 TO: Shana K. Yelverton, City Manager FROM: Stacey Black, Director of Human Resources SUBJECT: Reject all proposals for Group Dental Coverage for City of Southlake (RFP 1903B140CM190010) Action Requested: City Council reject all proposals for Group Dental Coverage for the City of Southlake (RFP 1903B140CM190010) Background Information: The City issued a Request for Proposals (RFP) for group dental insurance on April 5, 2019, and the RFP was scheduled to close on April 26, 2019. However, the City extended the submission deadline to May 10, 2019, at vendor request in Addendum #1. This year City received one proposal and one “no intent to bid” submission. The City last issued an RFP for dental insurance in 2017 and received proposals from 10 different vendors. Staff believes that one proposal provides an insufficient evaluation of the competitive market. It does not provide enough information for staff to determine if the City has received a competitive proposal. Due to the low number of submissions, staff recommends City Council reject all proposals. Should City Council reject the proposals, staff will evaluate the process and consider its options to attract more proposals from the market. Financial Considerations: There is no budget impact as a result of this request. Strategic Link: • Focus Area: Performance Management and Service Delivery • Corporate Objective: L3 Attract, develop and retain a skilled workforce • Employer of Choice Citizen Input/ Board Review: N/A Shana K. Yelverton, City Manager ITEM 4G May 29, 2019 Page 2 Legal Review: N/A Alternatives: Changes as may be desired by the City Council. Supporting Documents: Attachment A: RFP 1903B140CM190010 Staff Recommendation: Staff recommends City Council reject all proposals for Group Dental Coverage (RFP 1903B140CM190010). City of Southlake REQUEST FOR PROPOSALS Proposal Reference Number: RFP1903B140CM190010 Project Title: Provide Group Dental Coverage for City of Southlake Proposal Closing Date: 3:00 P.M.(CST), Friday, April 26, 2019 City of Southlake - RFP1903B140CM190010 - Page 1 of 15 TABLE OF CONTENTS Table of Contents ................................................................................................................................ Page 1 Request for Proposals (1) Introduction .............................................................................................................................. Page 2 (2) Definitions ................................................................................................................................ Page 3 (3) General Information ................................................................................................................. Page 3 (4) RFP Withdrawals and/or Amendments .................................................................................... Page 3 (5) Proposal Submittal Requirements ............................................................................................ Page 3 (6) Proposal Evaluation and Contract Award ................................................................................ Page 4 Appendix A – Scope of Services (1) Project Title .............................................................................................................................. Page 6 (2) Scope of Services Contact ........................................................................................................ Page 6 (3) Special Conditions .................................................................................................................... Page 6 (4) Proposal Evaluation Factors ..................................................................................................... Page 6 (5) Brand Manufacture Reference .................................................................................................. Page 6 (6) Key Events Schedule ................................................................................................................ Page 6 (7) Scope of Services ..................................................................................................................... Page 6 Appendix B – Proposal (-) Label Format for Submittal Packet’s Sealed Envelope ............................................................. Page 7 I Required Proposal Information (1) Proposed Product ..................................................................................................................... Page 8 (2) Cost of Proposed Product ......................................................................................................... Page 8 (3) Proposer’s Experience / Staff ................................................................................................... Page 8 (4) References ................................................................................................................................ Page 8 (5) Trade Secrets and/or Confidential Information ...................................................................... Page 10 (6) Federal, State and/or Local Identification Information ......................................................... Page 10 (7) Emergency Business Services Contact Notice ....................................................................... Page 10 II Contract Terms and Conditions (1) Delivery of Products and/or Services .................................................................................... Page 11 (2) Miscellaneous ........................................................................................................................ Page 11 (3) Financial Responsibility Provisions ...................................................................................... Page 12 Appendix C – Form CIQ ................................................................................................................. Page 13 Appendix D – No Intent to Submit Form ....................................................................................... Page 15 Appendix 1-3 – Submission Forms............................................................................................................... Exhibit 1 – Dental Census ............................................................................................................................. Exhibit 2 – Dental DHMO Benefit Summary ............................................................................................. Exhibit 3 – Dental PPO Benefit Summary .................................................................................................. Exhibit 4 – Group Dental Insurance Rates ................................................................................................. City of Southlake - RFP1903B140CM190010 - Page 2 of 15 Southlake, Texas Request for Proposals 1. Introduction A. Project Overview: The City of Southlake is requesting Proposals with the intent of awarding a contract for the purchase of goods and services contained in Appendix A – Scope of Services. B. Questions: Following are contacts for questions as identified. i. RFP Clarifications: All questions related to requirements or processes of this RFP should be submitted in writing to the Purchasing Manager identified in section 2 below. ii. Scope of Service Questions: All questions related to the scope of services should be submitted in writing to the contact person(s) noted in Appendix A – Scope of Services. iii. Replies: Responses to inquiries which directly affect an interpretation or effect a change to this RFP will be issued in writing by addendum posted to City website. All such addenda issued by City prior to the submittal deadline shall be considered part of the RFP. The City shall not be bound by any reply to an inquiry unless such reply is made by such formal written addendum. iv. Acknowledgement of Addenda: The Proposer must acknowledge all addenda by signing and returning such document(s) or by initialing appropriate area of the Proposal. C. Notification of Errors or Omissions: Proposers shall promptly notify the City of any omissions, ambiguity, inconsistency or error that they may discover upon examination of this RFP. The City shall not be responsible or liable for any errors and/or misrepresentation that result from the solicitations which are inadvertently incomplete, ambiguous, inconsistent or obviously erroneous. D. Conflict of Interest Questionnaire (Form CIQ): A person or business, and their agents, who seek to contract or enter into an agreement with the City, are required by Texas Local Government Code, Chapter 176, to file a conflict of interest questionnaire (FORM CIQ) which is found in Appendix C. The form must be filed with the City Secretary no later than seven (7) days after the date the person or business begins contract discussions or negotiations with the City, or submits an application, response to a request for proposals or bids, correspondence, or other writing related to any potential agreement with the City. E. Form 1295 Certificate of Interested Parties: In 2015, the Texas Legislature adopted House Bill 1295, which added section 2252.908 of the Government Code. The law states that a governmental entity or state agency may not enter into certain contracts with a business entity unless the business entity submits a disclosure of interested parties to the governmental entity or state agency at the time the business entity submits the signed contract to the governmental entity or state agency. The law applies only to a contract of a governmental entity or state agency that either (1) requires an action or vote by the governing body of the entity or agency before the contract may be signed or (2) has a value of at least $1 million. The disclosure requirement applies to a contract entered into on or after January 1, 2016. Please go to the Texas Ethics Commission webpage (www.ethics.state.tx.us) for full instructions and to complete the required steps for creation of Form 1295. Once the form is completed online, printed and signed please return the form with your proposal submission. City of Southlake - RFP1903B140CM190010 - Page 3 of 15 2. Definitions Proposal: The signed and executed submittal of the entirety of Appendix B – Proposal. Proposer: The Proposer and the Proposer’s designated contact signing the first page of the Proposal. City of Southlake (“City”): The City of Southlake, Texas. City Secretary’s Office: The office of the City Secretary of the City, located at 1400 Main Street, Suite #270, Southlake, Texas 76092. PH: (817) 748-8016; Fax: (817) 748-8270. Project: The name of this Request for Proposals as identified on the cover sheet and first page of Appendix A – Scope of Services. Purchasing Manager: The City of Southlake Purchasing Manager is Timothy Slifka CPPO, CPPB, Phone: (817) 748-8312, E-Mail: tslifka@ci.southlake.tx.us; Fax (817) 748-8048. Request for Proposals (RFP): The entirety of this document, including all Appendices and Addenda. Scope of Services: The entirety of Appendix A – Scope of Services. 3. General Information A. Tax Exempt Status: City purchases are exempt from State Sales Tax and Federal Excise Tax. Do not include tax in the Proposal. City will furnish Excise Tax Exemption Certificate upon request. B. Public Inspection of Proposals: The City strictly adheres to the Texas Public Information Act (Texas Government Code Chapter 552.001, et seq.) and all other governing statutes, regulations, and laws regarding the disclosure of RFP information. Proposals are not available for public inspection until after the contract award. If the Proposer has notified the City, in writing, that the Proposal contains trade secrets or confidential information, the City will generally take reasonable steps to prevent disclosure of such information, in accordance with the Public Information Act. This is a statement of general policy only, and in no event shall the City be liable for disclosure of such information by the City in response to a request, regardless of the City’s failure to take any such reasonable steps, even if the City is negligent in failing to do so. 4. RFP Withdrawals and/or Amendments A. RFP Withdrawal: The City reserves the right to withdraw this RFP for any reason. B. RFP Amendments: The City reserves the right to amend any aspect of this RFP by formal written Addendum prior to the Proposal submittal deadline and will endeavor to notify all potential Proposers that have registered with the City, but failure to notify shall impose no obligation or liability on the City. 5. Proposal Submittal Requirements A. Submittal Packet – Required Content: All proposals must be submitted electronically. The Proposer must visit www.securebidusa.com and register. Once registered for this complimentary service, the Proposer may submit Proposal Documents electronically by selecting the appropriate Proposal Identification. B. Submittal Deadline: The deadline for submittal of Proposals shall be as identified on page _7_ (seven) of Appendix B-Proposal. It is the Proposer’s responsibility to have the Proposal Documents City of Southlake - RFP1903B140CM190010 - Page 4 of 15 correctly electronically submitted by the submittal deadline. No extensions will be granted and no late submissions will be accepted. C. Proposals Received Late: Proposers are encouraged to submit their proposals as soon as possible. The time and date of receipt as recorded within the SecureBid electronic system shall be the official time of receipt. The City is not responsible for late submission regardless of the reason. Late Proposals will not be considered under any circumstances. D. Alterations or Withdrawals of Proposal Document: Any submitted Proposal may be withdrawn or a revised proposal substituted prior to the submittal deadline. Proposal Documents cannot be altered, amended or withdrawn by the Proposer after the submittal deadline, unless such alteration, amendment or withdrawal notice is approved in writing by the Purchasing Manager. E. Proposal Document Format: All Proposal Documents must be prepared in single-space type, on standard 8-1/2” x 11” vertically oriented pages, numbered at the bottom. The City only accepts electronic submissions via www.securebidusa.com. Any other format (via telephone, fax, email, etc.) may be rejected by the City at its discretion. F. Validity Period: Once the submittal deadline has passed, any Proposal Document shall constitute an irrevocable bid to provide the commodities and/or services set forth in the Scope of Services at the price(s) shown in the Proposal Document. Such proposal shall be irrevocable until the earlier of the expiration of ninety (90) days from the submittal deadline, or until a contract has been awarded by the City. 6. Proposal Evaluation and Contract Award A. Proposal Evaluation and Contract Award Process: An award of a contract to provide the goods or services specified herein will be made using competitive sealed proposals, in accordance with Chapter 252 of the Texas Local Government Code and with the City’s