Okaloosa County BOCC — August 19, 2014 — RFP #44-14 - Dental Insurance - MetLife Proposal - Exhibit A — reading text

Prefabricated Crowns * 1 per tooth in 10 calendar years ® Crown Buildups / Post Core * 1 per tooth in 5 calendar years = Dentures = 1in5 calendar years * Immediate Temporary Dentures — Complete = 1 replacement in 12 months / Partial » Dentures — Rebases / Relines = _1in24 months = Denture Adjustments = 1in 12 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 Summary of Benefits Dental Insurance - Dental Option 2 Employer Sponsored Dental Class Description All Active Ful foe (30 Retirees In-Network Out-of-Network In-Network Out-of-Network , Negotiated Fee R&C Negotiated Fee R&C Reimiatlresmint Schedule 90th Percentile Schedule 90th Percentile Type A - Preventive 100% 100% 100% 100% Type B - Basic 80% 80% 80% 80% Type C - Major 50% 50% 50% 50% Calendar Year B&C B&C B&C B&C Deductible applies to: $50 $50 $50 soo * Individual $150 $150 $150 $150 * Family Aggregate Aggregate Aggregate Aggregate Calendar Year Maximum (applies to A,B,C $1,200 $1,200 $1,200 $1,200 services) Orthodontia 50% 50% 50% 50% Orthodontia Lifetime Maxinuii $1,000 $1,000 $1,000 $1,000 * 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 (1) the dentist's actual charge (the ‘Actual Charge’), (2) the dentist's usual charge for the same or similar services (the ‘Usual Charge’) or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the ‘Customary Charge’). Services must be necessary in terms of generally accepted dental standards. MetLife Employer Sponsored Dental eee Lives Eat Monthiy Fat somal = Employee Only $20.84 526 $32,663 $391,961 = Employee + Family $60.45 359 = Total 885 Rates are guaranteed from October 1, 2014 - September 30, 2015 (12 months) 2” year Rate Cap: The first year’s renewal rates will not be increased by more than 7.0% above the current rates. MetLife Frequency & Allocations / Exclusions (Custom Comprehensive (Flex) - Custom Standard (Flex)) Class Description: All Active Full Time Employees 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 = _1timein6 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 = Fora child 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 TYPEB 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 = 4perio. 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 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 * _1in 5 calendar years Immediate Temporary Dentures — Complete / Partial 1 replacement in 12 months Dentures — Rebases / Relines 1 in 24 months Denture Adjustments 1 in 12 months Fixed Bridges 1 in 5 calendar years MetLife « 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 = 1 in 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 All Active Full Time Employees 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. Services, to the extent such services, or benefits for