190174-CONTRACT.PDF

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CONTRACT PURSUANT TO IFB
This Contract is entered into this 1st day of January 2019 by and between Maricopa County (“County”), a political
subdivision of the State of Arizona, and Cigna Dental Health Plan of Arizona, Inc. (“Contractor”) for the
purchase of a fully insured Prepaid Dental Plan with coverage commencing July 1, 2019.
1.0 CONTRACT TERM:
1.1 This Contract is for a term of three (3) years, beginning on the 1st day of July, 2019, and ending the
30th day of June, 2022.
1.2 The County may, at its option and with the agreement of the Contractor, renew the term of this
Contract for additional terms up to a maximum of three (3) additional years, (or at the County’s
sole discretion, extend the contract on a month-to-month basis for a maximum of six (6) months
after expiration). The County shall notify the Contractor in writing of its intent to extend the
Contract term at least sixty (60) calendar days prior to the expiration of the original contract term,
or any additional term thereafter.
1.3 CONTRACT COMPLETION:
The Contractor shall make all reasonable efforts for an orderly transition of its duties and
responsibilities to another provider and/or to the County. This may include, but is not limited to
the preparation of a transition plan and cooperation with the County or other providers in the
transition. The transition includes the transfer of all records, and other data in the possession,
custody or control of Contractor required to be provided to the County either by the terms of this
agreement or as a matter of law. The provisions of this clause shall survive the expiration or
termination of this agreement.
If termination of the contract occurred, Cigna, acting as an insurer, would agree to transfer
relevant claim information to a designated carrier upon receipt of a suitable confidentiality
and hold harmless agreement from that carrier.
2.0 PRICE ADJUSTMENTS:
Any requests for reasonable price adjustments must be submitted two hundred and seventy (270) calendar
days prior to the Contract expiration. Requests for adjustment in cost of labor and/or materials must be
supported by appropriate documentation. The reasonableness of the request will be determined by
comparing the request with the Consumer Price Index or by performing a market survey. If County agrees
to the adjusted price terms, County shall issue written approval of the change and provide an updated
version of the Contract. The new change shall not be in effect until the date stipulated on the Contract.
3.0 PAYMENTS:
3.1 As consideration for performance of the duties described herein, County shall pay Contractor the
sum(s) stated in Exhibit “A.”
3.2 Payment shall be made upon the County’s receipt of a properly completed invoice.

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3.3 INVOICES:
3.3.1 The Contractor shall submit one (1) legible copy of their detailed invoice before
payment(s) will be made. Incomplete invoices will not be processed. At a minimum, the
invoice must provide the following information:
• Company name, address and contact
• County bill-to name and contact information
• Contract Serial Number
• County purchase order number
• Project name and/or number
• Invoice number and date
• Payment terms
• Date of service
• Quantity
• Contract Item number(s)
• Description of Purchase (product or services)
• Pricing per unit of purchase
• Extended price
• Mileage w/rate (if applicable)
• Arrival and completion time (if applicable)
• Total Amount Due
3.3.2 Problems regarding billing or invoicing shall be directed to the Department as listed on
the Purchase Order.
3.3.3 Payment shall only be made to the Contractor by Accounts Payable through the Maricopa
County Vendor Express Payment Program. This is an Electronic Funds Transfer (EFT)
process. After Contract Award the Contractor shall complete the Vendor Registration
Form located on the County Department of Finance Vendor Registration Web Site
(http://www.maricopa.gov/922/Vendors).
3.3.4 Discounts offered in the contract shall be calculated based on the date a properly
completed invoice is received by the County.
3.3.5 EFT payments to the routing and account numbers designated by the Contractor will
include the details on the specific invoices that the payment covers. The Contractor is
required to discuss remittance delivery capabilities with their designated financial
institution for access to those details.
3.4 APPLICABLE TAXES:
3.4.1 Payment of Taxes: The Contractor shall pay all applicable taxes. With respect to any
installation labor on items that are not attached to real property performed by Contractor
under the terms of this Contract, the installation labor cost and the gross receipts for
materials provided shall be listed separately on the Contractor’s invoices.
3.4.2 State and Local Transaction Privilege Taxes: To the extent any State and local transaction
privilege taxes apply to sales made under the terms of this Contract it is the responsibility
of the seller to collect and remit all applicable taxes to the proper taxing jurisdiction of
authority.
3.4.3 Tax Indemnification: Contractor and all subcontractors shall pay all Federal, State, and
local taxes applicable to its operation and any persons employed by the Contractor.
Contractor shall, and require all subcontractors to hold Maricopa County harmless from
any responsibility for taxes, damages and interest, if applicable, contributions required
under Federal, and/or State and local laws and regulations, and any other costs including;
transaction privilege taxes, unemployment compensation insurance, Social Security, and
Worker’s Compensation.

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3.5 TAX (SERVICES):
No tax shall be invoiced or paid against Contractor’s labor. It is the responsibility of the
Contractor to determine any and all applicable taxes.
4.0 AVAILABILITY OF FUNDS:
4.1 The provisions of this Contract relating to payment for services shall become effective when funds
assigned for the purpose of compensating the Contractor as herein provided are actually available
to County for disbursement. The County shall be the sole judge and authority in determining the
availability of funds under this Contract. County shall keep the Contractor fully informed as to the
availability of funds.
4.2 If any action is taken by, any State agency, Federal department, or any other agency or
instrumentality to suspend, decrease, or terminate its fiscal obligations under, or in connection
with, this Contract, County may amend, suspend, decrease, or terminate its obligations under, or in
connection with, this Contract. In the event of termination, County shall be liable for payment
only for services rendered prior to the effective date of the termination, provided that such services
are performed in accordance with the provisions of this Contract. County shall give written notice
of the effective date of any suspension, amendment, or termination under this Section, at least ten
(10) days in advance.
5.0 DUTIES:
5.1 The Contractor shall perform all duties stated in Exhibit “B” (General Scope of Services) and
Exhibit B-1 (Plan Design), or as otherwise directed in writing by the Procurement Officer.
6.0 TERMS AND CONDITIONS:
6.1 INDEMNIFICATION:
To the fullest extent permitted by law, and to the extent that claims, damages, losses or expenses
are not covered and paid by insurance purchased by the Contractor, the Contractor shall defend
indemnify and hold harmless the County (as Owner), its agents, representatives, agents, officers,
directors, officials, and employees from and against all claims, damages, losses, and expenses
(including, but not limited to attorneys' fees, court costs, expert witness fees, and the costs and
attorneys' fees for appellate proceedings) arising out of, or alleged to have resulted from the
negligent acts, errors, omissions, or mistakes relating to the performance of this Contract.
Contractor's duty to defend, indemnify, and hold harmless the County, its agents, representatives,
agents, officers, directors, officials, and employees shall arise in connection with any claim,
damage, loss, or expense that is attributable to bodily injury, sickness, disease, death or injury to,
impairment of, or destruction of tangible property, including loss of use resulting there from,
caused by negligent acts, errors, omissions, or mistakes in the performance of this Contract, but
only to the extent caused by the negligent acts or omissions of the Contractor, a subcontractor, any
one directly or indirectly employed by them, or anyone for whose acts they may be liable,
regardless of whether or not such claim, damage, loss, or expense is caused in part by a party
indemnified hereunder.
The amount and type of insurance coverage requirements set forth herein will in no way be
construed as limiting the scope of the indemnity in this paragraph.
The scope of this indemnification does not extend to the sole negligence of County.