purchasing policy. The City will evaluate all proposals to determine which proposers are reasonably qualified for the award of the contract, applying the anticipated evaluation factors and emphasis to be placed on each factor as identified in the Scope of Services. The City may, at its option, conduct discussions with or accept proposal revisions from any reasonably qualified proposer. The City reserves the right to determine which proposal will be most advantageous to the City. B. Completeness: If the Proposal is incomplete or otherwise fails to conform to the requirements of the RFP, City alone will determine whether the variance is so significant as to render the Proposal non- responsive, or whether the variance may be cured by the Proposer or waived by the City, such that the Proposal may be considered for award. C. Ambiguity: Any ambiguity in the Proposal as a result of omission, error, lack of clarity or non - compliance by the Proposer with specifications, instructions and all conditions shall be construed in the favor of the City. In the event of a conflict between these standard RFP requirements and details provided in Appendix A – Scope of Services or Appendix B – Proposal, the Appendices shall prevail. D. Unit Prices and Extensions: If unit prices and their extensions do not coincide, the City may accept the price most beneficial to the City, and the Proposer will be bound thereby. E. Additional Information: City may request any other information necessary to determine Proposer’s ability to meet the minimum standards required by this RFP. F. Partial Contract Award: City reserves the right to award one contract for some or all the requirements proposed or award multiple contracts for various portions of the requirements to different Proposers City of Southlake - RFP1903B140CM190010 - Page 5 of 15 based on the unit prices proposed in response to this request, or to reject any and all Proposals and re-solicit for Proposals, as deemed to be in the best interest of City. G. Terminate for Cause: The occurrence of any one or more of the following events will justify termination of the contract by the City of Southlake for cause: i) The successful proposer fails to perform in accordance with the provisions of these specifications; or ii) The successful proposer violates any of the provisions of these specifications; or iii) The successful proposer disregards laws or regulations of any public body having jurisdiction; or iv) The successful proposer transfers, assigns, or conveys any or all of its obligations or duties under the contract to another without written consent of the City. v) If one or more of the events identified in Subparagraphs G i) through iv) occurs, the City of Southlake may, terminate the contract by giving the successful proposer seven (7) days written notice. In such case, the successful proposer shall only be entitled to receive payment for goods and services provided before the effective date of termination. The successful proposer shall not receive any payment on account of loss of anticipated profits or revenue or other economic loss resulting from such termination. vi) When the contract has been so terminated by the City of Southlake, such termination shall not affect any rights or remedies of the City then existing or which may thereafter accrue. H. Terminate for Convenience: This contract may be cancelled or terminated at any time by giving vendor thirty (30) days written notice. Vendor may be entitled to payment for services actually performed; to the extent said services are satisfactory. City of Southlake - RFP1903B140CM190010 - Page 6 of 15 Appendix A – Scope of Services 1. Project Title: Provide Group Dental Coverage for City of Southlake 2. Scope of Services Contact Questions about the technical nature of the Scope of Services, etc. may be directed to CHAD MINTER, Phone. 817.748.8193, e-mail: cminter@ci.southlake.tx.us 3. Special Conditions The following special conditions shall prevail over areas of conflict in previous pages: NONE 4. Proposal Evaluation Factors Emphasis Factor 30 % Experience, Qualifications, Reputation and References of Proposer 30 % Rates 20 % Schedule of Benefits 10 % Provider Network Access/Penetration 10 % Reporting, Plan Administration and Ease of Billing 5. Brand Manufacture Reference The City has determined that any manufacturer’s brand defined in the Scope of Services meets the City’s product and support need. The manufacturer’s reference is not intended to be restrictive, and is only descriptive of the type and quality the City desires to purchase. Quotes for similar manufactured products of like quality will be considered if the Proposal is fully noted with the manufacturer’s brand name and model. The City reserves the right to determine products and support of equal value, and whether other brands or models meet the City’s product and support needs. 6. Key Events Schedule Proposal Release Date April 5, 2019 Deadline for Submittal of Written Questions April 17, 2019 Sealed Proposals Due to and Opened by City Shown on First Page of this RFP Anticipated Committee Evaluation Review Date Week of April 29, 2019 Anticipated Award Date May 2019 7. Scope of Services The City of Southlake is seeking competitive sealed proposals for all or part of the following: Group Dental Coverage per the following specifications: PLEASE SEE ATTACHED APPENDIX’S AND EXHIBITS FOR ALL SPECIFICATIONS AND REQUIREMENTS. City of Southlake - RFP1903B140CM190010 - Page 7 of 15 Appendix B – Proposal Submittal Checklist: (To determine validity of proposal) ______Appendix 1-3 (Submission Forms) must be included in the proposal submittal ______Appendix B (pages _7_ through _14_) must be included in the proposal submittal ______Appendix C Conflict of Interest Form (page _14_) must be included in the proposal submittal. ______Form 1295 Certificate of Interested Party (see Section E page _2_) must be included in the proposal submittal. ______HB 89 and SB 252 acknowledgement (page _12_) All proposals submitted to the City of Southlake shall include this page with the submitted Proposal. RFP Number: RFP1903B140CM190010 Project Title: Provide Group Dental Coverage for City of Southlake Submittal Deadline: 3:00 P.M. (CST), Friday April 26, 2019 Submit electronically* to: www.securebidusa.com * Requires email account login and password. Proposer Information: Proposer’s Legal Name: Address: City, State & Zip Federal Employers Identification Number # Phone Number: Fax Number: E-Mail Address: Proposer Authorization I, the undersigned, have the authority to execute this Proposal in its entirety as submitted and enter into a contract on behalf of the Proposer. Printed Name and Position of Authorized Representative: ________________________________________ Signature of Authorized Representative: ____________________________________________ Signed this __________(day) of _________________________(month),________(year) I learned of this Request for Proposals by the following means:  Newspaper Advertisement  City E-mail Notification  Southlake Website  Cold Call to City  Mailed Me a Copy  SecureBid  Other City of Southlake - RFP1903B140CM190010 - Page 8 of 15 Appendix B – Proposal (continued) I. REQUIRED PROPOSAL INFORMATION. IN ORDER FOR A PROPOSAL TO BE CONSIDERED COMPLETE, AND TO BE EVALUATED FOR A CONTRACT AWARD BY THE CITY, PROPOSER MUST SUBMIT ALL OF THE FOLLOWING INFORMATION: 1. Proposed Products and/or Services A. Product or Service Description: Proposers should utilize this section to describe the technical aspects, capabilities, features and options of the product and/or service proposed in accordance with the required Scope of Services as identified in Appendix A. Promotional literature, brochures, or other technical information may be used. B. Additional Hardware Descriptions: Proposers should also include in this section a detailed description of what additional hardware and/or software, if any, would be required by the City in order to fully utilize the goods and/or services proposed. C. Guarantees and Warranties: Each Proposer shall submit a complete copy of any warranties or guarantees provided by the manufacturer or Proposer with the Proposal submitted. D. Project Schedule/Delivery Date: Proposer must provide a project schedule noting all projected completion dates for segments of the Project, from start-up to completion, and all delivery dates for goods covered by the RFP. The Proposal must show the number of days required to deliver and install the product or equipment after the receipt of the City’s Purchase Order. 2. Cost of Proposed Products and/or Services A. Pricing: Pricing shall reflect the full Scope of Services defined herein, inclusive of all associated cost for delivery, labor, insurance, taxes, overhead, and profit. B. Schedule of Pricing: Proposer shall quote unit pricing in accordance with the itemized listing of products or contract segments stated in the Scope of Services and using the following format: PLEASE COMPLETE ATTACHED SUBMISSION FORMS LABELED APPENDIX 1, 2, 3 3. Proposer’s Experience / Staff A. Project Team: Identify all members of the Proposer’s team (including both team members and management) who will be providing any services proposed and include information which details their experience. B. Removal or Replacement of Staff: If an assigned staff person must be removed or replaced for any reason, the replacement person must be approved by City prior to joining the project. C. Business Establishment: State the number of years the Proposer’s business has been established and operating. If Proposer’s business has changed names or if the principals operating the business operate any similar businesses under different names, or have operated any other businesses or changed the legal status or form of the business within the last five (5) years, all names, of predecessor business names, affiliated entities, and previous business entities operated by the principals, if different than present, must be provided; State the number of years’ experience the business has: _______; and the number of employees: _________. D. Project Related Experience: All Proposals must include detailed information that details the Proposer’s experience and expertise in providing the requested services that demonstrates the Proposer’s ability to logically plan and complete the requested project. City of Southlake - RFP1903B140CM190010 - Page 9 of 15 4. References Proposer shall provide four (4) references where Proposer has performed similar to or the same types of services as described herein. Reference #1: Client / Company Name: Contact Name: Contact Title: Phone: Email: Date and Scope of Work Provided: Reference #2: Client / Company Name: Contact Name: Contact Title: Phone: Email: Date and Scope of Work Provided: Reference #3: Client / Company Name: Contact Name: Contact Title: Phone: Email: Date and Scope of Work Provided: Reference #4: Client / Company Name: Contact Name: Contact Title: Phone: Email: Date and Scope of Work Provided: City of Southlake - RFP1903B140CM190010 - Page 10 of 15 5. Trade Secrets and/or Confidential Information Trade Secrets and/or Confidential Information: This proposal ___ (does) ___ (does not) contain trade secrets and/or confidential information. If applicable, describe such trade secrets and confidential information, and the basis for your assertion that such material qualifies for legal protection from disclosure. 6. Federal, State and/or Local Identification Information A. Centralized Master Bidders List registration number: ______________________________. B. Prime contractor HUB / MWBE registration number: ______________________________. C. An individual Proposer acting as a sole proprietor must also enter the Proposer’s Social Security Number: #_______-_______-_______. 7. Emergency Business Services Contact Notice During a natural disaster, or homeland security event, there may be a need for the City of Southlake to access your business for products or services after normal business hours and/or holidays. The City may request City employee pick up or vendor delivery of product or services. For this purpose, a primary and secondary emergency contact name and phone number are required. It is critical the vendor’s emergency contact information remains current. City shall be contacted by E - mail with any change to a contact name or phone number of these emergency contacts. Updates may be emailed to vendors@ci.southlake.tx.us. All products or services requested during an emergency event are to be supplied as per the established contract prices, terms and conditions. The vendor shall provide the fee (pricing) for an after-hours emergency opening of the business, if any. In general, orders will be placed using a City of Southlake procurement card (Master Card) or City issued Purchase Order. The billing is to include the emergency opening fee, if applicable. The contractor shall provide the names, phone numbers and fee (pricing), if any, for an after -hours emergency opening of the business listed below. Business Name: _____________________________________________________________________ Contract #: _________________________________________________________________________ Description: ________________________________________________________________________ Primary Contact (Name):______________________________________________________________ Primary Contact Phone Numbers: Home: ___________________ Cell: ___________________ Secondary Contact (Name):____________________________________________________________ Secondary Contact Phone Numbers: Home: ________________ ___ Cell: ___________________ After Hours emergency opening fee, if applicable: $_________________________________________ City of Southlake - RFP1903B140CM190010 - Page 11 of 15 II. CONTRACT TERMS AND CONDITIONS. EXCEPT WHERE PROPOSER MAKES SPECIFIC EXCEPTION IN THE SUBMITTED PROPOSAL, ANY CONTRACT RESULTING FROM THIS RFP WILL CONTAIN THE FOLLOWING TERMS AND CONDITIONS, WHICH PROPOSER HEREBY ACKNOWLEDGES, AND TO WHICH PROPOSER AGREES BY SUBMITTING A PROPOSAL: 1. Delivery of Products and/or Services A. Payment Terms: Unless otherwise specified in the Scope of Services or otherwise agreed to in writing by the City, payment terms for the City are Net 30 days upon receipt of invoice. B. Warranty of Products and Services: All products furnished under this contract shall be warranted to be merchantable and good quality and fit for the purposes intended as described in this Proposal, to the satisfaction of City and in accordance with the specifications, terms, and conditions of the Scope of Services, and all services performed shall be warranted to be of a good and workmanlike quality, in addition to, and not in lieu of, any other express written warranties provided. C. Late Delivery or Performance: If Proposer fails to deliver acceptable goods or services within the timeframes established in the Project Schedule, the City shall be authorized to purchase the goods or services from another source and assess any increase in costs to the defaulting Proposer, who agrees to pay such costs within ten days of invoice. D. Title to Goods and Risk of Loss: For goods to be provided by Proposers hereunder, if any, the title and risk of loss of the goods shall not pass to City until City actually receives, takes possession, and accepts the goods and the installation of such goods, has tested the system, and determined that it is in good and acceptable working order. 