Okaloosa County BOCC — August 5, 2014 — RFP #44-14 - Dental Insurance - MetLife Proposal - Exhibit A — reading text

such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. We will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first. 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. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing and biting of food. Caries susceptibility tests. MetLife Precision attachments associated with fixed and removable prostheses. Adjustment of a denture made within 6 months after installation by the same dentist who installed it. Duplicate prosthetic devices or appliances. Replacement of a lost or stolen appliance, cast restoration or denture. Intra and extraoral photographic images. Treatment of temporomandibular joint disorder. This exclusion does not apply to residents of Minnesota. Frequency & Allocations / Exclusions (Custom Comprehensive (Flex) - Custom Standard (Flex)) Class Description: Retirees TYPEA Benefits are payable immediately from the start date of an individual’s benefits = Examinations = 1 time in 6 months = _ Examinations — Problem Focused * 1 time in 12 months = Prophylaxis: Cleanings = 1 timein6 months = Sealants = 1 per molar in 3 years for a child under age 17 = Space Maintainers * No Limit for a child under age 19 = Fluoride = 2 times in 12 Months for a dependent child under age 14 * Full Mouth X-Rays = Once in 5 calendar years = Bitewing X-Rays = For achild under 19: 1 time in 12 months = Adult: 1 time in 12 months = Labs & Other Tests = Emergency Palliative Treatment = Periapical X-Rays = Other X-Rays TYPE B Benefits are payable immediately from the start date of an individual’s benefits * Consultations = 1in 12 months = Amalgam Fillings = 1 replacement per surface in 24 Months = Root Canal = 1 per tooth per lifetime * Periodontal Maintenance = 4 perio. Treatments in 1 calendar yr, includes 2 cleanings (total comb: 4) = Periodontal Surgery = 1 per quadrant in any 24 month period * Scaling & Root Planing = 1 per quadrant in any 12 month period = Repairs = _1in 12 months = _Recementations = _1in 12 months = General Anesthesia = Resin Composite Fillings(includes coverage for composite fillings on molars) = _Pulpotomy = Pulp Capping = Pulp Therapy ® Apexification & Recalcification * Periodontal Surgery — Soft & Connective Tissue Grafts * Periodontics — Non-Surgical * Oral Surgery: Simple Extractions * Oral Surgery: Surgical Extractions Other Oral Surgery General Services TYPE C MetLife Benefits are payable immediately from the start date of an individual's benefits « Prefabricated Crowns = 1 per tooth in 10 calendar years ® Crown Buildups / Post Core * 1 per tooth in 5 calendar years = Dentures * 1 in 5 calendar years * Immediate Temporary Dentures — Complete = 1 replacement in 12 months / Partial » Dentures — Rebases / Relines ® 1in24 months » Denture Adjustments * _1in12 months = Fixed Bridges * _1in5 calendar years * Inlays / Onlays /Crowns * 1 replacement per tooth in 5 calendar years = _ Implant Services * 1 per tooth position in 5 calendar years « Implant Repairs = 1 per tooth in 12 months = _ Implant Supported Prosthetic = 1 per tooth in 5 calendar years * Tissue Conditioning * _1in 36 months * Occlusal Adjustments = _1in12 months ® Harmful Habit Appliances * Occlusal Guards / Bruxism Appliances Orthodontics Benefits are payable immediately from the start date of an individual’s benefits * Orthodontic Diagnostics = Orthodontic Treatment Exclusions Retirees 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. Services for which a covered person would not be required to pay in the absence of dental insurance. Services or supplies received by a covered person before the insurance starts for that person. Services which are neither performed nor prescribed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling or polishing of teeth or fluoride treatment. Services which are primarily cosmetic unless such service is: required for reconstructive surgery which is incidental to or follows surgery which results from a trauma, an infection or other disease of the involved part; or required for reconstructive surgery because if a congenital disease or anomaly of a Child which has resulted in a functional defect; or (For residents of Texas) required for the treatment or correction of a congenital defect of a newborn child). Services or appliances which restore or alter occlusion or vertical dimension. Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease. Restorations or appliances used for the purpose of periodontal splinting. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. Initial installation of a Denture to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth. Decoration or inscription of any tooth, device, appliance, crown or other dental work. Missed appointments. Services covered under any workers’ compensation or occupational disease law. Services paid under any employer liability law. Services for which the employer of the person receiving such services is not required to pay. Services received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital. Services covered under other coverage provided by the Policyholder. Temporary or provisional restorations. Temporary or provisional appliances. Prescription drugs. Services for which the submitted documentation indicates a poor prognosis. MetLife Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. We will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first. 