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6.2 INSURANCE:
6.2.1 Contractor, at Contractor’s own expense, shall purchase and maintain the herein
stipulated minimum insurance from a company or companies duly licensed by the State
of Arizona and possessing a current A.M. Best, Inc. rating of B++. In lieu of State of
Arizona licensing, the stipulated insurance may be purchased from a company or
companies, which are authorized to do business in the State of Arizona, provided that
said insurance companies meet the approval of County. The form of any insurance
policies and forms must be acceptable to County.
6.2.2 All insurance required herein shall be maintained in full force and effect until all work or
service required to be performed under the terms of the Contract is satisfactorily
completed and formally accepted. Failure to do so may, at the sole discretion of County,
constitute a material breach of this Contract.
6.2.3 Contractor’s insurance shall be primary insurance as respects County, and any insurance
or self-insurance maintained by County shall not contribute to it.
To the extent that Cigna's insurance policies are triggered, Cigna's current
insurance program includes the “primary and non-contributory” language on a
blanket basis where required by a written contract only under the following
insurance policies:
- Automobile Liability
- Commercial General Liability (ISO CG 00 01 12 07 form)
- Workers’ Compensation and Employer’s Liability
- Umbrella/Excess Liability (excess only to automobile, general liability and
employer’s liability)
In other words, the above insurance policies will respond on a primary basis to the
extent that the claims arise from services rendered by Cigna.
6.2.4 Any failure to comply with the claim reporting provisions of the insurance policies or any
breach of an insurance policy warranty shall not affect the County’s right to coverage
afforded under the insurance policies.
6.2.5 The insurance policies may provide coverage that contains deductibles or self-insured
retentions. Such deductible and/or self-insured retentions shall not be applicable with
respect to the coverage provided to County under such policies. Contractor shall be
solely responsible for the deductible and/or self-insured retention and County, at its
option, may require Contractor to secure payment of such deductibles or self-insured
retentions by a surety bond or an irrevocable and unconditional letter of credit.
6.2.6 The insurance policies required by this Contract, except Workers’ Compensation and
Errors and Omissions, shall name County, its agents, representatives, officers, directors,
officials and employees as Additional Insureds.
6.2.7 The policies required hereunder, except Workers’ Compensation and Errors and
Omissions, shall contain a waiver of transfer of rights of recovery (subrogation) against
County, its agents, representatives, officers, directors, officials and employees for any
claims arising out of Contractor’s work or service.
6.2.8 Commercial General Liability:
Commercial General Liability insurance and, if necessary, Commercial Umbrella
insurance with a limit of not less than $1,000,000 for each occurrence, $2,000,000
Products/Completed Operations Aggregate, and $2,000,000 General Aggregate Limit.
The policy shall include coverage for premises liability, bodily injury, broad form
property damage, personal injury, products and completed operations and blanket
contractual coverage, and shall not contain any provisions which would serve to limit
third party action over claims. There shall be no endorsement or modifications of the

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CGL limiting the scope of coverage for liability arising from explosion, collapse, or
underground property damage.
6.2.9 Automobile Liability:
Commercial/Business Automobile Liability insurance and, if necessary, Commercial
Umbrella insurance with a combined single limit for bodily injury and property damage
of not less than $1,000,000 each occurrence with respect to any of the Contractor’s
owned, hired, and non-owned vehicles assigned to or used in performance of the
Contractor’s work or services or use or maintenance of the premises under this Contract.
6.2.10 Workers’ Compensation:
Workers’ Compensation insurance to cover obligations imposed by Federal and State
statutes having jurisdiction of Contractor’s employees engaged in the performance of the
work or services under this Contract; and Employer’s Liability insurance of not less than
$1,000,000 for each accident, $1,000,000 disease for each employee, and $1,000,000
disease policy limit.
Contractor, its contractors and its subcontractors waive all rights against Contract and its
agents, officers, directors and employees for recovery of damages to the extent these
damages are covered by the Workers’ Compensation and Employer’s Liability or
commercial umbrella liability insurance obtained by Contractor, its contractors and its
subcontractors pursuant to this Contract.
6.2.11 Errors and Omissions (Professional Liability) Insurance:
Errors and Omissions (Professional Liability) insurance and, if necessary, Commercial
Umbrella insurance, which will insure and provide coverage for errors or omissions or
professional liability of the Contractor, with limits of no less than $1,000,000 for each
claim.
6.2.12 Certificates of Insurance:
6.2.12.1 Prior to Contract award, Contractor shall furnish the County with valid and
complete certificates of insurance, or formal endorsements as required by the
Contract in the form provided by the County, issued by Contractor’s insurer(s),
as evidence that policies providing the required coverage, conditions and limits
required by this Contract are in full force and effect. Such certificates shall
identify this contract number and title.
6.2.12.2 In the event any insurance policy(ies) required by this Contract is(are) written on
a claims made basis, coverage shall extend for two years past completion and
acceptance of Contractor’s work or services and as evidenced by annual
Certificates of Insurance.
6.2.12.3 If a policy does expire during the life of the Contract, a renewal certificate must
be sent to County fifteen (15) calendar days prior to the expiration date.
6.2.13 Cancellation and Expiration Notice:
Applicable to all insurance policies required within the Insurance Requirements of this
Contract, Contractor’s insurance shall not be permitted to expire, be suspended, be
canceled, or be materially changed for any reason without thirty (30) days prior written
notice to Maricopa County. Contractor must provide to Maricopa County, within two (2)
business days of receipt, if they receive notice of a policy that has been or will be
suspended, canceled, materially changed for any reason, has expired, or will be expiring.
Such notice shall be sent directly to Maricopa County Office of Procurement Services

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and shall be mailed or hand delivered to 320 West Lincoln Street, Phoenix, AZ 85003, or
emailed to the Procurement Officer noted in the solicitation.
6.3 FORCE MAJEURE:
6.3.1 Neither party shall be liable for failure of performance, nor incur any liability to the other
party on account of any loss or damage resulting from any delay or failure to perform all
or any part of this Contract if such delay or failure is caused by events, occurrences, or
causes beyond the reasonable control and without negligence of the parties. Such events,
occurrences, or causes will include Acts of God/Nature (including fire, flood, earthquake,
storm, hurricane or other natural disaster), war, invasion, act of foreign enemies,
hostilities (whether war is declared or not), civil war, riots, rebellion, revolution,
insurrection, military or usurped power or confiscation, terrorist activities,
nationalization, government sanction, lockout, blockage, embargo, labor dispute, strike,
interruption or failure of electricity or telecommunication service.
6.3.2 Each party, as applicable, shall give the other party notice of its inability to perform and
particulars in reasonable detail of the cause of the inability. Each party must use best
efforts to remedy the situation and remove, as soon as practicable, the cause of its
inability to perform or comply.
6.3.3 The party asserting Force Majeure as a cause for non-performance shall have the burden
of proving that reasonable steps were taken to minimize delay or damages caused by
foreseeable events, that all non-excused obligations were substantially fulfilled, and that
the other party was timely notified of the likelihood or actual occurrence which would
justify such an assertion, so that other prudent precautions could be contemplated.
Agreed; however, nothing herein shall relieve the County from its obligation to pay
fees or premiums beyond the grace period.
6.4 WARRANTY OF SERVICES:
6.4.1 The Contractor warrants that all services provided hereunder will conform to the
requirements of the Contract, including all descriptions, specifications and attachments
made a part of this Contract. County’s acceptance of services or goods provided by the
Contractor shall not relieve the Contractor from its obligations under this warranty.
6.4.2 In addition to its other remedies, County may, at the Contractor's expense, require prompt
correction of any services failing to meet the Contractor's warranty herein. Services
corrected by the Contractor shall be subject to all the provisions of this Contract in the
manner and to the same extent as services originally furnished hereunder.
6.5 INSPECTION OF SERVICES:
6.5.1 The Contractor shall provide and maintain an inspection system acceptable to County
covering the services under this Contract. Complete records of all inspection work
performed by the Contractor shall be maintained and made available to County during
Contract performance and for as long afterwards as the Contract requires.
6.5.2 County has the right to inspect and test all services called for by the Contract, to the
extent practicable at all times and places during the term of the Contract. County shall
perform inspections and tests in a manner that will not unduly delay the work.
6.5.3 If any of the services do not conform to Contract requirements, County may require the
Contractor to perform the services again in conformity with Contract requirements, at no
cost to the County. When the defects in services cannot be corrected by re-performance,
County may:

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6.5.3.1 Require the Contractor to take necessary action to ensure that future
performance conforms to Contract requirements; and
6.5.3.2 Reduce the Contract price to reflect the reduced value of the services performed.
6.5.4 If the Contractor fails to promptly perform the services again or to take the necessary
action to ensure future performance in conformity with Contract requirements, County
may:
6.5.4.1 By Contract or otherwise, perform the services and charge to the Contractor,
through direct billing or through payment reduction, any cost incurred by
County that is directly related to the performance of such service; or
6.5.4.2 Terminate the Contract for default.
6.6 NO MINIMUM OR MAXIMUM PURCHASE OBLIGATION:
6.6.1 This Contract does not guarantee any minimum or maximum purchases will be made.
Orders will only be placed under this Contract when the County identifies a need and
proper authorization and documentation have been approved.
6.6.2 Contractors agree to accept verbal notification of cancellation of Purchase Orders from
the County Procurement Officer with written notification to follow. Contractor
specifically acknowledges to be bound by this cancellation policy.
6.7 STOP WORK ORDER:
The Procurement Officer may, at any time, by written order to the Contractor, require the
Contractor to stop all, or any part, of the work called for by this contract for a period of ninety (90)
calendar days after the order is delivered to the Contractor, and for any further period to which the
parties may agree. The order shall be specifically identified as a stop work order issued under this
clause. Upon receipt of the order, the Contractor shall immediately comply with its terms and take
all reasonable steps to minimize the incurrence of costs allocable to the work covered by the order
during the period of work stoppage. Within a period of 90 calendar days after a stop-work is
delivered to the Contractor, or within any extension of that period to which the parties shall have
agreed, the Procurement Officer shall either:
6.7.1 Cancel the stop work order; or
6.7.2 Terminate the work covered by the order as provided in the Default, or the Termination
for Convenience clause of this Contract.
6.7.3 The Procurement Officer may make an equitable adjustment in the delivery schedule
and/or Contract price, or otherwise, and the Contract shall be modified, in writing,
accordingly, if the Contractor demonstrates that the stop work order resulted in an
increase in costs to the Contractor.
Please note in the case of a fully insured product, we will issue our state filed policy and
certificate. These are filed documents, and there is limited flexibility to change the
provisions. As such, any conflict between the terms of this Solicitation and the insurance
policy, the terms of the insurance policy shall govern. If necessary, a side document
addressing mutually agreed-upon provisions may be prepared to address issues that are not
contained in the insurance policy or certificate.
6.8 TERMINATION FOR CONVENIENCE:
Maricopa County may terminate the Contract for convenience by providing sixty (60) calendar
days advance notice to the Contractor.

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6.9 TERMINATION FOR DEFAULT:
The County may, by written notice of default to the Contractor, terminate this Contract in whole
or in part if the Contractor fails to:
6.9.1 Deliver the supplies or to perform the services within the time specified in this Contract
or any extension;
6.9.2 Make progress, so as to endanger performance of this Contract; or
6.9.3 Perform any of the other provisions of this Contract.
The County’s right to terminate this contract under these subparagraphs may be exercised if the
Contractor does not cure such failure within ten (10) business days (or more if authorized in
writing by the County) after receipt of the notice from the Procurement Officer specifying the
failure.
6.10 STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST:
Notice is given that pursuant to A.R.S. § 38-511 the County may cancel any Contract without
penalty or further obligation within three years after execution of the Contract, if any person
significantly involved in initiating, negotiating, securing, drafting or creating the Contract on
behalf of the County is at any time while the Contract or any extension of the Contract is in effect,
an employee or agent of any other party to the Contract in any capacity or consultant to any other
party of the Contract with respect to the subject matter of the Contract. Additionally, pursuant to
A.R.S § 38-511 the County may recoup any fee or commission paid or due to any person
significantly involved in initiating, negotiating, securing, drafting or creating the Contract on
behalf of the County from any other party to the Contract arising as the result of the Contract.
6.11 CONTRACTOR LICENSE REQUIREMENT:
6.11.1 The Contractor shall procure all permits, insurance, licenses and pay the charges and fees
necessary and incidental to the lawful conduct of his/her business, and as necessary
complete any required certification requirements, required by any and all governmental
or non-governmental entities as mandated to maintain compliance with and in good
standing for all permits and/or licenses. The Contractor shall keep fully informed of
existing and future trade or industry requirements, Federal, State and Local laws,
ordinances, and regulations which in any manner affect the fulfillment of a Contract and
shall comply with the same. Contractor shall immediately notify both Office of
Procurement Services and the Department of any and all changes concerning permits,
insurance or licenses.
6.12 SUBCONTRACTING:
6.12.1 The Contractor may not assign to another contractor or subcontract to another party for
performance of the terms and conditions hereof without the written consent of the
County. All correspondence authorizing subcontracting must reference the Contract
Number and identify the job project.
6.12.2 The subcontractor’s rate for the job shall not exceed that of the Prime Contractor’s rate,
as bid in the pricing section, unless the Prime Contractor is willing to absorb any higher
rates or the County has approved the increase. The subcontractor’s invoice shall be
invoiced directly to the Prime Contractor, who in turn shall pass-through the costs to the
County, without mark-up. A copy of the subcontractor’s invoice must accompany the
Prime Contractor’s invoice.
Cigna agrees not to assign the contract in whole; however, while Cigna serves as the sole
provider of services requested in this proposal, a number of the services under our contracts
are performed by affiliates of Cigna or by subcontracted vendors with a particular expertise
in order to help contain costs without prior written approval for such subcontractors. These

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subcontracted arrangements are in place to service our entire book of business and have not
been specifically contracted to service this RFP arrangement. Cigna will remain wholly
responsible for provision of all services for which it contracts with the County.
Cigna agrees to seek prior written consent of the County for any subcontract work procured
specifically to provide the services requested in this proposal.
6.13 AMENDMENTS:
All amendments to this Contract shall be in writing and approved/signed by both parties. Maricopa
County Office of Procurement Services shall be responsible for approving all amendments for
Maricopa County.
Agreed; however, since this is a fully insured product, our insurance policy and certificate
will be issued and made part of the standard contract. Since the insurance policy and
certificate are filed documents, there is limited flexibility to change the provisions. As such,
any conflict between the terms of this standard contract and the insurance policy, the terms
of the insurance policy shall govern.
6.14 ADDITIONS/DELETIONS OF REQUIREMENTS:
The County reserves the right to add and/or delete materials and services to a Contract. If a
service requirement is deleted, payment to the Contractor will be reduced proportionately, to the
amount of service reduced in accordance with the bid price. If additional materials or services are
required from a Contract, prices for such additions will be negotiated between the Contractor and
the County.
6.15 STRICT COMPLIANCE:
Acceptance by County of a performance that is not in strict compliance with the terms of the
Contract shall not be deemed to be a waiver of strict compliance with respect to all other terms of
the Contract.
6.16 VALIDITY:
The invalidity, in whole or in part, of any provision of this Contract shall not void or affect the
validity of any other provision of the Contract.
6.17 SEVERABILITY:
The removal, in whole or in part, of any provision of this Contract shall not void or affect the
validity of any other provision of this Contract.
Acknowledged; however, if the removal will deprive either party of the economic or other
material benefits conferred by this Agreement, the parties shall negotiate a provision or
provisions the effect(s) of which return the parties as closely as possible to their original
positions.
6.18 RIGHTS IN DATA:
The County shall have the use of data and reports resulting from a Contract without additional cost
or other restriction except as may be established by law or applicable regulation. Each Party shall
supply to the other Party, upon request, any available information that is relevant to a Contract and
to the performance thereunder.
6.19 NON-DISCRIMINATION:
Contractor agrees to comply with all provisions and requirements of Arizona Executive Order
2009-09 including flow down of all provisions and requirements to any subcontractors. Executive
Order 2009-09 supersedes Executive order 99-4 and amends Executive order 75-5 and may be
viewed and downloaded at the Arizona State Library Research website
(http://azmemory.azlibrary.gov/cdm/singleitem/collection/execorders/id/680/rec/1) which is
hereby incorporated into this contract as if set forth in full herein. During the performance of this

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Contract, Contractor shall not discriminate against any employee, client or any other individual in
any way because of that person’s age, race, creed, color, religion, sex, disability or national origin.
6.20 ISRAEL BOYCOTT:
By signing this Contract, the Contractor certifies that they are in compliance with Article 9, A.R.S.
§ 35-393 et seq.
6.21 CERTIFICATION REGARDING DEBARMENT AND SUSPENSION:
6.21.1 The undersigned (authorized official signing on behalf of the Contractor) certifies to the
best of his or her knowledge and belief that the Contractor, it’s current officers and
directors;
6.21.1.1 are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from being awarded any contract or grant by
any United States Department or Agency or any state, or local jurisdiction;
6.21.1.2 have not within three (3) year period preceding this Contract;
6.21.1.2.1 been convicted of fraud or any criminal offense in connection with
obtaining, attempting to obtain, or as the result of performing a
government entity (Federal, State or local) transaction or contract;
and
6.21.1.2.2 been convicted of violation of any Federal or State antitrust statues or
conviction for embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen
property regarding a government entity transaction or contract;
6.21.1.2.3 are not presently indicted or criminally charged by a government
entity (Federal, State or local) with commission of any criminal
offenses in connection with obtaining, attempting to obtain, or as the
result of performing a government entity public (Federal, State or
local) transaction or contract; and are not presently facing any civil
charges from any governmental entity regarding obtaining,
attempting to obtain, or from performing any governmental entity
contract or other transaction; and have not within a three (3) year
period preceding this Contract had any public transaction (Federal,
State or local) terminated for cause or default.
6.21.1.3 If any of the above circumstances described in the paragraph are applicable to
the entity submitting a bid for this requirement, include with your bid an
explanation of the matter including any final resolution.
6.21.2 The Contractor shall include, without modification, this clause in all lower tier covered
transactions (i.e. transactions with subcontractors) and in all solicitations for lower tier
covered transactions related to this Contract.
6.22 VERIFICATION REGARDING COMPLIANCE WITH A.R.S. §41-4401 AND FEDERAL
IMMIGRATION LAWS AND REGULATIONS:
6.22.1 By entering into the Contract, the Contractor warrants compliance with the Immigration
and Nationality Act (INA using e-verify) and all other Federal immigration laws and
regulations related to the immigration status of its employees and A.R.S. §23-214(A). The
Contractor shall obtain statements from its subcontractors certifying compliance and shall
furnish the statements to the Procurement Officer upon request. These warranties shall
remain in effect through the term of the Contract. The Contractor and its subcontractors
shall also maintain Employment Eligibility Verification forms (I-9) as required by the