2. Miscellaneous A. Independent Contractor: Proposer agrees that Proposer and Proposer’s employees and agents have no employer-employee relationship with City. Proposer agrees that if Proposer is selected and awarded a contract, City shall not be responsible for the Federal Insurance Contribution Act (FICA) payments, Federal or State unemployment taxes, income tax withholding, Workers Compensation Insurance payments, or any other insurance payments, nor will City furnish any medical or retirement benefits or any paid vacation or sick leave. B. Assignments: The rights and duties awarded the successful Proposer shall not be assigned to another without the written consent of the Purchasing Manager. Such consent shall not relieve the assigner of liability in the event of default by the assignee. C. Liens: Proposer shall indemnify and save harmless the City against any and all liens and encumbrances for all labor, goods, and services which may be provided to the City by Proposer or Proposer’s vendor(s), and if the City requests, a proper release of all liens or satisfactory evidence of freedom from liens shall be delivered to the City. D. Gratuities / Bribes: Proposer certifies that no bribes in the form of entertainment, gifts, or otherwise, were offered or given by the successful Proposer, or its agent or representative, to any City officer, employee or elected representative, with respect to this RFP or any contract with the City, and that if any such bribe is found to have been made this shall be grounds for voiding of the contract. E. Financial Participation: Proposer certifies that it has not received compensation from the City to participate in preparing the specifications or RFP on which the Proposal is based and acknowledges that this contract may be terminated and/or payment withheld if this certification is inaccurate. F. Required Licenses: Proposer certifies that he holds all licenses required by the State of Texas for a provider of the goods and/or services described by the Scope of Services herein. City of Southlake - RFP1903B140CM190010 - Page 12 of 15 G. Authority to Submit Proposal and Enter Contract: The person signing on behalf of Proposer certifies that the signer has authority to submit the Proposal on behalf of the Proposer and to bind the Proposer to any resulting contract. H. Compliance with Applicable Law: Proposer agrees that the contract will be subject to, and Proposer will strictly comply with, all applicable federal, state, and local laws, ordinances, rules, and regulations. I. Compliance with HB 89: Proposer agrees per HB 89 vendor shall not boycott Israel at any time while providing products or services to the City of Southlake. [ ] Yes, we agree [ ] No, we do not agree J. Compliance with SB 252: Proposer agrees per SB 252 vendor shall not do business with Iran, Sudan or a foreign terrorist organization while providing products or services to the City of Southlake. [ ] Yes, we agree [ ] No, we do not agree 3. Financial Responsibility Provisions A. Insurance: The Proposer, consistent with its status as an independent contractor, shall carry, and shall require any of its subcontractors to carry, at least the following insurance in such form, with such companies, and in such amounts (unless otherwise specified) as City may require: i. Worker’s Compensation and Employer’s Liability insurance, including All States Endorsement, to the extent required by federal law and complying with the laws of the State of Texas; ii. Commercial General Liability insurance, including Blanket Contractual Liability, Broad Form Property Damage, Personal Injury, Completed Operations/Products Liability, Premises Liability, Medical Payments, Interest of Employees as additional insureds, and Broad Form General Liability Endorsements, for at least One Million Dollars ($1,000,000) Combined Single Limit Bodily Injury and Property Damage on an occurrence basis; iii. Comprehensive Automobile Liability insurance covering all owned, non-owned or hired automobiles to be used by the Contractor, with coverage for at least One Million Dollars ($1,000,000) Combined Single Limit Bodily Injury and Property Damage. B. Indemnification: Proposer agrees to defend, indemnify and hold harmless the City, all of its officers, Council members, agents and employees from and against all claims, actions, suits, demands, proceedings, costs, damages and liabilities, including reasonable attorneys’ fees, court costs and related expenses, arising out of, connected with, or resulting from any acts or omissions of Proposer or any agent, employee, subcontractor, or supplier of Proposer in the execution or performance of this contract without regard to whether such persons are under the direction of City agents or employees. City of Southlake - RFP1903B140CM190010 - Page 13 of 15 Appendix C – Form CIQ INFORMATION REGARDING VENDOR CONFLICT OF INTEREST QUESTIONNAIRE WHO: The following persons must file a Conflict of Interest Questionnaire with the City if the person has an employment or business relationship with an officer of the City that results in taxable income exceeding $2,500 during the preceding twelve – month period, or an officer or a member of the officer’s family has accepted gifts with an aggregate value of more than $250 during the previous twelve – month period and the person engages in any of the following actions: 1. contracts or seeks to contract for the sale or purchase of property, goods or services with the City, including any of the following: a. written and implied contracts, utility purchases, purchase orders, credit card purchases and any purchase of goods and services by the City; b. contracts for the purchase or sale of real property, personal property including an auction of property; c. tax abatement and economic development agreements; 2. submits a bid to sell goods or services, or responds to a request for proposal for services; 3. enters into negotiations with the City for a contract; or 4. applies for a tax abatement and/or economic development incentive that will result in a contract with the City THE FOLLOWING ARE CONSIDERED OFFICERS OF THE CITY: 1. Mayor and City Council Members; 2. City Manager; 3. Board and Commission members and appointed members by the Mayor and City Council; 4. Directors of 4A and 4B development corporations; 5. The executive directors or managers of 4A and 4B development corporations; and 6. Directors of the City of Southlake who have authority to sign contracts on behalf of the City. EXCLUSIONS: A questionnaire statement need not be filed if the money paid to a local government official was a political contribution, a gift to a member of the officer’s family from a family member; a contract or purchase of less than $2,500 or a transaction at a price and subject to terms available to the public; a payment for food, lodging, transportation or entertainment; or a transaction subject to rate or fee regulation by a governmental entity or agency. WHAT: A person or business that contracts with the City or who seeks to contract with the City must file a “Conflict of Interest Questionnaire” (FORM CIQ) which is available online at www.ethics.state.tx.us and a copy of which is attached to this guideline. The form contains mandatory disclosures regarding “employment or business relationships” with a municipal officer. Officials may be asked to clarify or interpret various portions of the questionnaire. WHEN: The person or business must file: 1. the questionnaire – no later than seven days after the date the person or business begins contract discussions or negotiations with the municipality, or submits an application, responds to a request for proposals or bids, correspondence, or other writing related to a potential contract or agreement with the City; and 2. an updated questionnaire – within seven days after the date of an event that would make a filed questionnaire incomplete or inaccurate. It does not matter if the submittal of a bid or proposal results in a contract. The statute requires a vendor to file a FORM CIQ at the time a proposal is submitted or negotiations commence. WHERE: The vendor or potential vendor must mail or deliver a completed questionnaire to the Finance Department. The Finance Department is required by law to post the statements on the City’s website. ENFORCEMENT: Failure to file a questionnaire is a Class C misdemeanor punishable by a fine not to exceed $500. It is an exception to prosecution that the person files a FORM CIQ not later than seven business days after the person received notice of a violation. NOTE: The City does not have a duty to ensure that a person files a Conflict of Interest Questionnaire. City of Southlake - RFP1903B140CM190010 - Page 14 of 15 City of Southlake - RFP1903B140CM190010 - Page 15 of 15 Appendix D – No Intent to Submit Form If your firm has chosen not to submit a proposal for this procurement, please complete this form and submit to: City of Southlake Purchasing Division, Department of Finance 1400 Main Street, Suite 440 Southlake, Texas 76092 Please check all items that apply:  Do not sell the item(s) required  Cannot provide Insurance required  Cannot be competitive  Cannot provide Bonding required  Cannot meet specifications highlighted in the attached request  Cannot comply with Indemnification requirement  Job too large  Job too small  Do not wish to do business with the City of Southlake  Other: _____________________  Cannot submit electronically Company Name (Please print): _____________________________________________ Authorized Officer Name (Please print): _______________________________________ Telephone: (_____) __________________ Fax: (_______) ________________________ GROUP DENTAL COVERAGE SUBMISSION FORM RFP1903B140CM190010 Page 1 of 6 APPENDIX 1 GROUP DENTAL COVERAGE RFP ASSUMPTIONS: 1. The City is seeking proposals for group dental insurance plan options. The proposal may be based on benefits similar to the current City of Southlake benefits as described in the Summary of Benefits section of the RFP. The City will consider alternative plan designs provided the benefit provisions are fully explained. 2. Benefits for all full-time employees will be considered. All dental insurance plans are to be fully insured. 3. Quote is to be based on the enclosed census for all participating active employees and COBRA participants. The City does not offer dental insurance to retirees. 4. The City currently offers a DPPO and DHMO plan. The City currently contributes $14.76/month towards the cost for DHMO employee-only coverage and $32.36/month towards the cost for DPPO employee-only coverage. Rates below are per pay period (24 pay periods): City Employee 5. The City currently has 342 full-time employees (360 budgeted). 317 employees currently elect some level of dental coverage. 6. The effective date is to be October 1, 2019. All participants enrolled in the Employee Benefits Plan as of September 30, 2019, are to be covered on the successful Proposer’s new plan. Continuity of coverage for current participants is to be on a "No Loss/No Gain" basis. In fulfilling continuity of coverage requirements, full credit must be allowed for all or any part of deductibles, coinsurance, or annual out-of-pocket maximum benefits satisfied prior to the Proposer’s contract effective date. All dental services incurred on or after October 1, 2019, for enrolled participants are to be eligible expenses. 7. The City's enrollment records are to be the basis for "take-over.” The selected provider shall supply knowledgeable employees to explain benefit provisions during enrollment meetings scheduled by the City. The selected provider will be responsible for providing enrollment materials prior to the enrollment benefit meetings. 8. The City requests monthly claims reports to be made available. GROUP DENTAL COVERAGE SUBMISSION FORM RFP1903B140CM190010 Page 2 of 6 9. The City is receptive to proposals that offer electronic enrollment services. 10. The City is requesting the option to terminate the contract during the term of the contracts or at the end of each anniversary date with sixty (60) days notice. Due to the requirement that the City publish notice and seek competitive proposals in the event of cancellation by the Proposer, however, the contracts are to contain provisions that provide that in the event the carrier intends to cancel, the carrier provides at least one hundred twenty (120) days notice of such intent to cancel (except for non-payment) and one hundred twenty (120) days notice for non-renewal or material change. 11. The City must receive renewal rates at least one hundred twenty (120) days prior to the effective date of a rate change. 12. Proposals are to be presented with standard commissions included. Please clearly state rate of commission on your proposal for full disclosure to the City. GROUP DENTAL COVERAGE SUBMISSION FORM RFP1903B140CM190010 Page 3 of 6 APPENDIX 2 GROUP DENTAL COVERAGE SUBMISSION FORM By submitting this proposal, the Proposer acknowledges the intent and conditions upon which the City plans to enter in contract. In the event that ambiguities are discovered in this final signed agreement, the Proposer accepts this RFP document as the basis for clarifying those ambiguities and establishing intent. The City will consider a wide range of dental plan options including but not limited to DHMO Plans and/or DPPO plans. Please indicate the monthly plan cost below. These figures should represent the entire cost. Twelve (12) -Month Rate Guarantee (10/1/2019 – 9/30/2020): *Attach additional plan proposals if necessary. Attach to this a summary of the plan design(s) for each proposal that includes information such as, but not limited to: • Summary of Benefits • Provider Directory • Deductible Per Person • Deductible Per Family • Maximum out-of-pocket Cost Per Person • Maximum out-of-pocket Cost Per • Office Visit Co-Pay • Preventative Services • Deviations or Exceptions from the specifications in this RFP • Authorized Agent information Family Additional Fees (Please explain) Plan #1 Plan #2 Plan #3 Employee Only $ $ $ Employee + Spouse $ $ $ Employee + Child(ren) $ $ $ Employee + Family $ $ $ GROUP DENTAL COVERAGE SUBMISSION FORM RFP1903B140CM190010 Page 4 of 6 APPENDIX 3 GROUP DENTAL COVERAGE QUESTIONS: 1) Describe organization submitting bid. a) Name of Dental Carrier ___________________________________________________ b) Address c) Contact person d) Telephone number e) Fax number f) Year founded 2) Current A.M. Best’s and rating for your company A.M. Best’s financial size classification If not rated by A.M. Best, please provide audited financial statements. 