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. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing and biting of food. Caries susceptibility tests. Precision attachments associated with fixed and removable prostheses. Adjustment of a denture made within 6 months after installation by the same dentist who installed it. Duplicate prosthetic devices or appliances. Replacement of a lost or stolen appliance, cast restoration or denture. Intra and extraoral photographic images. Treatment of temporomandibular joint disorder. This exclusion does not apply to residents of Minnesota. MetLife Highlights Broker Commissions included in the rate: Standard Scale Expected Participation: 98% and at least 10 covered lives. Employee Contributions: 1% Financial Arrangement: Non-retrospectively Experience Rated Situs is FLORIDA Only those residing in the United States are eligible for benefits Dependent Child Definition: A Child is covered up to age 26, A student is covered up to age 26. Ortho coverage applies to: Child Only. Children are covered to age 19. This quote assumes the plan is a Section 125 plan. An Open Enrollment period occurring annually is included. MetLife Underwriting Assumptions PlanSmart*- PlanSmart is a multifaceted program, offered at no additional cost, which enables you to provide your employees with access to a range of financial and retirement education resources through on-site workshops, with optional personal consultations and decision-support assistance. Retirewise - Retirewise is an in-depth program consisting of a four-part series of workshops that deliver objective information covering a broad spectrum of retirement issues from Estate Planning to Tax Planning. Each workshop is delivered by a locally based financial professional. *Certain conditions apply. Please discuss with your MetLife representative to determine if this program is right for your company. WillsCenter.com: Online will prep service offered through SmartLegalForms, Inc., available to all customers at no charge. If insurance coverage is provided, it will be governed by the terms and conditions of the insurance policy and applicable law. If administrative services are provided, they are governed by the terms and condition of the administrative services agreement and by applicable law. If MetLife is requested to duplicate contractual provisions from the prior carrier, such provisions must be compatible with all MetLife's standards. The quoted rates and or fees are based upon the request received. If new or additional information in connection with this request is provided, MetLife reserves the right to change its quote at any time before the effective date. After the effective date, rate and or fees are subject to the terms and conditions of the policy and or administrative services agreement. Only those eligible persons residing in the United States may be covered. Any others must be approved by MetLife. SIC Code: 9111 MetLife INTERMEDIARY AND PRODUCER COMPENSATION NOTICE MetLife enters into arrangements concerning the sale, servicing and/or renewal of MetLife group insurance and certain other group-related products (“Products”) with brokers, agents, consultants, third-party administrators, general agents, associations, and other parties that may participate in the sale, servicing and/or renewal of such Products (each an ““Intermediary”"). MetLife may pay your Intermediary compensation, which may include base compensation, supplemental compensation and/or a service fee. MetLife may pay compensation for the sale, servicing and/or renewal of Products, or remit compensation to an Intermediary on your behalf. Your Intermediary may also be owned by, controlled by or affiliated with another person or party, which may also be an Intermediary and who may also perform marketing and/or administration services in connection with your Products and be paid compensation by MetLife. Base compensation, which may vary from case to case and may change if you renew your Products with MetLife, may be payable to your Intermediary as a percentage of premium or a fixed dollar amount. In addition, supplemental compensation may be payable to your Intermediary. Under MetLife’s current supplemental compensation plan, the amount payable as supplemental compensation may range from 0% to 8% of premium. The supplemental compensation percentage may be based on: (1) the number of Products sold through your Intermediary during a prior one-year period; (2) the amount of premium or fees with respect to Products sold through your Intermediary during a prior one-year period; (3) the persistency percentage of Products in force through your Intermediary during a prior one-year period; (4) premium growth during a prior one-year period; (5) a fixed percentage of the premium for Products as set by MetLife. The supplemental compensation percentage will be set by MetLife prior to the beginning of each calendar year and it may not be changed