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Immigration Reform and Control Act of 1986, as amended from time to time, for all
employees performing work under the Contract and verify employee compliance using the
E-verify system and shall keep a record of the verification for the duration of the
employee’s employment or at least three (3) years, whichever is longer. I-9 forms are
available for download at USCIS.GOV.
6.22.2 The County retains the legal right to inspect Contractor and subcontractor employee
documents performing work under this Contract to verify compliance with paragraph 6.22.1
of this Section. Contractor and subcontractor shall be given reasonable notice of the
County’s intent to inspect and shall make the documents available at the time and date
specified. Should the County suspect or find that the Contractor or any of its subcontractors
are not in compliance, the County will consider this a material breach of the Contract and
may pursue any and all remedies allowed by law, including, but not limited to; suspension
of work, termination of the Contract for default, and suspension and/or debarment of the
Contractor. All costs necessary to verify compliance are the responsibility of the Contractor.
6.23 INFLUENCE:
As prescribed in MC1-1203 of the Maricopa County Procurement Code, any effort to influence an
employee or agent to breach the Maricopa County Ethical Code of Conduct or any ethical conduct
may be grounds for Disbarment or Suspension under MC1-902.
An attempt to influence includes, but is not limited to:
6.23.1 A Person offering or providing a gratuity, gift, tip, present, donation, money,
entertainment or educational passes or tickets, or any type of valuable contribution or
subsidy,
6.23.2 That is offered or given with the intent to influence a decision, obtain a contract, garner
favorable treatment, or gain favorable consideration of any kind.
If a Person attempts to influence any employee or agent of Maricopa County, the Chief
Procurement Officer, or his designee, reserves the right to seek any remedy provided by the
Maricopa County Procurement Code, any remedy in equity or in the law, or any remedy provided
by this contract.
6.24 UNIFORM ADMINISTRATIVE REQUIREMENTS:
By entering into this Contract the Contractor agrees to comply with all applicable provisions of
Title 2, Subtitle A, Chapter II, PART 200—UNIFORM ADMINISTRATIVE REQUIREMENTS,
COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS contained in
Title 2 C.F.R. § 200 et seq.
6.25 ACCESS TO AND RETENTION OF RECORDS FOR THE PURPOSE OF AUDIT AND/OR
OTHER REVIEW:
6.25.1 In accordance with section MCI 371 of the Maricopa County Procurement Code the
Contractor agrees to retain (physical or digital copies of) all books, records, accounts,
statements, reports, files, and other records and back-up documentation relevant to this
Contract for six (6) years after final payment or until after the resolution of any audit
questions which could be more than six (6) years, whichever is latest. The County,
Federal or State auditors and any other persons duly authorized by the Department shall
have full access to, and the right to examine, copy and make use of, any and all said
materials.
6.25.2 If the Contractor’s books, records , accounts, statements, reports, files, and other records
and back-up documentation relevant to this Contract are not sufficient to support and
document that requested services were provided, the Contractor shall reimburse Maricopa
County for the services not so adequately supported and documented.

SERIAL 190174-S
Under a fully insured arrangement, Cigna shall cooperate with an required audit or review
of applicable documents, conducted by a duly authorized County representative,. when
required by applicable state or federal law. Cigna is fully responsible for claims
administration, carries all risk associated with such processes, and is routinely examined by
state insurance commissioners. External audits are not typically permitted. Cigna has an
internal claim quality assurance program to monitor internal performance standards to
ensure the accuracy of claims payment.
6.26 AUDIT DISALLOWANCES:
If at any time it is determined by the County that a cost for which payment has been made is a
disallowed cost, the County shall notify the Contractor in writing of the disallowance. The course
of action to address the disallowance shall be at sole discretion of the County, and may include
either an adjustment to future invoices, request for credit, request for a check or a deduction from
current invoices submitted by the Contractor equal to the amount of the disallowance, or to require
reimbursement forthwith of the disallowed amount by the Contractor by issuing a check payable
to Maricopa County.
Under a fully insured arrangement, Cigna shall cooperate with an required audit or review
of applicable documents, conducted by a duly authorized County representative,. when
required by applicable state or federal law. Cigna is fully responsible for claims
administration, carries all risk associated with such processes, and is routinely examined by
state insurance commissioners. External audits are not typically permitted. Cigna has an
internal claim quality assurance program to monitor internal performance standards to
ensure the accuracy of claims payment.
6.27 OFFSET FOR DAMAGES:
In addition to all other remedies at Law or Equity, the County may offset from any money due to
the Contractor any amounts Contractor owes to the County for damages resulting from breach or
deficiencies in performance of the Contract.
Cigna agrees that the County shall have the right to offset monies due to Cigna if
Cigna fails to perform its services as required by this contract. within industry
standards.
Cigna will indemnify and hold the County, its officers, directors, agents,
and/or employees (acting in the scope of their employment and not as
claimants under the plan) harmless from and against all costs, damages, judgments,
attorney fees, expenses, obligations, and liabilities of any kind or nature that occur
as the result of Cigna’s failure to pay valid claims within the terms and conditions of
the policy where such failure is not due to any action or inaction by the County, its
officers, directors, agents, and/or employees.
6.28 CONFIDENTIAL INFORMATION:
Any information obtained in the course of performing this Contract may include information that
is proprietary or confidential to the County. This provision establishes the Contractor’s obligation
regarding such information.
The Contractor shall establish and maintain procedures and controls that are adequate to assure
that no information contained in its records and/or obtained from the County or from others in
carrying out its functions (services) under the Contract shall be used by or disclosed by it, its
agents, officers, or employees, except as required to efficiently perform duties under the Contract.
The Contractor’s procedures and controls at a minimum must be the same procedures and controls
it uses to protect its own proprietary or confidential information. If, at any time during the duration
of the Contract, the County determines that the procedures and controls in place are not adequate,
the Contractor shall institute any new and/or additional measures requested by the County within
fifteen (15) calendar days of the written request to do so.

SERIAL 190174-S
Any requests to the Contractor for County proprietary or confidential information shall be referred
to the County for review and approval, prior to any dissemination.
Agreed; however, if, at any time during the duration of the Contract, the County determines
that the procedures and controls in place are not adequate, Cigna shall institute any new
and/or additional measures mutually agreed upon by the County and Cigna.
6.29 PUBLIC RECORDS:
Under Arizona law, all Offers submitted and opened are public records and must be retained by
the Records Manager at the Office of Procurement Services. Offers shall be open to public
inspection and copying after Contract award and execution, except for such Offers or sections
thereof determined to contain proprietary or confidential information by the Office of Procurement
Services. If an Offeror believes that information in its Offer or any resulting Contract should not
be released in response to a public record request under Arizona law, the Offeror shall indicate the
specific information deemed confidential or proprietary and submit a statement with its offer
detailing the reasons that the information should not be disclosed. Such reasons shall include the
specific harm or prejudice which may arise from disclosure. The Records Manager of the Office of
Procurement Services shall determine whether the identified information is confidential pursuant
to the Maricopa County Procurement Code.
6.30 PRICES:
Contractor warrants that prices extended to County under this Contract are no higher than those
paid by any other customer for these or similar services.
6.31 INTEGRATION:
This Contract represents the entire and integrated agreement between the parties and supersedes
all prior negotiations, proposals, communications, understandings, representations, or agreements,
whether oral or written, express or implied.
To the extent that Cigna has provided responses in this RFP, which were definitive and
accepted by the County, Cigna agrees to issue policies reflecting the agreed-upon
specifications. The provisions of the insurance policy will supersede the RFP.
6.32 RELATIONSHIPS:
6.32.1 In the performance of the services described herein, the Contractor shall act solely as an
independent contractor, and nothing herein or implied herein shall at any time be
construed as to create the relationship of employer and employee, co-employee,
partnership, principal and agent, or joint venture between the County and the Contractor.
6.32.2 The County reserves the right of final approval on proposed staff for all Task Orders.
Also, upon request by the County, the Contractor will be required to remove any
employees working on County projects and substitute personnel based on the discretion
of the County within Two (2) business days, unless previously approved by the County.
6.33 GOVERNING LAW:
This Contract shall be governed by the laws of the State of Arizona. Venue for any actions or
lawsuits involving this Contract will be in Maricopa County Superior Court, Phoenix, Arizona.
6.34 ORDER OF PRECEDENCE:
In the event of a conflict in the provisions of this Contract and Contractor’s license agreement, if
applicable, the terms of this Contract shall prevail.
6.35 INCORPORATION OF DOCUMENTS:
The following are to be attached to and made part of this Contract:

SERIAL 190174-S
6.35.1 Exhibit A, Pricing;
6.35.2 Exhibit B, (Scope of Work);
6.35.3 Exhibit B-1, (Plan Design); and
Exhibit C, HIPAA Business Associate Agreement- Left out intentionally
Since this is a fully-insured offering, Cigna is not the Business Associate of the County as
defined under HIPAA. Rather, Cigna is the Covered Entity and a business associate
agreement is not needed. Cigna is governed by HIPAA as a Covered Entity and that Cigna
will comply with the HIPAA Privacy and Security Rules as amended by HITECH.
NOTICES:
All notices given pursuant to the terms of this Contract shall be addressed to:
For County:
Maricopa County
Office of Procurement Services
ATTN: Contract Administration
320 West Lincoln Street
Phoenix, Arizona 85003-2494
For Contractor:

SERIAL 190174-S
IN WITNESS WHEREOF, this Contract is executed on the date set forth above.
CONTRACTOR
AUTHORIZED SIGNATURE
Kimberly Shepard, Vice President
PRINTED NAME AND TITLE
5310 E High Street, Suite 200, Phoenix AZ 85054
ADDRESS
November 20, 2018
DATE
MARICOPA COUNTY
CHAIRMAN, BOARD OF SUPERVISORS DATE
ATTESTED:
CLERK OF THE BOARD DATE
APPROVED AS TO FORM:
DEPUTY COUNTY ATTORNEY DATE

SERIAL 190174-S
EXHIBIT A
PRICING
SERIAL 190174-S
NIGP CODE: 94828
RESPONDENT'S NAME: Cigna Dental Health Plan of Arizona, Inc.
COUNTY VENDOR NUMBER: 20110016961
ADDRESS: 1571 Sawgrass Corporate Parkway, Sunrise, FL 33323
REMIT TO ADDRESS: 5476 Collection Center Drive, Chicago, IL 60693-0547
TELEPHONE NUMBER: N/A
FACSIMILE NUMBER: N/A
COMPANY WEB SITE: www.cigna.com
CONTACT (REPRESENTATIVE): Erica Emmons
E-MAIL ADDRESS (REP): erica.emmons@cigna.com
PAYMENT TERMS:
NET 30
1.0 PRICING:
Per Employee/Per Month Costs
Employee Employee + Employee + Employee +
Plan Year Only Spouse Children Family
YEAR 1 $9.26 $15.66 $21.67 $25.52
YEAR 2 $9.26 $15.66 $21.67 $25.52
YEAR 3 $9.26 $15.66 $21.67 $25.52
YEAR 4 5% 5% 5% 5%
YEAR 5 5% 5% 5% 5%
YEAR 6 5% 5% 5% 5%

SERIAL 190174-S
EXHIBIT B
(GENERAL SCOPE OF SERVICES)
1.0 INTENT:
It is the intent of this contract to provide a fully insured Prepaid Dental Plan with coverage commencing July
1, 2019 to cover employees and their dependents throughout Maricopa County.
2.1 Scope of Services to Be Provided Under This Bid
2.1.1 Contract effective date will be July 1, 2019 with an initial term of three (3) years. Rates
shall be pre-determined for at least the first three (3) contract years.
2.1.2 The contract’s anniversary date shall fall on July 1st. All contract or benefit changes
shall only occur on this date unless previously agreed to in writing by all parties.
2.1.3 Written, nine (9) month rate change notification and/or any major plan change
notification including but not limited to benefit plan design (co-pay schedule) and
provider network changes shall be provided to the County prior to the anniversary dates
for years four (4), five (5), six (6) and shall include supporting documentation. The first
notification is due October 1, 2021 for year four (4) of the contract (2022). Preliminary,
non-binding renewal projections to assist the County in the budgetary process shall be
provided as requested.
2.1.4 Contractor shall notify the County in writing at least nice (9) months prior to a voluntary,
unilateral plan termination or plan replacement or reduction of benefits effective on the
next contract anniversary date.
2.1.5 Contractor shall have the ability to administer current plan design. The County shall self-
administer premiums. Premiums shall be paid monthly. Increases or decreases in
premium are effective in the same month in which the change is effective.
2.1.6 The County’s Consolidated Omnibus Budget Reconciliation Act (COBRA)
Administrator shall handle eligibility notifications, terminations and premium payments
for COBRA participants.
2.1.7 The County maintains the right to accept, reject, or cancel the contract at any time for
convenience or if there is a significant change, in the County’s opinion, in the
Contractor’s operation of the plan, including, but not limited to the provider network,
satisfaction with customer service, quality of the plan’s services, and County employees’
satisfaction with the administration of the plan.
2.1.8 Contractor shall be responsible for drafting, producing and distributing, subject to County
review and approval, all communication materials, certificates of coverage, plan
summaries and administrative forms. Such documents shall be finalized prior to the
annual Open Enrollment period or by any other dates negotiated by all parties. All
documents shall be available electronically for posting on the County’s intranet and
internet websites.
2.1.9 Contractor shall provide quarterly County-specific reports that summarize utilization,
customer service, call center statistics, problem resolution, and appeals activity and
outcomes.
2.1.10 Contractor shall provide summarized results of a County-specific satisfaction survey at
least annually. Results of the survey will be tied to performance guarantees.

SERIAL 190174-S
2.1.11 Contractor shall meet periodically, at least quarterly, with the Employee Benefits
Division management to conduct operational and strategic meetings regarding benefit
plan operations, issue resolution, customer service, and plan direction.
2.1.12 Contractor shall respond to account issues and member services issues within one (1)
business day and shall include in its response a plan to resolve the issue and timeframe
established to do so.
2.1.13 As required and at no additional charge to the County, Contractor shall provide personnel
to attend and facilitate presentations at Open Enrollment fairs, benefit fairs, and other
periodic employee informational meetings, (e.g.; transition of services meetings) and
health fairs focused on wellness and prevention. Meetings may be scheduled at County
locations throughout Maricopa County.
2.1.14 Contractor shall provide educational information to be used in newsletters to promote
wellness and preventive care.
2.1.15 Contractor shall be able to accept daily, bi-weekly, or weekly eligibility files for active
employees via custom electronic interfaces created with data from the County’s third
party administrator’s systems. The Contractor shall be able to accept and process
eligibility files within two business days of receipt. Contractor shall also be able to
generate an electronic exception report for the County and its third party administrator
within two (2) business days after processing eligibility files.
2.1.16 The County shall make the final determination on errors and has ultimate authority to
correct any and all administrative errors.
2.1.17 The contract and rates shall not include any commission load.
2.1.18 The Contractor shall have the capability to accept electronic fund transfers.
2.1.19 The Contractor shall provide a detailed implementation plan and meet with the Employee
Benefits Division management to establish administrative and claims payment
procedures.
2.1.20 Contractor shall provide initial ID cards for newly-eligible employees and their covered
dependents within ten (10) business days of receipt of the eligibility file or upon request
from plan participants.
2.1.21 Takeover shall be on a “no-loss, no-gain” basis. Contractor shall have a process to
handle dental treatment already in process but not completed by the beginning of this
contract.
2.1.22 Contractor shall provide run out services for a minimum of twelve (12) months following
the termination of the contract.
2.2 Mandatory Contractor Requirements
2.2.1 Contractor’s provider network shall include a minimum (open to new patients) of two
hundred fifty (250) General Dentists in Maricopa County and at least one hundred (100)
Specialists with current active contracts operating in Maricopa County and who have the
capacity to provide services to Maricopa County employees. The network shall be able
to provide services in the event of emergency, after hours or on weekends and holidays.
The Contractor shall have a credentialing process in place to validate the background and
quality of its providers.
2.2.2 Contractor shall provide a list of current General Dentists and Specialists and whether
their practices are currently open or closed to new members/patients. List shall not
include the same provider at more than one office location. List shall also include
provider’s office address and phone number.

