RT10-022_Ret_Dental_Bene_RFP_Amend_1.doc - www.asrs.state.az.us

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					                                              REQUEST FOR PROPOSAL                             Arizona State Retirement System
                                                                                                 3300 North Central Avenue
                                          Retiree Dental Benefits Program                                 Suite 1300
                                                                                                   Phoenix, Arizona 85012
                                                         RT10-022
                                                                                                         Page 1 of 154


                             NOTICE OF REQUEST FOR PROPOSAL
OFFER DUE            March 12, 2010                                                   PRE-PROPOSAL CONFERENCE
DATE:                at 3:00 P.M. MST
SPECIFIED            Arizona State Retirement System                         DATE:                 TIME:      LOCATION:
LOCATION TO          3300 N. Central Avenue                                  None                  None
DELIVER              13th Floor, Procurement Office
OFFERS:              Phoenix, AZ 85012


In accordance with A.R.S. § 41-2534, competitive sealed offers for the commodities and/or services specified will be received by the
Arizona State Retirement System (ASRS) at the above specified location until the time and date cited. Offers received by the correct
time and date will be opened and the name of each Offeror and the amount of the offer will be publicly read.

Offers must be in the actual possession of the ASRS Procurement Office by hand delivery, mail, or courier on or prior to the
date and time and at the specified location indicated above. Offers submitted by means other than hard copy, sealed proposals
shall be rejected. Late offers will not be considered, except as provided in the Arizona Procurement Code.

Offers must be submitted in a sealed envelope or package with the Solicitation number and the Offeror’s name and address clearly
indicated on the envelope or package. All offers must be typewritten or completed in ink. Additional instructions for preparing an
offer are included in this solicitation.

Persons with a disability may request a reasonable accommodation, such as a sign language interpreter, by contacting the Solicitation
Contact Person listed below. Requests should be made as early as possible to allow time to arrange the accommodation.

                                            Solicitation Contact Person:       Shireen Boone

                                            Solicitation Email Address:        RetireeDentalRFP@azasrs.gov

                                            Solicitation Date:                 February 12, 2010

OFFERORS ARE STRONGLY ENCOURAGED TO CAREFULLY READ THE ENTIRE SOLICITATION.


 PLEASE NOTE
 If this document is downloaded from the State Procurement Office (SPO) website
 http://www.azdoa.gov/agencies/spo/solicitation_information.asp or from the Arizona State Retirement System
 (ASRS) website https://www.azasrs.gov/web/Procurement.do it is the responsibility of all offerors interested in
 responding to this solicitation to verify the issuance of an amendment prior to the RFP closing date.
 Amendments may be posted at either of the websites listed above; however, it is recommended that all offerors
 interested in responding to this solicitation should email the solicitation contact at
 RetireeDentalRFP@azasrs.gov requesting to be added to the respondents list for this solicitation. In the event
 an amendment is issued, it will be emailed to each respondent on that list.




                                                                                                 Section: Notice of Invitation for Bid
                                                                                                                Form#RFP.02/03/10
                                                      REQUEST FOR PROPOSAL                                      Arizona State Retirement System
                                                                                                                  3300 North Central Avenue
                                                  Retiree Dental Benefits Program                                          Suite 1300
                                                                                                                    Phoenix, Arizona 85012
                                                                   RT10-022
                                                                                                                           Page 2 of 154


                                                      TABLE OF CONTENTS
                                                    *NOTE TO OFFERORS*
      Please update this table of contents once you have finished adding your documentation under the column labeled
                                                      “Proposal Page *”.”

                                                                                            Solicitation                                       Proposal
                                                                                                 Page #                                         Page #
NOTICE OF REQUEST FOR PROPOSAL .......................................................................1

TABLE OF CONTENTS .....................................................................................................2

OFFER AND ACCEPTANCE ............................................................................................4

SCOPE OF WORK ..............................................................................................................5

PRICING SCHEDULE ......................................................................................................19

UNIFORM INSTRUCTIONS TO OFFERORS (05-01-03) .............................................22

SPECIAL INSTRUCTIONS TO OFFERORS ..................................................................27

UNIFORM TERMS & CONDITIONS (05-01-03) ...........................................................34

SPECIAL TERMS & CONDITIONS ...............................................................................41

EXHIBIT A: Demographic Information ............................................................................50

EXHIBIT B: Experience Data ...........................................................................................54

EXHIBIT C: Plans’ Schedule of Benefits (Advance Plan & Basic Plan) .......................120

EXHIBIT C: Plans’ Schedule of Benefits (Prepay Plan and 2010 Open Enrollment) ....129

ATTACHMENT A: Exceptions ......................................................................................123