3) Provide three Texas references, preferably government entities: Client Name Contact Person Telephone # # Employees _________________ ______________ _____________ _________________ _________________ ______________ _____________ _________________ _________________ ______________ _____________ _________________ 4) Describe claim payment services. a) Where will claims be paid? ________________________________________________ b) Is a toll-free number available for checking claim status? _________________________ c) What is the normal claim-processing time? ___________________________________ 5) Describe dental predetermination of benefits procedure. _________________________________________________________________________ _________________________________________________________________________ GROUP DENTAL COVERAGE SUBMISSION FORM RFP1903B140CM190010 Page 5 of 6 6) Describe any special features of your program. _________________________________________________________________________ _________________________________________________________________________ 7) For what period of time are quoted rates guaranteed? _____________________________ 8) Is a longer rate guarantee available? ___________________________________________ If so, please indicate other rate guarantee periods and applicable adjustment to rates. _________________________________________________________________________ _________________________________________________________________________ 9) Describe renewal underwriting procedures. _________________________________________________________________________ _________________________________________________________________________ 10) Does your bid require the use of a dental network? ________________________________ If so, please provide a copy of the dental provider network for the Tarrant County area. 11) Describe services to be provided by local agent. Include address of local agent’s office and indicate agent commission included in your premium. Agent Commission: % of premium: _____________ Agent Commission: Amount: ________ Address: _____________________________________________________________________ Services: ____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ GROUP DENTAL COVERAGE SUBMISSION FORM RFP1903B140CM190010 Page 6 of 6 12) If your bid differs in any way from what is specified herein, please indicate any/all differences. Otherwise, it will be assumed that your bid conforms to these specifications in every respect. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________ ____________________________________ Company Name Authorized Signature ____________________________________ ____________________________________ Address Type Signatory's Name & Title ____________________________________ ____________________________________ Phone Number ____________________________________ ____________________________________ Date Zip Code GENDER DOB Ins. Plan Desc Ins. Coverage Desc 76180 M 04/07/1963 DENTAL PPO EMPLOYEE + SPOUSE 76020 M 06/08/1968 DENTAL PPO EMPLOYEE + FAMILY 76148 F 03/20/1966 DENTAL PPO EMPLOYEE ONLY 76148 F 07/03/1953 DENTAL PPO EMPLOYEE ONLY 76262 M 08/13/1971 DENTAL PPO EMPLOYEE + FAMILY 75075 M 05/19/1967 DENTAL PPO EMPLOYEE + FAMILY 76051 M 09/13/1953 DENTAL PPO EMPLOYEE ONLY 76012 F 08/19/1964 DENTAL PPO EMPLOYEE ONLY 76244 M 08/20/1963 DENTAL PPO EMPLOYEE + FAMILY 76078 M 07/11/1973 DENTAL PPO EMPLOYEE + FAMILY 76021 M 12/06/1962 DENTAL PPO EMPLOYEE + FAMILY 76180 F 07/21/1953 DENTAL PPO EMPLOYEE ONLY 76078 M 10/11/1969 DENTAL PPO EMPLOYEE ONLY 76244 M 02/02/1970 DENTAL PPO EMPLOYEE ONLY 76073 M 05/15/1970 DENTAL PPO EMPLOYEE + FAMILY 76180 M 10/12/1961 DENTAL PPO EMPLOYEE + SPOUSE 76137 M 03/29/1971 DENTAL PPO EMPLOYEE + FAMILY 76262 M 05/14/1971 DENTAL PPO EMPLOYEE + FAMILY 76054 F 05/22/1964 DENTAL PPO EMPLOYEE + CHILD(REN) 76063 M 11/25/1957 DENTAL PPO EMPLOYEE ONLY 76233 M 04/26/1966 DENTAL PPO EMPLOYEE + FAMILY 76208 M 02/28/1964 DENTAL PPO EMPLOYEE + SPOUSE 76073 M 01/03/1971 DENTAL PPO EMPLOYEE + FAMILY 76227 M 10/11/1970 DENTAL PPO EMPLOYEE + FAMILY 76051 M 09/10/1963 DENTAL PPO EMPLOYEE + CHILD(REN) 76230 M 10/06/1958 DENTAL PPO EMPLOYEE ONLY 76092 M 09/17/1979 DENTAL PPO EMPLOYEE ONLY 76054 M 08/13/1967 DENTAL PPO EMPLOYEE ONLY 76023 M 02/26/1966 DENTAL DHMO EMPLOYEE ONLY 76092 M 06/27/1951 DENTAL PPO EMPLOYEE + SPOUSE 75067 M 03/01/1964 DENTAL PPO EMPLOYEE ONLY 76028 M 11/20/1961 DENTAL PPO EMPLOYEE + SPOUSE 76085 M 07/14/1968 DENTAL PPO EMPLOYEE + CHILD(REN) 76262 M 08/31/1974 DENTAL PPO EMPLOYEE ONLY 76247 M 09/11/1978 DENTAL PPO EMPLOYEE + CHILD(REN) 76248 M 06/20/1972 DENTAL PPO EMPLOYEE + FAMILY 76049 M 07/17/1973 DENTAL PPO EMPLOYEE + FAMILY 76177 M 05/29/1980 DENTAL PPO EMPLOYEE ONLY 76067 M 05/22/1973 DENTAL PPO EMPLOYEE + FAMILY 76248 M 11/13/1970 DENTAL PPO EMPLOYEE + CHILD(REN) 75077 F 01/24/1971 DENTAL PPO EMPLOYEE ONLY 76051 M 04/28/1965 DENTAL PPO EMPLOYEE + FAMILY 76248 F 03/03/1964 DENTAL PPO EMPLOYEE ONLY 76092 M 10/02/1969 DENTAL PPO EMPLOYEE ONLY 76226 M 06/19/1970 DENTAL PPO EMPLOYEE + CHILD(REN) 76078 M 05/12/1957 DENTAL PPO EMPLOYEE + SPOUSE 76180 M 06/02/1976 DENTAL PPO EMPLOYEE + SPOUSE 76148 M 12/22/1978 DENTAL PPO EMPLOYEE ONLY 76092 M 10/15/1961 DENTAL PPO EMPLOYEE ONLY 76244 F 11/01/1971 DENTAL PPO EMPLOYEE + SPOUSE 75034 M 06/25/1975 DENTAL PPO EMPLOYEE + FAMILY 76247 F 10/29/1951 DENTAL PPO EMPLOYEE + SPOUSE 76180 F 10/10/1961 DENTAL PPO EMPLOYEE + SPOUSE 76182 F 07/20/1980 DENTAL PPO EMPLOYEE + CHILD(REN) 76227 M 10/02/1978 DENTAL PPO EMPLOYEE ONLY 76226 F 11/21/1977 DENTAL PPO EMPLOYEE + SPOUSE 76108 M 08/20/1962 DENTAL PPO EMPLOYEE + FAMILY 76234 M 11/25/1974 DENTAL PPO EMPLOYEE + FAMILY 76244 M 07/18/1966 DENTAL PPO EMPLOYEE + FAMILY 76248 F 11/13/1956 DENTAL PPO EMPLOYEE ONLY 76248 M 06/10/1978 DENTAL PPO EMPLOYEE + FAMILY 76179 M 05/23/1960 DENTAL PPO EMPLOYEE + SPOUSE 76255 M 10/01/1966 DENTAL PPO EMPLOYEE + FAMILY 76053 M 10/21/1949 DENTAL PPO EMPLOYEE + SPOUSE 76137 M 04/22/1964 DENTAL PPO EMPLOYEE + CHILD(REN) 76244 M 01/21/1973 DENTAL PPO EMPLOYEE + FAMILY 75056 M 12/03/1979 DENTAL PPO EMPLOYEE + CHILD(REN) 76177 M 08/22/1980 DENTAL PPO EMPLOYEE + FAMILY 76244 F 12/30/1975 DENTAL PPO EMPLOYEE + CHILD(REN) 76092 F 08/10/1955 DENTAL PPO EMPLOYEE ONLY 76060 M 11/12/1973 DENTAL PPO EMPLOYEE + SPOUSE 76244 F 12/15/1983 DENTAL PPO EMPLOYEE ONLY 76230 M 07/11/1957 DENTAL PPO EMPLOYEE ONLY 76052 M 05/03/1972 DENTAL PPO EMPLOYEE ONLY 76180 F 01/01/1971 DENTAL PPO EMPLOYEE + CHILD(REN) 76137 M 06/10/1968 DENTAL PPO EMPLOYEE + SPOUSE 76244 M 11/29/1958 DENTAL PPO EMPLOYEE ONLY 76262 M 03/17/1980 DENTAL PPO EMPLOYEE + CHILD(REN) 76137 F 07/02/1978 DENTAL PPO EMPLOYEE + CHILD(REN) 76247 F 08/24/1976 DENTAL PPO EMPLOYEE ONLY 76137 M 11/03/1982 DENTAL PPO EMPLOYEE + SPOUSE 75020 M 08/06/1981 DENTAL DHMO EMPLOYEE ONLY 76040 M 08/15/1956 DENTAL PPO EMPLOYEE ONLY 76262 M 05/12/1960 DENTAL PPO EMPLOYEE + CHILD(REN) 76021 F 04/19/1968 DENTAL PPO EMPLOYEE + FAMILY 76262 M 08/03/1980 DENTAL PPO EMPLOYEE ONLY 76244 M 07/21/1968 DENTAL PPO EMPLOYEE + FAMILY 76248 F 09/28/1968 DENTAL PPO EMPLOYEE ONLY 76053 F 08/14/1980 DENTAL PPO EMPLOYEE ONLY 76244 M 11/22/1988 DENTAL PPO EMPLOYEE + CHILD(REN) 76244 F 06/29/1972 DENTAL PPO EMPLOYEE ONLY 76248 M 06/24/1962 DENTAL PPO EMPLOYEE + FAMILY 75028 F 11/29/1970 DENTAL PPO EMPLOYEE ONLY 76051 F 02/22/1980 DENTAL DHMO EMPLOYEE + FAMILY 76248 M 01/02/1960 DENTAL PPO EMPLOYEE ONLY 76078 F 07/07/1982 DENTAL PPO EMPLOYEE + FAMILY 76180 F 12/17/1955 DENTAL PPO EMPLOYEE + SPOUSE 76116 M 07/11/1969 DENTAL PPO EMPLOYEE + FAMILY 76039 M 01/25/1972 DENTAL DHMO EMPLOYEE + CHILD(REN) 76265 M 04/28/1975 DENTAL PPO EMPLOYEE + FAMILY 76110 M 02/19/1964 DENTAL PPO EMPLOYEE ONLY 76137 M 01/20/1983 DENTAL PPO EMPLOYEE ONLY 76114 M 05/28/1966 DENTAL PPO EMPLOYEE ONLY 76226 F 11/12/1976 DENTAL PPO EMPLOYEE ONLY 76234 M 12/26/1985 DENTAL PPO EMPLOYEE + FAMILY 76244 M 08/25/1972 DENTAL PPO EMPLOYEE + SPOUSE 76248 M 09/07/1977 DENTAL PPO EMPLOYEE + CHILD(REN) 76180 F 12/09/1972 DENTAL PPO EMPLOYEE ONLY 76017 M 06/24/1957 DENTAL PPO EMPLOYEE ONLY 76052 F 04/25/1962 DENTAL PPO EMPLOYEE ONLY 76148 M 02/26/1983 DENTAL PPO EMPLOYEE + CHILD(REN) 76180 M 08/17/1988 DENTAL PPO EMPLOYEE + FAMILY 76244 M 08/10/1983 DENTAL DHMO EMPLOYEE ONLY 76247 F 07/22/1975 DENTAL PPO EMPLOYEE + CHILD(REN) 76054 F 06/26/1986 DENTAL PPO EMPLOYEE ONLY 76052 M 03/24/1980 DENTAL PPO EMPLOYEE + FAMILY 75062 M 12/26/1984 DENTAL DHMO EMPLOYEE + SPOUSE 76244 M 06/09/1969 DENTAL PPO EMPLOYEE + CHILD(REN) 76180 M 09/23/1975 DENTAL PPO EMPLOYEE + CHILD(REN) 76052 M 09/10/1975 DENTAL PPO EMPLOYEE ONLY 75067 F 05/14/1980 DENTAL PPO EMPLOYEE ONLY 76021 M 05/28/1986 DENTAL PPO EMPLOYEE ONLY 76021 F 01/28/1969 DENTAL PPO EMPLOYEE + CHILD(REN) 76131 F 03/05/1963 DENTAL PPO EMPLOYEE ONLY 76244 M 04/15/1980 DENTAL PPO EMPLOYEE + FAMILY 76092 F 12/03/1988 DENTAL PPO EMPLOYEE ONLY 76114 M 06/13/1980 DENTAL PPO EMPLOYEE + CHILD(REN) 75023 M 06/21/1970 DENTAL PPO EMPLOYEE ONLY 75060 M 07/01/1978 DENTAL DHMO EMPLOYEE + FAMILY 76262 M 06/06/1981 DENTAL PPO EMPLOYEE + FAMILY 76177 M 06/23/1984 DENTAL PPO EMPLOYEE + FAMILY 76020 M 11/17/1983 DENTAL PPO EMPLOYEE + FAMILY 75050 M 10/23/1959 DENTAL PPO EMPLOYEE + SPOUSE 76247 F 01/13/1996 DENTAL PPO EMPLOYEE ONLY 76182 F 01/30/1959 DENTAL PPO EMPLOYEE ONLY 76078 M 04/23/1985 DENTAL PPO EMPLOYEE + CHILD(REN) 76051 M 12/18/1986 DENTAL PPO EMPLOYEE ONLY 76051 M 11/13/1975 DENTAL PPO EMPLOYEE ONLY 76262 M 05/03/1971 DENTAL PPO EMPLOYEE + CHILD(REN) 76131 M 01/04/1986 DENTAL PPO EMPLOYEE + SPOUSE 76244 M 12/18/1961 DENTAL PPO EMPLOYEE ONLY 76016 M 06/10/1982 DENTAL PPO EMPLOYEE + FAMILY 76247 M 07/08/1984 DENTAL PPO EMPLOYEE ONLY 75077 M 05/03/1989 DENTAL PPO EMPLOYEE + FAMILY 76065 M 10/01/1985 DENTAL PPO EMPLOYEE + FAMILY 76131 M 09/09/1987 DENTAL PPO EMPLOYEE ONLY 76177 M 01/04/1988 DENTAL PPO EMPLOYEE + FAMILY 76137 M 12/17/1981 DENTAL PPO EMPLOYEE ONLY 76248 M 08/15/1974 DENTAL PPO EMPLOYEE + FAMILY 76266 M 12/18/1986 DENTAL PPO EMPLOYEE + SPOUSE 76052 M 05/01/1981 DENTAL PPO EMPLOYEE ONLY 75158 M 03/16/1991 DENTAL PPO EMPLOYEE ONLY 76266 M 07/29/1987 DENTAL PPO EMPLOYEE + FAMILY 76262 F 04/08/1965 DENTAL PPO EMPLOYEE ONLY 76013 M 10/31/1982 DENTAL PPO EMPLOYEE + FAMILY 76262 M 10/05/1987 DENTAL PPO EMPLOYEE ONLY 76137 M 07/05/1983 DENTAL PPO EMPLOYEE + CHILD(REN) 75219 M 02/24/1990 DENTAL PPO EMPLOYEE ONLY 76092 F 10/30/1962 DENTAL PPO EMPLOYEE + FAMILY 75048 M 03/02/1984 DENTAL PPO EMPLOYEE ONLY 76137 M 04/22/1986 DENTAL PPO EMPLOYEE ONLY 76092 F 05/07/1969 DENTAL PPO EMPLOYEE ONLY 76226 M 06/14/1958 DENTAL PPO EMPLOYEE + CHILD(REN) 76248 M 06/19/1951 DENTAL PPO EMPLOYEE + SPOUSE 76179 F 02/09/1973 DENTAL PPO EMPLOYEE + CHILD(REN) 75215 F 12/28/1991 DENTAL PPO EMPLOYEE + SPOUSE 76262 F 02/19/1991 DENTAL PPO EMPLOYEE ONLY 76023 F 08/05/1981 DENTAL PPO EMPLOYEE ONLY 76148 M 02/05/1986 DENTAL PPO EMPLOYEE + CHILD(REN) 76010 M 01/01/1980 DENTAL PPO EMPLOYEE ONLY 76137 M 08/13/1989 DENTAL PPO EMPLOYEE ONLY 76271 M 03/28/1989 DENTAL PPO EMPLOYEE + FAMILY 76087 M 06/21/1986 DENTAL PPO EMPLOYEE + FAMILY 76179 F 10/02/1987 DENTAL PPO EMPLOYEE + SPOUSE 76002 M 05/30/1978 DENTAL PPO EMPLOYEE + FAMILY 76262 F 07/08/1988 DENTAL DHMO EMPLOYEE + CHILD(REN) 76028 M 09/22/1969 DENTAL PPO EMPLOYEE ONLY 76244 M 12/07/1986 DENTAL PPO EMPLOYEE + SPOUSE 76248 M 10/25/1978 DENTAL DHMO EMPLOYEE + FAMILY 76131 M 12/11/1986 DENTAL DHMO EMPLOYEE + FAMILY 76262 M 11/20/1988 DENTAL PPO EMPLOYEE + FAMILY 76137 M 04/15/1988 DENTAL PPO EMPLOYEE + SPOUSE 76248 M 03/29/1981 DENTAL PPO EMPLOYEE + FAMILY 76034 M 09/05/1990 DENTAL PPO EMPLOYEE ONLY 76118 M 06/11/1967 DENTAL PPO EMPLOYEE + CHILD(REN) 75019 F 09/17/1972 DENTAL PPO EMPLOYEE + FAMILY 76054 F 12/28/1974 DENTAL PPO EMPLOYEE + FAMILY 76177 F 04/15/1975 DENTAL PPO EMPLOYEE ONLY 75061 F 06/22/1975 DENTAL PPO EMPLOYEE ONLY 75244 F 07/10/1979 DENTAL PPO EMPLOYEE + CHILD(REN) 76131 M 06/03/1993 DENTAL PPO EMPLOYEE ONLY 75009 M 11/08/1991 DENTAL PPO EMPLOYEE ONLY 76248 M 11/21/1985 DENTAL PPO EMPLOYEE ONLY 76117 M 12/18/1995 DENTAL PPO EMPLOYEE ONLY 76262 M 06/15/1983 DENTAL PPO EMPLOYEE ONLY 76248 M 01/02/1986 DENTAL PPO EMPLOYEE + FAMILY 76248 F 06/19/1993 DENTAL PPO EMPLOYEE ONLY 75062 M 04/11/1982 DENTAL PPO EMPLOYEE + FAMILY 76135 M 01/20/1990 DENTAL PPO EMPLOYEE + FAMILY 76180 F 06/24/1986 DENTAL PPO EMPLOYEE ONLY 76131 M 10/02/1993 DENTAL DHMO EMPLOYEE ONLY 75154 M 02/28/1983 DENTAL PPO EMPLOYEE + FAMILY 76028 M 12/12/1985 DENTAL PPO EMPLOYEE ONLY 76087 M 08/05/1992 DENTAL PPO EMPLOYEE ONLY 76180 M 03/07/1969 DENTAL PPO EMPLOYEE + CHILD(REN) 76180 F 07/08/1988 DENTAL PPO EMPLOYEE ONLY 75077 F 08/16/1960 DENTAL PPO EMPLOYEE + SPOUSE 76049 M 03/25/1985 DENTAL PPO EMPLOYEE + CHILD(REN) 76209 M 08/21/1991 DENTAL PPO EMPLOYEE ONLY 76148 M 05/17/1968 DENTAL DHMO EMPLOYEE + CHILD(REN) 76085 M 11/02/1988 DENTAL PPO EMPLOYEE ONLY 76177 F 02/02/1983 DENTAL PPO EMPLOYEE ONLY 76052 M 04/27/1989 DENTAL PPO EMPLOYEE + FAMILY 76022 M 08/12/1988 DENTAL DHMO EMPLOYEE ONLY 76137 F 12/10/1976 DENTAL PPO EMPLOYEE + CHILD(REN) 76051 F 01/24/1994 DENTAL PPO EMPLOYEE ONLY 76082 M 02/15/1967 DENTAL PPO EMPLOYEE ONLY 76262 M 10/22/1963 DENTAL DHMO EMPLOYEE ONLY 76092 M 10/26/1970 DENTAL PPO EMPLOYEE + FAMILY 76051 F 09/12/1988 DENTAL PPO EMPLOYEE ONLY 76262 M 10/10/1980 DENTAL PPO EMPLOYEE + FAMILY 75077 M 05/16/1977 DENTAL PPO EMPLOYEE + FAMILY 76244 M 10/03/1991 DENTAL PPO EMPLOYEE + SPOUSE 75075 M 01/24/1961 DENTAL PPO EMPLOYEE + FAMILY 76182 M 11/03/1986 DENTAL DHMO EMPLOYEE ONLY 76140 F 08/26/1983 DENTAL PPO EMPLOYEE ONLY 76053 F 10/17/1991 DENTAL PPO EMPLOYEE ONLY 76244 M 07/14/1986 DENTAL PPO EMPLOYEE ONLY 76177 M 03/12/1988 DENTAL PPO EMPLOYEE ONLY 75061 M 08/27/1985 DENTAL PPO EMPLOYEE + FAMILY 76262 F 12/21/1966 DENTAL PPO EMPLOYEE + SPOUSE 75039 M 04/15/1992 DENTAL PPO EMPLOYEE ONLY 76177 F 10/01/1960 DENTAL PPO EMPLOYEE ONLY 76180 M 03/24/1988 DENTAL PPO EMPLOYEE ONLY 76227 M 06/08/1982 DENTAL PPO EMPLOYEE + CHILD(REN) 76071 M 06/30/1992 DENTAL PPO EMPLOYEE + SPOUSE 76227 M 10/21/1990 DENTAL PPO EMPLOYEE + SPOUSE 75022 F 10/01/1973 DENTAL PPO EMPLOYEE + FAMILY 76476 M 06/12/1996 DENTAL PPO EMPLOYEE ONLY 76244 M 10/15/1984 DENTAL PPO EMPLOYEE + CHILD(REN) 76205 M 12/02/1987 DENTAL PPO EMPLOYEE ONLY 75189 M 05/03/1987 DENTAL DHMO EMPLOYEE ONLY 75234 M 07/26/1988 DENTAL PPO EMPLOYEE ONLY 75023 M 04/11/1993 DENTAL PPO EMPLOYEE ONLY 75201 F 01/04/1994 DENTAL PPO EMPLOYEE ONLY 76033 F 08/14/1975 DENTAL PPO EMPLOYEE + CHILD(REN) 76177 M 04/27/1978 DENTAL PPO EMPLOYEE ONLY 76021 M 06/27/1968 DENTAL PPO EMPLOYEE + FAMILY 76063 F 05/23/1995 DENTAL PPO EMPLOYEE ONLY 76182 M 02/12/1980 DENTAL PPO EMPLOYEE + CHILD(REN) 76271 M 08/31/1968 DENTAL PPO EMPLOYEE + FAMILY 76244 M 08/23/1971 DENTAL PPO EMPLOYEE + CHILD(REN) 76248 M 05/05/1998 DENTAL PPO EMPLOYEE ONLY 76131 F 11/12/1971 DENTAL DHMO EMPLOYEE + CHILD(REN) 76137 M 04/05/1961 DENTAL PPO EMPLOYEE + FAMILY 76051 M 06/27/1964 