SERIAL 190174-S
2.2.3 Contractor shall provide a Geo-Access report indicating the locations of all in-network
dentist offices including General Dentists and Specialists (This should be included in Bid
response as Exhibit D). Contract requires that there be two (2) General Dentists within a
five (5) mile radius of each zip code in which County employees live. Contract requires
that there be two (2) Specialists within a ten (10) mile radius of each zip code in which
County employees live.
2.2.4 The Contractor shall have a net worth (total assets – total liabilities) of $5,000,000.00 or
more during the most recent fiscal year report.
2.2.5 Contractor shall have at least five (5) client accounts with populations of more than two
thousand five hundred (2,500) employees within the Southwest Region. A minimum of
five (5) current references must be included with the Bid, listing the current contact
information (name, title, phone number, e-mail address) of each reference.
2.2.6 Contractor must have been in the Pre-Paid Dental business for at least three (3)
consecutive years.
2.2.7 Contractor shall be able to accept the subscriber identification number as the employee
identification number, a nine (9) digit County-assigned number, unique to Maricopa
County employees.
2.2.8 Contractor shall conduct business in compliance with HIPAA (Health Information
Portability and Accountability Act) and applicable State statutes.
2.2.9 Contractor shall, at minimum, provide toll-free access to customer service representatives
between the hours of 7:00 a.m. and 5:00 p.m. MST (Phoenix Local Time), Monday
through Friday, and some weekend hours.
2.2.10 Contractor shall provide performance guarantees that put a percentage of their premiums
(instead of fees) at risk for specific services.
2.2.11 Contractor shall maintain a website where employees may look up current providers,
view explanation of benefits, and print temporary ID cards.
2.3 USAGE REPORT:
The Contractor shall furnish the County a usage report upon re quest delineating the acquisition
activity governed by the Contract. The format of the report shall be approved by the County and
shall disclose the quantity and dollar value of each contract item by individual unit.
2.4 TAX (SERVICES):
No tax shall be invoiced or paid against Contractor’s labor. It is the responsibility of the
Contractor to determine any and all applicable taxes and include the cost in the proposal price.

SERIAL 190174-S
EXHIBIT B-1
PLAN DESIGN
GENERAL SPECIALIST
DENTIST COPAY* /
COPAY ESTIMATED
Code PROCEDURE DESCRIPTION
COST TO
THE
MEMBER
DIAGNOSTIC - Procedures that aid the dentist in evaluating
existing conditions and determining required dental care.
D9431 OFFICE VISIT-PER PATIENT/PER VISIT $3.00
D0120 PERIODIC ORAL EVALUATION - EST PATIENT $0.00 $33.00
D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $12.00 $48.00
D0145 ORAL EVALUATION -NEW OR ESTABLISHED PATIENT $0.00
UNDER AGE 3/COUNSELING WITH PRIMARY CAREGIVER $45.00
D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR $0.00
ESTABLISHED PATIENT $51.00
D0160 DETAILED AND EXTENSIVE ORAL EVALUATION- $55.00
PROBLEM FOCUSED, BY REPORT $90.00
D0170 REEVALUATION-LIMITED, PROBLEM $15.00
FOCUSED(ESTABLISHED PATIENT; NOT POST-OP VISIT) $45.00
D0180 COMPREHENSIVE PERIODONTAL EVALUATION NEW OR $0.00
ESTABLISHED PATIENT $65.00
D0210 INTRAORAL-COMPLETE SERIES (INCLUDING $0.00
BITEWINGS) $81.00
D0220 INTRAORAL-PERIAPICAL FIRST FILM $0.00 $18.00
D0230 INTRAORAL-PERIAPICAL EACH ADDITIONAL FILM $0.00 $15.00
D0240 INTRAORAL-OCCLUSAL FILM $0.00 $24.00
D0270 BITEWING-SINGLE FILM $0.00 $18.00
D0272 BITEWINGS-TWO FILMS $0.00 $27.00
D0273 BITEWINGS-THREE FILMS $0.00 $30.00
D0274 BITEWINGS-FOUR FILMS $0.00 $39.00
D0330 PANORAMIC FILM $0.00 $68.00
D0460 PULP VITALITY TESTS $0.00 $31.00
D0470 DIAGNOSTIC CASTS $10.00 $73.00
PREVENTIVE - Procedures that prevent the occurrence of
oral diseases.
D1110 PROPHYLAXIS (Cleaning) ADULT $0.00 $56.00
D1120 PROPHYLAXIS (Cleaning) CHILD $0.00 $44.00
TOPICAL APPLICATION OF FLORIDE VARNISH (LIMIT 2 $0.00
PER CALENDAR YEAR). THERE IS A COMBINED LIMIT OF
A TOTAL OF 2 D1206s AND /OR D1208s PER CALENDAR
D1206 YEAR $27.00
TOPICAL APPLICATION OF FLUORIDE (LIMIT 2 PER $0.00
CALENDAR YEAR). THERE IS A COMBINED LIMIT OF A
TOTAL OF 2 D1208s AND/OR D1206s PER CALENDAR
D1208 YEAR. $23.00
D1310 NUTRITIONAL COUNSELING FOR CONTROL OF DENTAL $0.00
DISEASE $30.00
D1330 ORAL HYGIENE INSTRUCTIONS $0.00 $36.00
D1351 SEALANT-PER TOOTH $12.00 $34.00

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D1510 SPACE MAINTAINER-FIXED-UNILATERAL $20.00 $199.00
D1515 SPACE MAINTAINER-FIXED-BILATERAL $20.00 $304.00
D1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $20.00 $197.00
D1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $20.00 $298.00
D1550 RE-CEMENTATION OF SPACE MAINTAINER $20.00 $45.00
D1555 REMOVAL OF FIXED SPACE MAINTAINER -BY DENTIST $25.00
WHO DID NOT PLACE APPLIANCE $51.00
RESTORATIVE Those procedures for restoring lost tooth
structure.
D2140 AMALGAM FILLING-ONE SURFACE, PRIMARY OR $9.00
PERMANENT $84.00
D2150 AMALGAM FILLING-TWO SURFACES, PRIMARY OR $13.00
PERMANENT $105.00
D2160 AMALGAM FILLING-THREE SURFACES, PRIMARY OR $17.00
PERMANENT $127.00
D2161 AMALGAM FILLING-FOUR OR MORE SURFACES, $21.00
PRIMARY OR PERMANENT $151.00
D2330 RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR $22.00 $107.00
D2331 RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR $28.00 $129.00
D2332 RESIN-BASED COMPOSITE-THREE SURFACES, $40.00
ANTERIOR $157.00
D2335 RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES $52.00
OR INVOLVING INCISAL ANGLE (ANTERIOR) $188.00
D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR $70.00 $234.00
D2391 RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR $22.00 $117.00
D2392 RESIN-BASED COMPOSITE-TWO SURFACES, $28.00
POSTERIOR $147.00
D2393 RESIN-BASED COMPOSITE-THREE SURFACES, $44.00
POSTERIOR $179.00
D2394 RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, $44.00
POSTERIOR $210.00
D2510 INLAY-METALLIC-ONE SURFACE $135.00
D2520 INLAY-METALLIC-TWO SURFACES $150.00
D2530 INLAY-METALLIC-THREE OR MORE SURFACES $170.00
CROWNS - single restorations only.
D2710 RESIN-BASED COMPOSITE (INDIRECT ) CROWN - 3/4 $250.00
D2712 RESIN-BASED COMPOSITE (INDIRECT) CROWN $250.00
D2720 RESIN WITH HIGH NOBLE METAL $250.00
D2721 CROWN-RESIN WITH PREDOMINANTLY BASE METAL $250.00
D2722 CROWN - RESIN WITH NOBLE METAL $250.00
D2740 CROWN-PORCELAIN/CERAMIC SUBSTRATE $260.00
D2750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $250.00
D2751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE $250.00
METAL
D2752 CROWN-PORCELAIN FUSED TO NOBLE METAL $250.00
D2780 CROWN-3/4 CAST HIGH NOBLE METAL $250.00
D2781 CROWN-3/4 CAST PREDOMINANTLY BASE METAL $250.00
D2782 CROWN-3/4 CAST NOBLE METAL $250.00
D2783 CROWN-3/4 PORCELAIN/CERAMIC $250.00
D2790 CROWN-FULL CAST HIGH NOBLE METAL $250.00
D2791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $250.00