ATTACHMENT B1: References for Offeror ..................................................................124

ATTACHMENT B2: References for Offeror ..................................................................125

ATTACHMENT B3: References for Offeror ..................................................................126

ATTACHMENT C1: References for Subcontractor .......................................................127

ATTACHMENT C2: References for Subcontractor .......................................................128

                                                                                                                                Section: Table of Contents
                                                                                                                                      Form#RFP.02/03/10
                                                   REQUEST FOR PROPOSAL                                   Arizona State Retirement System
                                                                                                            3300 North Central Avenue
                                               Retiree Dental Benefits Program                                       Suite 1300
                                                                                                              Phoenix, Arizona 85012
                                                               RT10-022
                                                                                                                    Page 3 of 154

ATTACHMENT C3: References for Subcontractor .......................................................129

ATTACHMENT D: Minimum Requirements .................................................................130

ATTACHMENT E: Questionnaire ..................................................................................129

ATTACHMENT F: Narrative..........................................................................................129

END OF DOCUMENT....................................................................................................154




                                                                                                                         Section: Table of Contents
                                                                                                                               Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                      3300 North Central Avenue
                                            Retiree Dental Benefits Program                                    Suite 1300
                                                                                                        Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                             Page 4 of 154


                                           OFFER AND ACCEPTANCE
TO THE STATE of ARIZONA:
The Undersigned hereby offers and agrees to furnish the commodities and/or services in compliance with all terms, conditions,
specifications and amendments in the Solicitation and any written exceptions in the offer. Signature also certifies Small Business
status if checked in CERTIFICATION section 4 below.

Federal Employer ID No.:        [ID Number]                              Contact Name:                [Contact's Name]
Company Name:                   [Company Name]                           Contact Email:               [Contact's Email Address]
Address:                        [Company Address]                        Contact Phone:               [Contact's Phone Number]
Suite / Floor:                  [Company Suite/Floor]                    Facsimile:                   [Contact's Fax Number]
City:                           [Company City]                           Authorized Signature:
State / Zip:                    [Company State/Zip]                      Printed Name:                [Authorized Signer's Name]
Company Website:                [Company Website Address]                Position Title:              [Authorized Signer's Title]
                                                                         Date Signed:                 [Date Signed]


CERTIFICATION:
By signature in the Offer section above, the Offeror certifies:
1. The submission of the offer did not involve collusion or other anti-competitive practices.
2. The Offeror shall not discriminate against any employee or applicant for employment in violation of Federal Executive Order
    11246, State Executive Order 75.5 amended by 99.4 or A.R.S. §§ 41-1461 through 1465.
3. The Offeror has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future
    employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted offer.
    Failure to provide a valid signature affirming the stipulations required by this clause shall result in rejection of the offer. Signing
    the offer with a false statement shall void the offer, any resulting contract and may be subject to legal remedies provided by law.
4. The Offeror certifies that the above referenced organization         is, or     is not a small business with less than 100 employees or
    has gross revenues of $4 million or less.
5. The Offeror certifies that the above referenced organization           is, or      is not a Minority or a Woman based business as in
    accordance with Executive Order 2007-21 issued by Governor Napolitano. Check the following boxes that apply:
        African American,       Asian,     Hispanic, or     Native American.
6. In accordance with A.R.S. § 35-397, the Offeror hereby certifies that the Offeror does not have scrutinized business operations in
    Iran or Sudan.
7. Compliance with A.R.S. § 41-3532 when offering electronics or information technology products, services, or maintenance.

ACCEPTANCE OF OFFER
The Offer is hereby accepted.
The Contractor is now bound to sell the commodities and/or services listed by the attached contract and based upon the solicitation,
including all terms, conditions, scope of work, specifications, amendments, etc., and the Contractor’s offer as accepted by the Arizona
State Retirement System.
This contract shall henceforth be referred to as Contract No. RT10-022-        . The Contractor has been cautioned to not commence
any billable work or to provide any commodities and/or services under this contract until Contractor receives a purchase order,
contract release document, or written notice to proceed.

                                                  Arizona State Retirement System

                                                  Awarded this ________ day of _________________________ 20______.


                                                  Procurement Officer Signature

                                                                                                          Section: Offer And Acceptance
                                                                                                                    Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                      Retiree Dental Benefits Program                          Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                  RT10-022
                                                                                            Page 5 of 154

                                              SCOPE OF WORK


1.   HISTORY AND OVERVIEW – ARIZONA STATE RETIREMENT SYSTEM (ASRS)

     1.1. The Arizona State Retirement System (ASRS) was created in 1953 to provide defined contribution
          retirement benefits to employees of the state, university, and political subdivisions in Arizona. Arizona
          teachers voted to join the ASRS in 1954, effective January 1, 1955. In 1970 the state legislature
          authorized the creation of a defined benefit play contingent upon the election to transfer at least 70
          percent of ASRS membership. More than 80 percent voted to transfer to the “plan” effective July 1,
          1971.