DENTAL PPO EMPLOYEE ONLY 76131 F 07/08/1992 DENTAL PPO EMPLOYEE ONLY 76039 F 02/12/1974 DENTAL PPO EMPLOYEE ONLY 76013 F 05/01/1986 DENTAL PPO EMPLOYEE ONLY 76039 F 10/08/1987 DENTAL PPO EMPLOYEE + FAMILY 76021 F 12/13/1988 DENTAL DHMO EMPLOYEE + CHILD(REN) 76023 M 05/04/1989 DENTAL PPO EMPLOYEE ONLY 76262 M 04/03/1990 DENTAL DHMO EMPLOYEE + FAMILY 76051 F 09/21/1992 DENTAL PPO EMPLOYEE ONLY 76248 M 05/04/1979 DENTAL PPO EMPLOYEE + FAMILY 76051 F 01/29/1961 DENTAL PPO EMPLOYEE + CHILD(REN) 76247 F 04/24/1991 DENTAL PPO EMPLOYEE + CHILD(REN) 76137 M 04/03/1996 DENTAL PPO EMPLOYEE ONLY 76092 F 07/06/1977 DENTAL PPO EMPLOYEE + CHILD(REN) 75063 M 05/02/1990 DENTAL PPO EMPLOYEE ONLY 76092 M 03/14/1984 DENTAL PPO EMPLOYEE + FAMILY 76247 F 07/15/1975 DENTAL PPO EMPLOYEE ONLY 76262 F 03/16/1981 DENTAL PPO EMPLOYEE + SPOUSE 75009 M 02/17/1989 DENTAL PPO EMPLOYEE ONLY 76180 M 09/05/1993 DENTAL PPO EMPLOYEE ONLY 76051 M 11/25/1985 DENTAL PPO EMPLOYEE ONLY 76209 M 08/12/1994 DENTAL PPO EMPLOYEE ONLY 76209 F 04/30/1990 DENTAL PPO EMPLOYEE ONLY 75001 F 11/02/1982 DENTAL PPO EMPLOYEE ONLY 76209 M 01/23/1987 DENTAL PPO EMPLOYEE ONLY 75065 M 05/28/1974 DENTAL PPO EMPLOYEE + FAMILY 76092 M 07/15/1986 DENTAL PPO EMPLOYEE ONLY 76054 M 03/29/1982 DENTAL PPO EMPLOYEE ONLY 76182 M 07/17/1993 DENTAL PPO EMPLOYEE ONLY 76054 M 10/11/1982 DENTAL PPO EMPLOYEE ONLY 75098 F 02/09/1989 DENTAL DHMO EMPLOYEE ONLY 76020 F 02/05/1970 DENTAL PPO EMPLOYEE ONLY 76053 F 11/19/1980 DENTAL DHMO EMPLOYEE + FAMILY 76095 F 05/31/1981 DENTAL DHMO EMPLOYEE ONLY 76431 M 01/12/1993 DENTAL DHMO EMPLOYEE ONLY 76053 M 09/16/1967 DENTAL DHMO EMPLOYEE + FAMILY 76053 F 05/05/1986 DENTAL PPO EMPLOYEE ONLY 76021 F 11/03/1993 DENTAL PPO EMPLOYEE ONLY 76248 M 08/06/1987 DENTAL PPO EMPLOYEE ONLY 75039 F 08/31/1992 DENTAL DHMO EMPLOYEE ONLY 76248 M 04/18/1993 DENTAL DHMO EMPLOYEE + SPOUSE 76051 M 07/03/1985 DENTAL PPO EMPLOYEE ONLY 75071 M 07/18/1977 DENTAL PPO EMPLOYEE + FAMILY 76148 F 08/26/1970 DENTAL PPO EMPLOYEE ONLY 76262 M 04/23/1989 DENTAL DHMO EMPLOYEE ONLY 76226 M 09/16/1982 DENTAL PPO EMPLOYEE ONLY 75243 F 08/28/1989 DENTAL PPO EMPLOYEE ONLY 76092 M 04/09/1960 DENTAL PPO EMPLOYEE + CHILD(REN) 76182 M 05/18/1986 DENTAL PPO EMPLOYEE + SPOUSE 76112 F 03/21/1979 DENTAL PPO EMPLOYEE ONLY 76021 M 09/04/1987 DENTAL DHMO EMPLOYEE ONLY 76085 M 07/25/1988 DENTAL PPO EMPLOYEE + FAMILY 76014 M 11/20/1991 DENTAL PPO EMPLOYEE ONLY 76022 M 11/15/1970 DENTAL DHMO EMPLOYEE + FAMILY 76182 M 04/09/1957 DENTAL PPO EMPLOYEE ONLY 75039 F 04/19/1994 DENTAL DHMO EMPLOYEE ONLY 76135 F 06/25/1963 DENTAL DHMO EMPLOYEE ONLY 76227 M 10/27/1959 DENTAL PPO EMPLOYEE + SPOUSE 76108 F 05/14/1988 DENTAL PPO EMPLOYEE ONLY 76180 M 02/06/1996 DENTAL PPO EMPLOYEE ONLY 76021 M 02/27/1971 DENTAL PPO EMPLOYEE ONLY 76177 M 12/29/1994 DENTAL DHMO EMPLOYEE ONLY SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* MET245 GCERT2012-DHMO-SOB TX 1 01/15 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and Your Dependent’s costs may include Co-Payments for a Covered Service. *Care under this plan is provided through a network of Selected General Dentists. Your Selected General Dentist is responsible for determining when the services of a Specialty Care Dentist are needed, and facilitating any necessary referral. You and Your Dependents will be advised of the name, address and telephone number of the Specialty Care Dentist in Your or Your Dependent’s Service Area. Missed Appointments: If You or Your Dependents need to cancel or reschedule an appointment, please notify the Selected General Dental Office as far in advance as possible. This will allow the Selected General Dental Office to accommodate another person in need of attention. If You or Your Dependents fail to do this in a timely fashion, You or Your Dependents may be charged a missed appointment fee. Service Your and Your Dependent’s Co-Payment Office visit - per visit (including all fees for sterilization and/or infection control) $5 Code Service Your and Your Dependent’s Co-Payment Diagnostic Treatment D0120 Periodic oral evaluation - established patient $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0 D0150 Comprehensive oral evaluation - new or established patient $0 D0160 Detailed and extensive oral evaluation - problem focused, by report $0 D0170 Re-evaluation - limited, problem focused (established patient; not post- operative visit) $0 D0171 Re-evaluation – post-operative office visit $0 D0180 Comprehensive periodontal evaluation - new or established patient $0 D0190 Screening of a patient $0 D0191 Assessment of a patient $0 Radiographs / Diagnostic Imaging (X-rays) D0210 Intraoral – complete series of radiographic images $0 D0220 Intraoral – periapical first radiographic image $0 D0230 Intraoral – periapical each additional radiographic image $0 D0240 Intraoral – occlusal radiographic image $0 D0250 Extraoral – first radiographic image $0 D0260 Extraoral – each additional radiographic image $0 D0270 Bitewing – single radiographic image $0 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 2 Code Service Your and Your Dependent’s Co-Payment D0272 Bitewings – two radiographic images $0 D0273 Bitewings – three radiographic images $0 D0274 Bitewings – four radiographic images $0 D0277 Vertical bitewings – 7 to 8 radiographic images $0 D0330 Panoramic radiographic image $0 D0340 Cephalometric radiographic image $0 D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $0 D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw $180 D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible $180 D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium $180 D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium $180 D0380 Cone beam CT image capture with limited field of view – less than one whole jaw $180 D0381 Cone beam CT image capture with field of view of one full dental arch – mandible $180 D0382 Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium $180 D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium $180 D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report $0 Tests and Examinations D0415 Collection of microorganisms for culture and sensitivity $0 D0425 Caries susceptibility tests $0 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures $50 D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 D0472 Accession of tissue, gross examination, preparation and transmission of written report $0 D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report $0 D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report $0 D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report $0 D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report $0 D0502 Other oral pathology procedures, by report $0 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 3 Code Service Your and Your Dependent’s Co-Payment Preventive Services D1110 Prophylaxis – adult $0 Additional-adult prophylaxis (maximum of 2 additional per year) $35 D1120 Prophylaxis – child $0 Additional-child prophylaxis (maximum of 2 additional per year) $25 D1206 Topical application of fluoride varnish $0 D1208 Topical application of fluoride – excluding varnish $0 D1310 Nutritional counseling for control of dental disease $0 D1320 Tobacco counseling for the control and prevention of oral disease $0 D1330 Oral hygiene instructions $0 Includes periodontal hygiene instruction D1351 Sealant – per tooth $0 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $0 D1353 Sealant repair - per tooth $0 D1510 Space maintainer – fixed – unilateral $25 D1515 Space maintainer – fixed – bilateral $25 D1520 Space maintainer – removable – unilateral $35 D1525 Space maintainer – removable – bilateral $35 D1550 Re-cement or re-bond space maintainer $15 D1555 Removal of fixed space maintainer $15 Restorative Treatment D2140 Amalgam – one surface, primary or permanent $0 D2150 Amalgam – two surfaces, primary or permanent $0 D2160 Amalgam – three surfaces, primary or permanent $0 D2161 Amalgam – four or more surfaces, primary or permanent $0 D2330 Resin-based composite – one surface, anterior $0 D2331 Resin-based composite – two surfaces, anterior $0 D2332 Resin-based composite – three surfaces, anterior $0 D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) $0 D2390 Resin-based composite crown, anterior $30 D2391 Resin-based composite – one surface, posterior $30 D2392 Resin-based composite – two surfaces, posterior $45 D2393 Resin-based composite – three surfaces, posterior $65 D2394 Resin-based composite – four or more surfaces, posterior $65 Crowns An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co- Payment per molar, for the use of porcelain. Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D2510 Inlay – metallic – one surface $225 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 4 Code Service Your and Your Dependent’s Co-Payment D2520 Inlay – metallic – two surfaces $235 D2530 Inlay – metallic – three or more surfaces $245 D2542 Onlay – metallic – two surfaces $245 D2543 Onlay – metallic – three surfaces $260 D2544 Onlay – metallic – four or more surfaces $270 D2610 Inlay – porcelain/ceramic – one surface $245 D2620 Inlay – porcelain/ceramic – two surfaces $245 D2630 Inlay – porcelain/ceramic – three or more surfaces $245 D2642 Onlay – porcelain/ceramic – two surfaces $245 D2643 Onlay – porcelain/ceramic – three surfaces $245 D2644 Onlay – porcelain/ceramic – four or more surfaces $245 D2650 Inlay – resin-based composite – one surface $245 D2651 Inlay – resin-based composite – two surfaces $245 D2652 Inlay – resin-based composite – three or more surfaces $245 D2662 Onlay – resin-based composite – two surfaces $245 D2663 Onlay – resin-based composite – three surfaces $245 D2664 Onlay – resin-based composite – four or more surfaces $245 D2710 Crown – resin-based composite (indirect) $245 D2712 Crown – ¾ resin-based composite (indirect) $245 D2720 Crown – resin with high noble metal $245 D2721 Crown – resin with predominantly base metal $245 D2722 Crown – resin with noble metal $245 D2740 Crown – porcelain/ceramic substrate $245 D2750 Crown – porcelain fused to high noble metal $245 D2751 Crown – porcelain fused to predominantly base metal $245 D2752 Crown – porcelain fused to noble metal $245 D2780 Crown – ¾ cast high noble metal $245 D2781 Crown – ¾ cast predominantly base metal $245 D2782 Crown – ¾ cast noble metal $245 D2783 Crown – ¾ porcelain/ceramic $245 D2790 Crown – full cast high noble metal $245 D2791 Crown – full cast predominantly base metal $245 D2792 Crown – full cast noble metal $245 D2794 Crown – titanium $245 D2799 Provisional crown – further treatment or completion of diagnosis necessary prior to final impression $70 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $0 D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core $0 D2920 Re-cement or re-bond crown $0 D2930 Prefabricated stainless steel crown – primary tooth $25 D2931 Prefabricated stainless steel crown – permanent tooth $25 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 5 Code Service Your and Your Dependent’s Co-Payment D2932 Prefabricated resin crown $45 D2933 Prefabricated stainless steel crown with resin window $45 D2940 Protective restoration $0 D2941 Interim therapeutic restoration - primary dentition $0 D2950 Core buildup, including any pins when required $70 D2951 Pin retention – per tooth, in addition to restoration $10 D2952 Post and core in addition to crown, indirectly fabricated $50 D2953 Each additional indirectly fabricated post – same tooth $50 D2954 Prefabricated post and core in addition to crown $30 D2955 Post removal $10 D2957 Each additional prefabricated post – same tooth $30 D2960 Labial veneer (resin laminate) – chairside $250 D2961 Labial veneer (resin laminate) – laboratory $300 D2962 Labial veneer (porcelain laminate) – laboratory $350 D2970 Temporary crown (fractured tooth) $0 D2971 Additional procedures to construct new crown under existing partial denture framework $50 D2980 Crown repair necessitated by restorative material failure $0 D2981 Inlay repair necessitated by restorative material failure $0 D2982 Onlay repair necessitated by restorative material failure $0 D2983 Veneer repair necessitated by restorative material failure $0 D2990 Resin infiltration of incipient smooth surface lesions $0 Endodontics All procedures exclude final restoration. D3110 Pulp cap – direct (excluding final restoration) $5 D3120 Pulp cap – indirect (excluding final restoration) $5 D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament $30 D3221 Pulpal debridement, primary and permanent teeth $55 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $30 D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) $40 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) $40 D3310 Endodontic therapy, anterior tooth (excluding final restoration) $100 D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $152 D3330 Endodontic therapy, molar tooth (excluding final restoration) $210 D3331 Treatment of root canal obstruction; non-surgical access $85 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $96 D3333 Internal root repair of perforation defects $85 D3346 Retreatment of previous root canal therapy – anterior $180 D3347 Retreatment of previous root canal therapy – bicuspid $280 D3348 Retreatment of previous root canal therapy – molar $325 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 6 Code Service Your and Your Dependent’s Co-Payment D3351 Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.) $70 D3352 Apexification/recalcification – interim medication replacement $70 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) $70 D3355 Pulpal regeneration - initial visit $70 D3356 Pulpal regeneration - interim medication replacement $35 D3357 Pulpal regeneration - completion of treatment $70 D3410 Apicoectomy – anterior $95 D3421 Apicoectomy – bicuspid (first root) $95 D3425 Apicoectomy – molar (first root) $95 D3426 Apicoectomy (each additional root) $60 D3427 Periradicular surgery without apicoectomy $71 D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site $180 D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site $95 D3430 Retrograde filling – per root $60 D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery $95 D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery $215 D3450 Root amputation – per root $95 D3460 Endodontic endosseous implant $555 D3910 Surgical procedure for isolation of tooth with rubber dam $0 D3920 Hemisection (including any root removal), not including root canal therapy $90 D3950 Canal preparation and fitting of preformed dowel or post $15 Periodontics Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant $110 D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant $83 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth $25 D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant $150 D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant $113 D4245 Apically positioned flap $165 D4249 Clinical crown lengthening – hard tissue $150 D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant $300 D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant $225 D4263 Bone replacement graft – first site in quadrant $180 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 7 Code Service Your and Your Dependent’s Co-Payment D4264 Bone replacement graft – each additional site in quadrant $95 D4265 Biologic materials to aid in soft and osseous tissue regeneration $95 D4266 Guided tissue regeneration – resorbable barrier, per site $215 D4267 Guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal) $255 D4268 Surgical revision procedure, per tooth $0 D4270 Pedicle soft tissue graft procedure $245 D4273 Subepithelial connective tissue graft procedures, per tooth $75 D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $100 D4275 Soft tissue allograft $380 D4276 Combined connective tissue and double pedicle graft, per tooth $75 D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in a graft $245 D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site $123 D4320 Provisional splinting – intracoronal $95 D4321 Provisional splinting – extracoronal $85 D4341 Periodontal scaling and root planing – four or more teeth per quadrant $50 D4342 Periodontal scaling and root planing – one to three teeth per quadrant $38 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $50 D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth $65 D4910 Periodontal maintenance $40 D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) $0 Additional periodontal maintenance procedures (beyond 2 per 12 months) $55 Removable Prosthodontics Delivery of removable and fixed Prosthodontics includes up to 3 adjustments within 6 months of delivery date of service. D5110 Complete denture – maxillary $325 D5120 Complete denture – mandibular $325 D5130 Immediate denture – maxillary $350 D5140 Immediate denture – mandibular $350 D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) $400 D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) $400 D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $425 D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth $425 D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) $425 D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) $425 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 8 Code Service Your and Your Dependent’s Co-Payment D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth) $300 D5410 Adjust complete denture – maxillary $10 D5411 Adjust complete denture – mandibular $10 D5421 Adjust partial denture – maxillary $10 D5422 Adjust partial denture – mandibular $10 D5510 Repair broken complete denture base $35 D5520 Replace missing or broken teeth – complete denture (each tooth) $35 D5610 Repair resin denture base $35 D5620 Repair cast framework $35 D5630 Repair or replace broken clasp $35 D5640 Replace broken teeth – per tooth $35 D5650 Add tooth to existing partial denture $35 D5660 Add clasp to existing partial denture $35 D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $165 D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $165 D5710 Rebase complete maxillary denture $75 D5711 Rebase complete mandibular denture $75 D5720 Rebase maxillary partial denture $75 D5721 Rebase mandibular partial denture $75 D5730 Reline complete maxillary denture (chairside) $65 D5731 Reline complete mandibular denture (chairside) $65 D5740 Reline maxillary partial denture (chairside) $65 D5741 Reline mandibular partial denture (chairside) $65 D5750 Reline complete maxillary denture (laboratory) $85 D5751 Reline complete mandibular denture (laboratory) $85 D5760 Reline maxillary partial denture (laboratory) $85 D5761 Reline mandibular partial denture (laboratory) $85 D5810 Interim complete denture (maxillary) $230 D5811 Interim complete denture (mandibular) $230 D5820 Interim partial denture (maxillary) $160 D5821 Interim partial denture (mandibular) $170 D5850 Tissue conditioning, maxillary $20 D5851 Tissue conditioning, mandibular $20 D5862 Precision attachment, by report $160 Implant Services Pre-Surgical Services D6190 Radiographic/surgical implant index, by report $130 Surgical Services D6010 Surgical placement of implant body: endosteal implant $1,005 D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant $770 D6013 Surgical placement of mini implant $1,005 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 9 Code Service Your and Your Dependent’s Co-Payment D6040 Surgical placement: eposteal implant $1,860 D6050 Surgical placement: transosteal implant $1,170 D6051 Interim abutment $123 D6052 Semi-precision attachment abutment $335 D6100 Implant removal, by report $240 D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure $34 D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure $68 D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure. Placement of a barrier membrane or biologic materials to aid in osseous regeneration are reported separately $100 D6104 Bone graft at time of implant placement $100 Implant Supported Prosthetics • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co- Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D6055 Connecting bar – implant supported or abutment supported $345 D6056 Prefabricated abutment – includes modification and placement $245 D6057 Custom fabricated abutment – includes placement $335 D6058 Abutment supported porcelain/ceramic crown $685 D6059 Abutment supported porcelain fused to metal crown (high noble metal) $660 D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $640 D6061 Abutment supported porcelain fused to metal crown (noble metal) $645 D6062 Abutment supported cast metal crown (high noble metal) $655 D6063 Abutment supported cast metal crown (predominantly base metal) $640 D6064 Abutment supported cast metal crown (noble metal) $720 D6065 Implant supported porcelain/ceramic crown $725 D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $700 D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) $725 D6068 Abutment supported retainer for porcelain/ceramic FPD $680 D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $680 D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $595 D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) $635 D6072 Abutment supported retainer for cast metal FPD (high noble metal) $625 D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) $445 D6074 Abutment supported retainer for cast metal FPD (noble metal) $640 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 10 Code Service Your and Your Dependent’s Co-Payment D6075 Implant supported retainer for ceramic FPD $720 D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) $700 D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) $510 D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prosthesis and abutments $55 D6090 Repair implant supported prosthesis, by report $190 D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment $170 D6092 Re-cement or re-bond implant/abutment supported crown $50 D6093 Re-cement or re-bond implant/abutment supported fixed partial denture $70 D6094 Abutment supported crown (titanium) $650 D6095 Repair implant abutment, by report $140 D6110 Implant/abutment supported removable denture for edentulous arch-maxillary $995 D6111 Implant/abutment supported removable denture for edentulous arch- mandibular $995 D6112 Implant/abutment supported removable denture for partially edentulous arch- maxillary $945 D6113 Implant/abutment supported removable denture for partially edentulous arch- mandibular $945 D6114 Implant/abutment supported fixed denture for edentulous arch-maxillary $2,380 D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular $2,380 D6116 Implant/abutment supported fixed denture for partially edentulous arch- maxillary $1,410 D6117 Implant/abutment supported fixed denture for partially edentulous arch- mandibular $1,410 D6194 Abutment supported retainer crown for FPD (titanium) $520 Crowns/Fixed Bridges - Per Unit • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co- Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D6205 Pontic – indirect resin based composite $245 D6210 Pontic – cast high noble metal $245 D6211 Pontic – cast predominantly base metal $245 D6212 Pontic – cast noble metal $245 D6214 Pontic – titanium $245 D6240 Pontic – porcelain fused to high noble metal $245 D6241 Pontic – porcelain fused to predominantly base metal $245 D6242 Pontic – porcelain fused to noble metal $245 D6245 Pontic – porcelain/ceramic $265 D6250 Pontic – resin with high noble metal $245 D6251 Pontic – resin with predominantly base metal $245 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 11 Code Service Your and Your Dependent’s Co-Payment D6252 Pontic – resin with noble metal $245 D6253 Provisional pontic – further treatment or completion of diagnosis necessary prior to final impression $70 D6545 Retainer – cast metal for resin bonded fixed prosthesis $100 D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis $100 D6549 Resin retainer – for resin bonded fixed prosthesis $75 D6600 Inlay – porcelain/ceramic, two surfaces $245 D6601 Inlay – porcelain/ceramic, three or more surfaces $245 D6602 Inlay – cast high noble metal, two surfaces $245 D6603 Inlay – cast high noble metal, three or more surfaces $245 D6604 Inlay – cast predominantly base metal, two surfaces $245 D6605 Inlay – cast predominantly base metal, three or more surfaces $245 D6606 Inlay – cast noble metal, two surfaces $245 D6607 Inlay – cast noble metal, three or more surfaces $245 D6608 Onlay – porcelain/ceramic, two surfaces $245 D6609 Onlay – porcelain/ceramic, three or more surfaces $245 D6610 Onlay – cast high noble metal, two surfaces $245 D6611 Onlay – cast high noble metal, three or more surfaces $245 D6612 Onlay – cast predominantly base metal, two surfaces $245 D6613 Onlay – cast predominantly base metal, three or more surfaces $245 D6614 Onlay – cast noble metal, two surfaces $245 D6615 Onlay – cast noble metal, three or more surfaces $245 D6624 Inlay – titanium $245 D6634 Onlay – titanium $245 D6710 Crown – indirect resin based composite $245 D6720 Crown – resin with high noble metal $245 D6721 Crown – resin with predominantly base metal $245 D6722 Crown – resin with noble metal $245 D6740 Crown – porcelain/ceramic $245 D6750 Crown – porcelain fused to high noble metal $245 D6751 Crown – porcelain fused to predominantly base metal $245 D6752 Crown – porcelain fused to noble metal $245 D6780 Crown – ¾ cast high noble metal $245 D6781 Crown – ¾ cast predominantly base metal $245 D6782 Crown – ¾ cast noble metal $245 D6783 Crown – ¾ porcelain/ceramic $245 D6790 Crown – full cast high noble metal $245 D6791 Crown – full cast predominantly base metal $245 D6792 Crown – full cast noble metal $245 D6793 Provisional retainer crown – further treatment or completion of diagnosis necessary prior to final impression $70 D6794 Crown – titanium $245 D6930 Re-cement or re-bond fixed partial denture $0 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 12 Code Service Your and Your Dependent’s Co-Payment D6940 Stress breaker $110 D6950 Precision attachment $195 D6980 Fixed partial denture repair necessitated by restorative material failure $45 Oral Surgery • Includes routine post operative visits/treatment. • The removal of asymptomatic third molars is not a Covered Service unless pathology (disease) exists. D7111 Extraction, coronal remnants – deciduous tooth $5 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $5 D7210 Surgical removal of erupted tooth requiring removal of bone and/or section ing of tooth and including elevation of mucoperiosteal flap if indicated $30 D7220 Removal of impacted tooth – soft tissue $50 D7230 Removal of impacted tooth – partially bony $65 D7240 Removal of impacted tooth – completely bony $80 D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $100 D7250 Surgical removal of residual tooth roots (cutting procedure) $40 D7251 Coronectomy – intentional partial tooth removal $80 D7260 Oroantral fistula closure $270 D7261 Primary closure of a sinus perforation $275 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $50 D7280 Surgical access of an unerupted tooth $100 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $90 D7283 Placement of device to facilitate eruption of impacted tooth $90 D7285 Incisional biopsy of oral tissue – hard (bone, tooth) $150 D7286 Incisional biopsy of oral tissue – soft $60 D7287 Exfoliative cytological sample collection $50 D7288 Brush biopsy – transepithelial sample collection $50 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $40 D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $40 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant $15 D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant $60 D7321 Alveoloplasty not in conjunction with extracti ons – one to three teeth or tooth spaces, per quadrant $25 D7340 Vestibuloplasty – ridge extension (secondary epithelialization) $370 D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $990 D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm $130 D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm $335 D7471 Removal of lateral exostosis (maxilla or mandible) $80 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 13 Code Service Your and Your Dependent’s Co-Payment D7472 Removal of torus palatinus $60 D7473 Removal of torus mandibularis $60 D7485 Surgical reduction of osseous tuberosity $60 D7510 Incision and drainage of abscess – intraoral soft tissue $35 D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $35 D7520 Incision and drainage of abscess – extraoral soft tissue $35 D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) $35 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $125 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $505 D7910 Suture of recent small wounds up to 5 cm $25 D7921 Collection and application of autologous blood concentrate product $95 D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla – autogenous or nonautogenous, by report $600 D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach $825 D7952 Sinus augmentation via a vertical approach $825 D7953 Bone replacement graft for ridge preservation – per site $100 D7960 Frenulectomy – aka frenectomy or frenotomy – separate procedure not incidental to another procedure $50 D7963 Frenuloplasty $50 D7970 Excision of hyperplastic tissue – per arch $55 D7971 Excision of pericoronal gingiva $40 D7972 Surgical reduction of fibrous tuberosity $125 Orthodontics • Benefits cover twenty-four (24) months of usual & customary Orthodontic treatment and an additional twenty-four (24) months of retention. • Comprehensive Orthodontic benefits include all phases of treatment and fixed/removable appliances. D8010 Limited orthodontic treatment of the primary dentition $1,000 D8020 Limited orthodontic treatment of the transitional dentition $1,000 D8030 Limited orthodontic treatment of the adolescent dentition $1,000 D8040 Limited orthodontic treatment of the adult dentition $1,000 D8070 Comprehensive orthodontic treatment of the transitional dentition $1,850 D8080 Comprehensive orthodontic treatment of the adolescent dentition $1,850 D8090 Comprehensive orthodontic treatment of the adult dentition $1,850 D8660 Pre-orthodontic treatment examination to monitor growth and development $35 D8670 Periodic orthodontic treatment visit $35 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $300 D8693 Re-cement or re-bond fixed retainers $0 SCHEDULE OF BENEFITS (continued) GCERT2012-DHMO-SOB 14 Code Service Your and Your Dependent’s Co-Payment D8694 Repair of fixed retainers, includes reattachment $0 • There is a Co-Payment of $250 for Orthodontic treatment planning and records (pre/post x-rays (cephalometric, panoramic, etc.), photos, study models). • There is a Co-Payment of $25 per visit for Orthodontic visits beyond twenty- four (24) months of active treatment or retention. Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain – minor procedure $10 D9120 Fixed partial denture sectioning $0 D9210 Local anesthesia not in conjunction with operative or surgical procedures $0 D9211 Regional block anesthesia $0 D9212 Trigeminal division block anesthesia $0 D9215 Local anesthesia in conjunction with operative or surgical procedures $0 D9219 Evaluation for deep sedation or general anesthesia $0 D9220 Deep sedation/general anesthesia – first 30 minutes $150 D9221 Deep sedation/general anesthesia – each additional 15 minutes $45 D9230 Inhalation of nitrous oxide/analgesia, anxiolysis $15 D9241 Intravenous moderate (conscious) sedation/analgesia – first 30 minutes $150 D9242 Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes $45 D9248 Non-intravenous moderate (conscious) sedation $15 D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician $0 D9430 Office visit for observation (during regularly scheduled hours) – no other services performed $0 D9440 Office visit – after regularly scheduled hours $30 D9450 Case presentation, detailed and extensive treatment planning $0 D9610 Therapeutic parenteral drug, single administration $15 D9612 Therapeutic parenteral drugs, two or more administrations, different medications $25 D9630 Other drugs and/or medicaments, by report $15 D9910 Application of desensitizing medicament $15 D9930 Treatment of complication (post-surgical) – unusual circumstances, by report $0 D9931 Cleaning and inspection of a removable appliance $55 D9940 Occlusal guard, by report $85 D9942 Repair and/or reline of occlusal guard $40 D9951 Occlusal adjustment – limited $30 D9952 Occlusal adjustment – complete $100 D9986 Missed appointment (less than 24-hr notice) Not to exceed $25 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) $0 Current Dental Terminology © American Dental Association DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES GCERT2012-DHMO-SOB 15 General 1. Specialty Care Dentists will accept the contracted fee for all Covered Services. 2. General anesthesia or IV sedation is a Covered Service only if it is provided in a Selected General Dental Office, administered by the Selected General Dentist or Specialty Care Dentist, and is in conjunction with covered oral and periodontal surgical procedures or when deemed necessary by the Selected General Dentist or Specialty Care Dentist. 3. Sterilization and infection control are not billable to Us or You or Your Dependent and are included within the charges for other services provided on that date of service. a. Local Anesthetic is included in all restorative and surgical procedure fees. b. All adhesives, liners, bases and occlusal adjustments are included as a part of the restorative procedure. Diagnostic 1. Panoramic or full mouth x-rays (including bitewings): once every three (3) years, unless Dentally Necessary for a specific dental problem. 2. All costs for additional periapical and bitewing x-rays provided on the same day that a full mouth x-ray is provided to You or Your Dependent are included in the costs for the full mouth x-ray. Preventive 1. Routine cleanings (oral Prophylaxis), periodontal maintenance services (following active periodontal therapy) and fluoride treatments are limited to twice a year. Two (2) additional cleanings (routine and periodontal) are available at the Co-Payment listed in the SCHEDULE OF BENEFITS. Additional Prophylaxis are available, if Dentally Necessary. 2. Sealants and/or preventive resin restorations: Plan benefit applies to primary and permanent molar teeth, limited to age 19, one (1) per tooth, per thirty-six (36) months, unless Dentally Necessary. 3. Space maintainers are covered to age 14 once per area, per lifetime. Replacement of lost space maintainers are not a Covered Service. Restorative Treatment Crowns, Implants and Fixed Bridges 1. An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. 2. Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. 3. There is a $75 Co-Payment per molar, for the use of porcelain. 4. Prefabricated stainless steel Crowns or prefabricated resin Crowns are limited to no more than one (1) replacement for the same tooth surface within five (5) years. 5. Charges for temporary Crowns/restorations are included within the costs of the permanent Crown/restoration. 6. Provisional Crowns/restorations are to be used for an interim of at least six (6) months duration. Interim Crowns/restorations are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. 7. Replacement of any Cast Restorations with the same or a different type of Cast Restoration are limited to no more than once every five (5) years. DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES (continued) GCERT2012-DHMO-SOB 16 8. Core buildups are limited to no more than once per tooth in a period of five (5) years. 9. Post and cores are limited to no more than once per tooth in a period of five (5) years. 10. Labial veneers are limited to no more than once per tooth in a period of five (5) years. Prosthodontics 1. Relinings and rebasings are limited to one (1) every twelve (12) months. 2. Dentures (full or partial): Replacement only after five (5) years have elapsed following any prior provision of such Dentures under a SafeGuard Plan, unless due to the loss of a natural tooth which cannot be added to the existing partial. Replacements will be a benefit under this Plan only if the existing Denture is unsatisfactory and cannot be made satisfactory as determined by the treating Selected General Dentist or Specialty Care Dentist. 3. Replacement of an immediate full Denture with a permanent full Denture if the immediate full Denture cannot be made permanent and such replacement is done within twelve (12) months of the installation of the immediate full Denture. 4. Adjustments of Dentures if at least six (6) months have passed since the installation of the existing removable Denture. 5. Delivery of removable and fixed Prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. 6. Tissue conditioning eligible one (1) per appliance each twenty-four (24) months. 7. Provisional prostheses are to be used for an interim of at least six (6) months duration. Interim prostheses are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. Implant Services 1. Implants are limited to no more than once for the same tooth position in a five (5) year period. 2. Repairs of implants are limited to not more than once in a twelve (12) month period. 3. Implant supported prosthetics are limited to no more than once for the same tooth position in a five (5) year period: when needed to replace congenitally missing teeth; or when needed to replace natural teeth. 4. The following are limited to no more than two (2) each per year: Implants, Implant supported prosthetics, and Implant abutments. Endodontics 1. The Co-Payments listed for Endodontic procedures do not include the cost of the final restoration. 2. Materials used for canal irrigation are included in the Endodontic procedure fees. Oral Surgery 1. The removal of asymptomatic third molars is not a Covered Service. Pathology (disease) must exist for it to be covered by the program. 2. Includes routine post operative visits/treatments. DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES (continued) GCERT2012-DHMO-SOB 17 Periodontics 1. Irrigation (such as Chlorhexidine), is included with the other services rendered that day. 2. Local chemotherapeutic agents are limited to no more than six (6) teeth per arch. Treatment plans involving more than six (6) teeth per arch, require prior Plan approval. 3. Periodontal maintenance is eligible following active periodontal therapy, which includes scaling and root planing, surgery, etc. 4. Periodontal scaling and root planing, is limited to not more than once per Quadrant in any twenty-four (24) month period. 5. Periodontal surgery, including gingivectomy, gingivoplasty and osseous surgery, is limited to no more than one surgical procedure per Quadrant in any thirty-six (36) month period. 6. Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. Orthodontics 1. If You or Your Dependent require the services of an orthodontist, a referral must first be facilitated by Your Selected General Dentist. If a referral is not obtained before the Orthodontic treatment begins, You will be responsible for all costs associated with any Orthodontic treatment. 2. If You or Your Dependent terminate coverage from the SafeGuard Plan after the start of Orthodontic treatment, You will be responsible for any additional charges incurred for the remaining Orthodontic treatment. 3. Orthodontic treatment must be provided by a Selected General Dentist or Specialty Care Dentist whose specialty is orthodontics or pediatric dentistry for the Co-Payments listed in this SCHEDULE OF BENEFITS to apply. 4. Plan benefits shall cover twenty-four (24) months of usual and customary Orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a charge of $25 per visit. 5. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. 6. Continuing Orthodontic treatment is available if You or Your Dependent qualify by enrolling within 30 days of the Effective Date for an eligible policyholder; You or Your Dependent had Orthodontic coverage under the policyholder's prior plan and were in active Orthodontic treatment, covered by that Plan, as of the Effective Date of this group contract. Upon receipt of a completed Continuing Orthodontic Form by Us, with all supporting documentation, We will accept liability for continuing payment of the remaining balance owed, up to a maximum of $1,500 times the percentage of the total treatment remaining as of this group contract’s Effective Date, subject to the section titled DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES and DENTAL BENEFITS: EXCLUSIONS. The Continuing Orthodontic provision is not available: thirty (30) days after this group contract’s Effective Date; to a person who enrolls after the group contract’s Effective Date; or to a person who is not in active Orthodontic treatment as of the Effective Date of this group contract. DENTAL BENEFITS: EXCLUSIONS GCERT2012-DHMO-SOB 18 1. Any procedures not specifically listed as a Covered Service in this SCHEDULE OF BENEFITS or dental procedures or services performed solely for Cosmetic purposes (unless s pecifically listed as a Covered Service in this SCHEDULE OF BENEFITS), are not covered. 2. Covered Services must be performed by Your Selected General Dental Office or a SafeGuard Specialty Care Dentist to whom You are referred in accordance with the terms of Your evidence of coverage and SCHEDULE OF BENEFITS. Services performed by any Dentist not contracted with SafeGuard are not Covered Services, without prior approval by SafeGuard or Your Selected General Dentist, in accordance with the terms of Your evid ence of coverage and SCHEDULE OF BENEFITS (except for out-of-area emergency services). 3. Dental procedures started prior to Your or Your Dependent’s eligibility under this SCHEDULE OF BENEFITS or started after Your or Your Dependent’s benefits have ended. For example, teeth prepared for Crowns, root canals in progress (the tooth has been opened into the pulp (nerve chamber)), or full or partial Dentures for which an impression has been taken. 4. Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or improving You or Your Dependent’s dental health, as determined by the Selected General Dentist, and Us based on generally accepted dental standards of care. 5. Orthognathic surgery. 6. Inpatient/outpatient hospital charges of any kind, including prescriptions or medications , except for palliative care for an Emergency Dental Condition. General anesthesia or IV sedation is not covered for any reason if rendered in an out patient facility or hospital. Dental charges will be covered, if the procedure performed is covered by the Plan. 7. Replacement of Dentures, Crowns, appliances or Bridgework that have been lost, stolen or damaged. 8. Treatment of malignancies, cysts, or neoplasms, unless specifically listed as a Covered Service in the SCHEDULE OF BENEFITS. Any services related to pathology laboratory fees. 9. Procedures, appliances, or restorations whose primary purpose is to change the vertical dimension of occlusion, correct congenital malformation, developmental, or m edically induced dental disorders including, but not limited to, treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specifically listed as a Covered Service in this SCHEDULE OF BENEFITS. 10. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. 11. Dental services required while serving in the armed forces of any country or international authority. 12. Dental services considered Experimental or Investigational in nature. If We make a determination that a Dental service is Experimental or Investigational in nature, this Adverse Determination may be appealed as described in the section titled APPEAL OF ADVERSE DETERMINATION in Your Evidence of Coverage. 13. Treatment required due to an accident from an external force, unless otherwise listed as Covered Service in this SCHEDULE OF BENEFITS. 14. The following are not included as Orthodontic benefits: Repair or replacement of lost or broken appliances; Retreatment of Orthodontic cases; Treatment involving: Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; Hormonal imbalances or other factors affecting growth or developmental abnormalities; Treatment related to temporomandibular joint disorders; DENTAL BENEFITS: EXCLUSIONS (continued) GCERT2012-DHMO-SOB 19 Composite or ceramic brackets, lingual adaptation of Orthodontic bands and other specialized or Cosmetic alternatives to standard fixed and removable Orthodontic appliances. Invisalign services are excluded. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] Dental Plan Design for: City Of Southlake Original Plan Effective Date: October 1, 2017 Network: PDP Plus The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a healthier smile and a healthier you. Coverage Type: In-Network1 % of Negotiated Fee2 Out-of-Network1 % of R&C Fee4 Type A - Preventive 100% 100% Type B - Basic Restorative 80% 80% Type C - Major Restorative 50% 50% Type D - Orthodontia 50% 50% Deductible3 Individual $50 $50 Family $150 $150 Annual Maximum Benefit: Per Individual $1750 $1750 Orthodontia Lifetime Maximum - Ortho applies to Adult and Child Up to dependent age limit $1500 per Person $1500 per Person Dependent Age: Eligible for benefits until the day that he or she turns 26. 