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D2794 CROWN - TITANIUM $250.00
D2792 CROWN-FULL CAST NOBLE METAL $250.00
D2799 PROVISIONAL CROWN-TEMPORARY RESTORATION OF $38.00
AT LEAST SIX MONTHS
D2910 RE-CEMENT INLAY, ONLAY, OR PARTIAL COVERAGE $20.00
RESTORATION
D2920 RE-CEMENT CROWN $20.00
D2930 PREFABRICATED STAINLESS STEEL CROWN-PRIMARY $50.00
TOOTH
D2931 PREFABRICATED STAINLESS STEEL CROWN- $50.00
PERMANENT TOOTH
D2940 SEDATIVE FILLING TEMPORARY FILLING TO RELIEVE $0.00
PAIN
D2950 CORE BUILDUP INCLUDING ANY PINS $40.00
D2951 PIN RETENTION-PER TOOTH, IN ADDITION TO $40.00
RESTORATION
D2952 POST AND CORE IN ADDITION TO CROWN, INDIRECTLY $70.00
FABRICATED
D2953 EACH ADDITIONAL INDIRECTLY FABRICATED POST- $45.00
SAME TOOTH
D2954 PREFABRICATED POST AND CORE IN ADDITION TO $60.00
CROWN
D2960 LABIAL VENEER (RESIN LAMINATE)-CHAIRSIDE $175.00
D2961 LABIAL VENEER (RESIN LAMINATE)-LABORATORY $175.00
D2962 LABIAL VENEER (PORCELAIN LAMINATE)-LABORATORY $250.00
D2970 TEMPORARY CROWN (FRACTURED TOOTH) $40.00
ENDODONTICS (Root Canal Therapy) - Procedures for
treating diseases of the dental pulp (nerve).
D3110 PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) $5.00 $52.00
D3120 PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION) $5.00 $48.00
D3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL $30.00
RESTORATION)-REMOVAL OF PULP CORONAL TO THE
DENTINOCEMENTAL JUNCTION AND APPLICATION OF
MEDICAMENT $124.00
D3221 PULPAL DEBRIDEMENT PRIMARY AND PERMANENT $55.00
TEETH $142.00
D3230 PULPAL THERAPY (RESORBABLE FILLING)-ANTERIOR, $75.00
PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) $165.00
D3240 PULPAL THERAPY (RESORBABLE FILLING)-POSTERIOR, $85.00
PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) $178.00
D3310 ANTERIOR (EXCLUDING FINAL RESTORATION) $170.00 $514.00
D3320 BICUSPID (EXCLUDING FINAL RESTORATION) $190.00 $587.00
D3330 MOLAR (EXCLUDING FINAL RESTORATION) $265.00 $738.00
D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY- $320.00
ANTERIOR $664.00
D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY- $350.00
BICUSPID $747.00
D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY- $450.00
MOLAR $874.00
D3351 APEXIFICATION/RECALCIFICATION-INITIAL VISIT (APICAL $90.00
CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT
RESORPTION, ETC.) $214.00
D3352 APEXIFICATION/RECALCIFICATION-INTERIM $90.00
MEDICATION REPLACEMENT (APICAL
CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT
RESORPTION, ETC.) $137.00

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D3353 APEXIFICATION/RECALCIFICATION-FINAL VISIT $90.00
(INCLUDES COMPLETED ROOT CANAL THERAPY-APICAL
CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT
RESORPTION, ETC.) $342.00
D3410 APICOECTOMY/PERIRADICULAR SURGERY-ANTERIOR $170.00 $568.00
D3421 APICOECTOMY/PERIRADICULAR SURGERY-BICUSPID $170.00
(FIRST ROOT) $604.00
D3425 APICOECTOMY/PERIRADICULAR SURGERY-MOLAR $170.00
(FIRST ROOT) $674.00
D3426 APICOECTOMY/PERIRADICULAR SURGERY-(EACH $125.00
ADDITIONAL ROOT) $221.00
D3430 RETROGRADE FILLING-PER ROOT $90.00 $157.00
D3450 ROOT AMPUTATION-PER ROOT $90.00 $368.00
D3920 HEMISECTION (INCLUDING ANY ROOT REMOVAL) NOT $90.00
INCLUDING ROOT CANAL THERAPY $239.00
PERIODONTICS - Procedures for treating diseases of the
gingival tissues (gum) and periodontal membrane.
D4210 GINGIVECTOMY OR GINGIVOPLASTY- FOUR OR MORE $225.00
CONTIGUOUS TEETH OR BOUNDED TEETH SPACES -
PER QUADRANT $368.00
D4211 GINGIVECTOMY OR GINGIVOPLASTY-ONE TO THREE $150.00
CONTIGUOUS TEETH OR BOUNDED TEETH SPACES -
PER QUADRANT $185.00
D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT $250.00
PLANING-FOUR OR MORE CONTIGOUS TEETH OR
BOUNDED TEETH SPACES -PER QUADRANT $466.00
D4241 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT $200.00
PLANING-ONE TO THREE CONTIGUOUS TEETH OR
BOUNDED TEETH SPACES -PER QUADRANT $388.00
D4249 CLINICAL CROWN LENGTHENING-HARD TISSUE $250.00 $496.00
D4260 OSSEOUS SURGERY INCLUDING FLAP ENTRY & $365.00
CLOSURE-FOUR OR MORE CONTIGUOUS TEETH OR
BOUNDED TEETH SPACES -PER QUADRANT $750.00
D4261 OSSEOUS SURGERY INCLUDING FLAP ENTRY & $300.00
CLOSURE - ONE TO THREE CONTIGUOUS TEETH OR
BOUNDED TEETH SPACES -PER QUADRANT $625.00
D4320 PROVISIONAL SPLINTING-INTRACORONAL $75.00 $270.00
D4321 PROVISIONAL SPLINTING-EXTRACORONAL $80.00 $198.00
D4341 PERIODONTAL SCALING AND ROOT PLANING-FOUR OR $90.00
MORE TEETH PER QUADRANT $154.00
D4342 PERIODONTAL SCALING AND ROOT PLANING-ONE TO $75.00
THREE TEETH PER QUADRANT $119.00
D4355 FULL MOUTH DEBRIDEMENT TO ENABLE $80.00
COMPREHENSIVE EVALUATION AND DIAGNOSIS $101.00
D4381 LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A $25.00
CONTROLLED RELEASE VEHICLE INTO DISEASED
CREVICULAR TISSUE, PER TOOTH, BY REPORT $49.00
D4910 PERIODONTAL MAINTENANCE $60.00 $91.00
PROSTHODONTICS - Procedures for providing artificial
replacements of missing natural teeth.
D5110 COMPLETE DENTURE-MAXILLARY $325.00
D5120 COMPLETE DENTURE-MANDIBULAR $325.00
D5130 IMMEDIATE DENTURE-MAXILLARY $350.00
D5140 IMMEDIATE DENTURE-MANDIBULAR $350.00
D5211 MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING $375.00
ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
D5212 MANDIBULAR PARTIAL DENTURE-RESIN BASE $375.00
(INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND
TEETH)