     1.2. At the end of fiscal year 2008-2009, total ASRS membership, including active, inactive, and retired
          members was 551,344 and the number of ASRS employer members was 748, including public school
          districts, charter schools, community colleges and state universities, local, county and state
          governments, and special districts.

     1.3. In addition to pension benefits, the ASRS provides a health insurance premium benefit and sponsors
          medical and dental coverage for retired members. Active members receiving long-term disability
          income benefits are also eligible to enroll in ASRS medical and dental coverage.

     1.4. Retirees with the Arizona State Retirement System, Public Safety Personnel Retirement System,
          Elected Officials’ Retirement Plan and Corrections Officer Retirement Plan have additional monies
          reflected in their pension checks to help offset or reduce the cost of the retiree’s health insurance
          premiums. The full cost of health insurance premiums is then shown in the deduction column of the
          monthly payment summary. Details of the Premium Benefit Program may be found on page 61 of the
          ASRS 2010 Open Enrollment Guide (Exhibit C).

     1.5. A.R.S. § 38-782 currently states that “the Board shall establish group health and accident coverage for
          eligible retired and disabled members and their dependents. Eligible retired and disabled members are
          those who are receiving retirement benefits from ASRS or long-term disability benefits pursuant to §
          38-651.03 or article 2.1 of this chapter and who elect not to obtain health and accident insurance
          through their former employer.”         This section further includes retired members and eligible
          dependents of the Public Safety Personnel Retirement System, Elected Officials’ Retirement Plan,
          Corrections Officer Retirement Plan and the University Optional Retirement Plans. If laws are
          changed to allow current retirees of participating employers or active public retirees of non-
          participating employers to enroll in the plan(s), the Contractor shall accommodate the retirees in the
          contracted plan(s).

     1.6. Members eligible to enroll in the coverage shall include: Any retired member of the Arizona State
          Retirement System (ASRS), Public Safety Personnel Retirement System (PSPRS), Elected Officials’
          Retirement Plan (EORP), Corrections Officer Retirement Plan (CORP), University Optional
          Retirement Plan (ORP), or any member receiving an ASRS Long Term Disability benefit who is no

                                                                                                Section: Scope of Work
                                                                                                  Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                      Retiree Dental Benefits Program                          Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                  RT10-022
                                                                                            Page 6 of 154

           longer eligible for health insurance benefits through their former employer’s plan. Eligible retired or
           disabled members may also elect to enroll eligible dependents and domestic partners.

     1.7. Federal laws and regulations govern programs affiliated with the health insurance coverage offered to
          the participants of this program.

     1.8. Summary information is contained in the Attachments to this document. Exhibit A provides specific
          demographic information regarding coverages and numbers of retirees participating in the dental plans.
          Exhibit B provides actual experience data provided by current carrier. Exhibit C provides copies of
          current dental plans’ schedules of benefits.

     1.9. Dental plan designs for eligible members are Indemnity and Prepaid Plans.

2.   GENERAL REQUIREMENTS

     2.1. The Contractor shall have the capability and requisite experience and expertise to provide the services
          specified herein to the Arizona State Retirement System hereinafter referred to as the “ASRS,” in
          accordance with the provisions and requirements set forth herein. The Contractor shall understand and
          agree that no quantity of service is guaranteed under the Contract and that the ASRS does not
          guarantee that the Contractor’s services will be utilized to any degree. The ASRS reserves the right to
          contract for the services as a whole, or any of the various parts/scenarios listed separately.

     2.2. In the performance of the services set forth herein, the Contractor shall expressly understand and agree
          that a contract exists between the Contractor and the Arizona State Retirement System upon approval
          and acceptance of a proposal as set forth in the Offer and Acceptance Form. In addition, the
          Contractor understands and agrees that the Contract shall be performed on behalf of the ASRS, which
          shall be responsible for administration of the contract.

     2.3. The Contractor shall provide a Retiree Dental Insurance Program, hereinafter referred to as the
          “Program,” based on the options the Contractor has selected to underwrite as specified elsewhere in
          this document.

     2.4. The Contractor shall agree that participation in the Program shall be at the sole discretion of each
          retiree; i.e., participation by the individual retirees shall be voluntary.

     2.5. The Contractor shall agree that, although the underwriting information provided in the schedules is
          believed to be reasonably correct, it shall not be considered in any way a warranty, and shall not impair
          coverage or rates under a policy issued based on the information provided.