1. "In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist. 2. Negotiated fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. 3. Applies to Type B and C services only. 4. Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of:  the dentist’s actual charge (the 'Actual Charge'),  the dentist’s usual charge for the same or similar services (the 'Usual Charge') or  the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] Understanding Your Dental Benefits Plan The Preferred Dentist Program is designed to provide the dental coverage you need with the features you want. Like the freedo m to visit the dentist of your choice – in or out of the network. . If you receive in-network services, you will be responsible for any applicable cost sharing, negotiated charges after benefit maximums are met, and costs for non-covered services. If you receive out-of-network services, you will be responsible for any applicable cost sharing, charges in excess of the benefit maximum, charges in excess of the negotiated fee schedule amount, and charges for non - covered services.  Plan benefits for in-network covered services are based on a percentage of the Negotiated fee – the Fee that participating dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees are subject to change.  Plan benefits for out-of-network services are based on a percentage of the Reasonable and Customary (R&C) charge. If you choose a dentist who does not participate in the network, your out-of-pocket expenses may be greater. Once you’re enrolled you may take advantage of online self-service capabilities with MyBenefits.  Check the status of your claims  Locate a participating dentist  Access MetLife’s Oral Health Library  Elect to view your Explanation of Benefits online To register, just go to www.metlife.com/mybenefits and follow the easy registration instructions. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] Selected Covered Services and Frequency Limitations* Type A - Preventive How Many/How Often: Oral Examinations 2 in 12 months Full Mouth X-rays 1 in 36 months Bitewing X-rays (Adult/Child) 1 in a year Prophylaxis - Cleanings 2 in 12 months Topical Fluoride Applications 2 in 12 months - Children to age 16 Sealants 1 in 36 months - Children to age 16 Space Maintainers No limit - Children up to age 16 Type B - Basic Restorative How Many/How Often: Amalgam and Composite Fillings 1 in 24 months. Endodontics Root Canal 1 per tooth per lifetime Periodontal Surgery 1 in 36 months per quadrant Periodontal Scaling & Root Planing 1 in 24 months per quadrant Periodontal Maintenance 2 in 1 year, includes 2 cleanings Oral Surgery (Simple Extractions) Emergency Palliative Treatment General Anesthesia Consultations 1 in 12 months Type C - Major Restorative How Many/How Often: Crowns/Inlays/Onlays 1 per tooth in 60 months Prefabricated Crowns 1 per tooth in 60 months Repairs Oral Surgery (Surgical Extractions) Other Oral Surgery Bridges 1 in 60 months Dentures 1 in 60 months Implant Services 1 service per tooth in 10 years - 1 repair per 10 years Type D – Orthodontia  Adult and Child Coverage. Dependent children up to age 26. Age limitations may vary by state. Please see your Plan descrip tion for complete details. In the event of a conflict with this summary, the terms of the certificate will govern.  All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.  Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic foll ow-up visits will be payable on a monthly basis during the scheduled course of the orthodontic treatment. Allowable expenses for the initial placement, periodic follow-up visits and procedures performed in connection with the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary.  Orthodontic benefits end at cancellation of coverage *Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you receive a more costly treatment alternative, your dentist may charge you or your dependent for the difference between the cost of the service that was performed and the least costly treatment alternative. The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] We will not pay Dental Insurance benefits for charges incurred for: 1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature; 2. Services for which You would not be required to pay in the absence of Dental Insurance; 3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person; 4. Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate). 5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dent al hygienist which are supervised and billed by a Dentist and which are for:  scaling and polishing of teeth; or  fluoride treatments. For NY Sitused Groups, this exclusion does not apply. 6. Services or appliances which restore or alter occlusion or vertical dimension. 7. Restoration of tooth structure damaged by attrition, abrasion or erosion. 8. Restorations or appliances used for the purpose of periodontal splinting. 9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. 10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. 11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work. 12. Missed appointments. 13. Services  covered under any workers’ compensation or occupational disease law;  covered under any employer liability law;  for which the employer of the person receiving such services is not required to pay; or  received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. For North Carolina and Virginia Sitused Groups, this exclusion does not apply. 14. Services paid under any worker’s compensation, occupational disease or employer liability law as follows:  for persons who are covered in North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Indus trial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act;  or for persons who are not covered in North Carolina, services paid or payable under any workers compensation or occupational disease law. This exclusion only applies for North Carolina Sitused Groups. 15. Services:  for which the employer of the person receiving such services is not required to pay; or  received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital. This exclusion only applies for North Carolina Sitused Groups. 16. Services covered under any workers' compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under that law. This exclusion only applies for Virginia Sitused Groups. 17. Services:  for which the employer of the person receiving such services is not required to pay; or  received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital. This exclusion only applies for Virginia Sitused Groups. 18. Services covered under other coverage provided by the Employer. 19. Temporary or provisional restorations. 20. Temporary or provisional appliances. 21. Prescription drugs. 22. Services for which the submitted documentation indicates a poor prognosis. 23. The following when charged by the Dentist on a separate basis:  claim form completion;  infection control such as gloves, masks, and sterilization of supplies; or  local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide. 24. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food. For NY Sitused Groups, this exclusion does not apply. 25. Caries susceptibility tests. 26. Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 27. Other fixed Denture prosthetic services not described elsewhere in this certificate. 28. Precision attachments, except when the precision attachment is related to implant prosthetics. 29. Initial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 30. Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 31. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it. 32. Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] 33. Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. 34. Fixed and removable appliances for correction of harmful habits.1 35. Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of Minnesota.1 36. Repair or replacement of an orthodontic device.1 37. Duplicate prosthetic devices or appliances. 38. Replacement of a lost or stolen appliance, Cast Restoration, or Denture. 39. Intra and extraoral photographic images. 40. Services or supplies furnished as a result of a referral prohibited by Section 1 -302 of the Maryland Health Occupations Article. A prohibited referral is one in which a Health Care Practitioner refers You to a Health Care Entity in which the Health Care Practitioner or Health Care Practitioner’s immediate family or both own a Beneficial Interest or have a Compensation Agreement. For the purposes of this exclusion, the terms “Referral”, “Health Care Practitioner” , “Health Care Entity”, “Beneficial Interest” and Compensation Agreement have the same meaning as provided in Section 1 -301 of the Maryland Health Occupations Article. This exclusion only applies for Maryland Sitused Groups 1Some of these exclusions may not apply. Please see your plan design and certificate for details. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] Common Questions … Important Answers Who is a participating dentist? A participating, or network, dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment i n full for covered services provided to plan members, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees typically range from 15-45% below the average fees charged in a dentist’s community for the same or substantially similar services.* In addition to the standard MetLife network, your employer may provide you with access to a select network of dental providers that may be unique to your employer’s dental program. When visiting these providers, you may receive a better benefit, have lower out-of-pocket costs and/or have access to care at facilities at your worksite. Please sign into MyBenefits for more details. * Based on internal analysis by MetLife. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan how often members visit participating dentists and the cost of services rendered. Negotiated fees are subject to change. How do I find a participating dentist? There are thousands of general dentists and specialists to choose from nationwide --so you are sure to find one that meets your needs. You can receive a list of these participating dentists online at www.metlife.com/dental or call 1 -800-275-4638 to have a list faxed or mailed to you. What services are covered by my plan? All services defined under your group dental benefits plan are cove red. Please review the enclosed plan benefits summary to learn more.* *The information in this document represents an overview of your plan benefits, but is not a complete description of the plan . Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this overview and your certificate of insurance, your certificate of insurance governs. May I choose a non-participating dentist? Yes. You are always free to select the dentist of your choice. However, if you choose a non -participating (out-of-network) dentist, your out-of-pocket costs may be higher. Can my dentist apply for participation in the network? Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask you r dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application.* The website and phone number are for use by dental professionals only. * Due to contractual requirements, MetLife is prevented from soliciting certain providers. How are claims processed? Dentists may submit your claims for you which means you have little or no paperwork. You can track your claims onl ine and even receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/dental or request one by calling 1-800-275-4638. Can I get an estimate of what my out-of-pocket expenses will be before receiving a service? Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care a nd requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you reque st a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the offic e. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment. Can MetLife help me find a dentist outside of the U.S. if I am traveling? Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1 -312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be considered unde r your out-of-network benefits.** Please remember to hold on to all receipts to submit a dental claim. *International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. (AXA Assistance). AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits pro vided by MetLife. Referral services are not available in all locations. ** Refer to your dental benefits plan summary for your out-of-network dental coverage. Metropolitan Life Insurance Company, New York, NY 10166 PEANUTS ©United Feature Syndicate, Inc. L0916478823[exp0218][All States] How does MetLife coordinate benefits with other insurance plans? Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dent al benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions requires MetLife to determine benefits aft er benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan. Do I need an ID card? No, You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enro lled in a MetLife Dental Plan. Your dentist can easily verify information about your coverage through a toll-free automated Computer Voice Response system. Do my dependents have to visit the same dentist that I select? No. You and your dependents each have the freedom to choose any dentist. If I do not enroll during my initial enrollment period can I still purchase Dental Insurance at a later date? Yes, employees who do not elect coverage during their 31 -day application period may still elect coverage later. Dental coverage would be subject to the following waiting periods.  No waiting period on Preventive Services  6 months on Basic Restorative (Fillings)  12 months on all other Basic Services  24 months on Major Services  24 months on Orthodontia Services (if applicable) The information contained herein is a summary of the provisions of a MetLife Dental Plan. For complete terms and provisions of the plan, please see your certificate of insurance, the terms of which shall govern in all instances. CITY OF SOUTHLAKE 05946619 Date Premium ($) Lives - Employee Total Claims ($) 10/01/2017 $16,512.64 264 $12,100.36 11/01/2017 $16,625.24 264 $8,476.80 12/01/2017 $16,612.68 266 $15,936.60 01/01/2018 $16,515.60 262 $16,668.50 02/01/2018 $16,537.40 265 $16,898.26 03/01/2018 $16,427.76 266 $23,748.52 04/01/2018 $16,233.56 265 $19,942.34 05/01/2018 $16,400.64 269 $14,851.93 06/01/2018 $16,458.08 271 $13,793.90 07/01/2018 $16,492.76 272 $20,756.12 08/01/2018 $16,637.72 273 $16,022.30 09/01/2018 $16,236.80 270 $14,514.00 10/01/2018 $17,188.60 282 $18,593.80 11/01/2018 $17,330.60 284 $14,881.12 12/01/2018 $17,290.96 284 $16,581.68 01/01/2019 $17,343.16 281 $13,797.00 $266,844.20 4338 $257,563.23 96.52% loss ratio