SERIAL 190174-S
D5213 MAXILLARY PARTIAL DENTURE-CAST METAL $400.00
FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING
ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
D5214 MANDIBULAR PARTIAL DENTURE- CAST METAL $400.00
FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING
ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
D5281 REMOVABLE UNILATERAL PARTIAL DENTURE-ONE $160.00
PIECE CAST METAL (INCLUDING CLASPS AND TEETH)
D5410 ADJUST COMPLETE DENTURE-MAXILLARY $25.00
D5411 ADJUST COMPLETE DENTURE-MANDIBULAR $25.00
D5421 ADJUST PARTIAL DENTURE-MAXILLARY $25.00
D5422 ADJUST PARTIAL DENTURE-MANDIBULAR $25.00
D5510 REPAIR BROKEN COMPLETE DENTURE BASE $10.00
D5520 REPLACE MISSING OR BROKEN TEETH-COMPLETE $10.00
DENTURE (EACH TOOTH)
D5610 REPAIR RESIN PARTIAL DENTURE BASE $10.00
D5620 REPAIR PARTIAL DENTURE CAST FRAMEWORK $10.00
D5630 REPAIR OR REPLACE PARTIAL DENTURE BROKEN $10.00
CLASP
D5640 REPLACE PARTIAL DENTURE BROKEN TEETH-PER $10.00
TOOTH
D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $10.00
D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $10.00
D5710 REBASE COMPLETE MAXILLARY DENTURE $20.00
D5711 REBASE COMPLETE MANDIBULAR DENTURE $20.00
D5720 REBASE MAXILLARY PARTIAL DENTURE $20.00
D5721 REBASE MANDIBULAR PARTIAL DENTURE $20.00
D5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) $69.00
D5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $69.00
D5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) $69.00
D5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) $69.00
D5750 RELINE COMPLETE MAXILLARY DENTURE $10.00
(LABORATORY)
D5751 RELINE COMPLETE MANDIBULAR DENTURE $10.00
(LABORATORY)
D5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) $10.00
D5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) $10.00
D5820 INTERIM PARTIAL DENTURE (MAXILLARY) $150.00
D5821 INTERIM PARTIAL DENTURE (MANDIBULAR) $150.00
D5850 TISSUE CONDITIONING, MAXILLARY $20.00
D5851 TISSUE CONDITIONING, MANDIBULAR $20.00
D6210 PONTIC-CAST HIGH NOBLE METAL $250.00
D6211 PONTIC-CAST PREDOMINANTLY BASE METAL $250.00
D6212 PONTIC-CAST NOBLE METAL $250.00
D6240 PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL $250.00
D6241 PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE $250.00
METAL
D6242 PONTIC-PORCELAIN FUSED TO NOBLE METAL $250.00
D6245 PONTIC-PORCELAIN/CERAMIC $235.00
D6251 PONTIC-RESIN WITH PREDOMINANTLY BASE METAL $250.00

SERIAL 190174-S
D6545 RETAINER-CAST METAL FOR RESIN BONDED FIXED $165.00
PROSTHESIS
D6721 CROWN-RESIN WITH PREDOMINANTLY BASE METAL $250.00
D6740 CROWN-PORCELAIN/CERAMIC $235.00
D6750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $250.00
D6751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE $250.00
METAL
D6752 CROWN-PORCELAIN FUSED TO NOBLE METAL $250.00
D6780 CROWN-3/4 CAST HIGH NOBLE METAL $250.00
D6781 CROWN-3/4 CAST PREDOMINANTLY BASE METAL $250.00
D6782 CROWN-3/4 CAST NOBLE METAL $250.00
D6783 CROWN-3/4 PORCELAIN/CERAMIC $250.00
D6790 CROWN-FULL CAST HIGH NOBLE METAL $250.00
D6791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $250.00
D6792 CROWN-FULL CAST NOBLE METAL $250.00
D6930 RE-CEMENT FIXED PARTIAL DENTURE $30.00
ORAL SURGERY - Procedures for treating non-restorable
teeth and diseases or injury in the oral cavity.
D7111 EXTRACTION, CORONAL REMNANTS-DECIDUOUS $35.00
TOOTH $60.00
D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT $55.00
(ELEVATION AND/OR FORCEPS REMOVAL) $81.00
D7210 SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING $60.00
ELEVATION OF MUCOPERIOSTEAL FLAP AND REMOVAL
OF BONE AND/OR SECTION OF TOOTH $136.00
D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $85.00 $162.00
D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY $100.00 $202.00
D7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $120.00 $235.00
D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS $70.00
(CUTTING PROCEDURE) $141.00
D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION OF $150.00
ACCIDENTALLY EVULSED OR DISPLACED TOOTH $298.00
D7310 ALVEOLOPLASTY IN CONJUNCTION WITH $110.00
EXTRACTIONS-FOUR OR MORE TEETH OR TOOTH
SPACES,PER QUADRANT $131.00
D7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH $110.00
EXTRACTIONS-FOUR OR MORE TEETH OR TOOTH
SPACES, PER QUADRANT $166.00
D7510 INCISION AND DRAINAGE OF ABSCESS-INTRAORAL $80.00
SOFT TISSUE $115.00
D7960 FRENULECTOMY (FRENECTOMY OR FRENOTOMY)- $90.00
SEPARATE PROCEDURE $227.00
D7971 EXCISION OF PERICORONAL GINGIVA $90.00 $116.00
INTERCEPTIVE ORTHODONTIC TREATMETN OF THE $448.00
D8050 PRIMARY DENTITION - BANDING $503.00
INTERCEPTIVE ORTHODONTIC TREATMENT OF THE $448.00
D8060 TRANSITIONAL DENTITION - BANDING $503.00
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $798.00
D8070 TRANSITIONAL DENTITION - BANDING $794.00
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $1,025.00
D8080 ADOLESCENT DENTITION - BANDING $1,049.00
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $1,125.00
D8090 ADULT DENTITION - BANDING $1,151.00
D8660 PRE-ORTHODONTIC TREATMENT VISIT $120.00 $150.00
D8670 24 MONTH TREATMENT FEE $3,264.00 $3,408.00

SERIAL 190174-S
D8670 CHARGE PER MONTH FOR 24 MONTHS $136.00 $142.00
D8670 24 MONTH TREATMENT FEE $3,936.00 $4,104.00
D8670 CHARGE PER MONTH FOR 24 MONTHS $164.00 $171.00
ORTHODONTIC RETENTION – REMOVAL OF $230.00
APPLICANCES, CONSTRUCTION, AND PLACEMENT OF
D8680 RETAINER(S) $531.00
UNSPECIFIED ORTHODONTIC PROCEDURE – BY $228.00
REPORT (ORTHODONTIC TREATMENT PLAN AND
D8999 RECORDS) $242.00
OTHER SERVICES
D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL $5.00
PAIN-MINOR PROCEDURE $59.00
D9230 ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS $25.00
OXIDE $35.00
D9430 OFFICE VISIT FOR OBSERVATION (DURING REGULARLY $0.00
SCHEDULED HOURS)-NO OTHER SERVICES
PERFORMED
D9431 OFFICE VISIT-PER PATIENT/PER VISIT Not On PCS
D9440 OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS $45.00 $73.00
D9630 OTHER DRUGS AND/OR MEDICAMENTS, BY REPORT Not On PCS
D9630 OTHER DRUGS AND/OR MEDICAMENTS, PERIDEX Not On PCS
D9920 BEHAVIOR MANAGEMENT, BY REPORT $35.00
D9940 OCCLUSAL GUARD, BY REPORT $90.00 $257.00
D9951 OCCLUSAL ADJUSTMENT LIMITED $45.00 $64.00
D9952 OCCLUSAL ADJUSTMENT COMPLETE $120.00 $243.00
D9973 EXTERNAL BLEACHING-PER TOOTH $60.00
D9974 INTERNAL BLEACHING-PER TOOTH $60.00
D9988 MISSED APPOINTMENT-FIRST $25.00
D9988 MISSED APPOINTMENT-ADDITIONAL $25.00
UCR Usual customary and reasonable or normal office fees
LAB FEE Fees charged by the dental laboratory to fabricate certain
dental products, including crowns, dentures or bridges. This
fee varies depending on the dental laboratory and materials
used.
* The specialty fees will vary by area as well as provider
Proposed Pre-Auction/Bid Rates (Year 1 Rates):
Plan Option:
Employee Only:
Employee + Spouse:
Employee + Child(ren):
Employee + Family:
MCSV7
Crown and Bridge – All charges for crown and bridge (Fixed partial denture) are per unit (Each replacement or
supporting tooth equals one unit) – Replacement limit 1 every 5 years. The charges below include the cost of base
metal. Noble metal and high noble metal (Precious) or titanium metal, if used, will be charged to the member at an
additional maximum amount of $150.00 per tooth. If a cast post and core is made of high noble metal, an additional

SERIAL 190174-S
fee up to $100.00 per tooth may be charged for the upgraded post and core. Porcelain, if used on molar teeth, will
be charged to the Member at an additional maximum amount of $75.00 per tooth. Porcelain/Ceramic substrate
crowns on molar teeth are not covered.
This applies to D2510-D6792
Complex rehabilitation – An additional $125 charge per unit for multiple crown units/ complex rehabilitation (6 or
more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – Ask your
dentist for the guidelines)
Prosthetics (Removable tooth replacement – Dentures) includes up to 4 adjustments within first 6 months after
insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional
charge to the member of $200.00 per denture.
This applies to D5110-D5660