     2.6. The Contractor shall provide ASRS with a preliminary first renewal on or before May 15, 2011, for
          the first renewal period, and a firm offer no later than June 15, 2011 for a January 1, 2012 effective
          date. Preliminary renewals for any subsequent years shall be provided on or before May 15 and
          firm renewal offers no later than June 15. Any request shall be accompanied by supporting
                                                                                                Section: Scope of Work
                                                                                                  Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                         Arizona State Retirement System
                                                                                         3300 North Central Avenue
                                      Retiree Dental Benefits Program                             Suite 1300
                                                                                           Phoenix, Arizona 85012
                                                    RT10-022
                                                                                               Page 7 of 154

           documentation. Similarly, the Contractor shall provide the ASRS forty-five (45) days advance notice
           of program/operation changes or modifications of any type.

     2.7. The Contractor may supply a multi year renewal for years one and two and/or a not-to-exceed for year
          two.

     2.8. The Contractor shall provide standard services such as grievance and appeal procedures, claims
          investigations, over/under payment reconciliation, patient surveys, and similar activities.

     2.9. If warranted, the Contractor shall use address labels only for purposes designated by the ASRS, and
          shall provide assurance that such labels (with names and addresses) shall remain confidential.

     2.10. The Contractor shall ensure that quality care is provided in all services rendered and shall immediately
           take necessary corrective steps when inappropriate care is identified.

     2.11. The Contractor must have the capability to maintain eligibility files and transmit and receive updates
           from ASRS electronically in a format that complies with ASRS requirements. This format is utilized
           to balance participation from ASRS records to the records of the Contractor on a monthly basis. The
           Contractor is expected to maintain a field that has a one-to-one correlation to a field that is specified by
           ASRS. Also, the Contractor must be able to send a reconciliation full file back to ASRS that complies
           with HIPAA. The Contractor agrees to adjust the file format based upon the needs and requirements of
           ASRS.

     2.12. The Contractor will be responsible for all costs associated with any investigation and/or audit
           necessary to ensure that claims are adjudicated properly.

     2.13. The Contractor shall provide a survey of member and provider satisfaction annually. The Contractor
           shall obtain approval of the survey instrument from ASRS.


3.   SPECIFIC REQUIREMENTS, Component One:

     3.1. The Contractor shall provide services for some, one or all of the following dental benefit plans,
          recognizing the overall benefit plan provisions contained in the Questionnaire portion of this RFP.
          Contractor is not required to provide proposals for all scenarios or all plans within a scenario. Multiple
          pricing schedules for each scenario may be submitted.

                  Current Dental Plans
                  2 Indemnity Dental Plans (Advance and Basic Plans)
                  Prepaid Dental Plan (Applicable in Select States)

4.   ALTERNATIVE BENEFIT PLAN OFFERINGS, Component Two:
                                                                                                   Section: Scope of Work
                                                                                                     Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                    3300 North Central Avenue
                                    Retiree Dental Benefits Program                          Suite 1300
                                                                                      Phoenix, Arizona 85012
                                                 RT10-022
                                                                                            Page 8 of 154



     For this component, the ASRS is allowing for new, innovative, unique and affordable offerings to be
     provided in addition to or in place of those required in Component One.

5.   FUNDING FOR OPEN ENROLLMENT AND COMMUNICATIONS:

     5.1. The open enrollment and communications funding must be viewed by the Contractor as a marketing
          and advertising business expense and shall include such costs in the proposal. Planned uses for the
          funds are as follows:

          5.1.1. Development/Production of a Benefits Summary/Enrollment Brochure.

          5.1.2. Postage Expense

          5.1.3. Materials Development and Training for Trainers and Hotline Operators

          5.1.4. Contractor will provide on-sight personnel to assist in all Open Enrollment activities FOR A
                 PERIOD OF APPROXIMATELY FOUR (4) MONTHS ANNUALLY or as long as is
                 required to manage the enrollment and reconciliation process. DATES WILL VARY
                 ACCORDING TO THE ASRS OPEN ENROLLMENT TIME SCHEDULE. THESE
                 POSITIONS ARE IN ADDITION TO ANY OTHER ON-SITE PERSONNEL
                 EMPLOYED BY CONTRACTOR.

     5.2. The Contractor agrees that ASRS shall approve, in advance, any and all literature that is provided to
          participants. The Contractor must adhere to approval and notification procedures established by CMS
          and DOI. The Contractor shall provide written verification of any federal or state authority that
          prohibits changes as required by ASRS within 7 working days of requested changes by ASRS.

     5.3. The allocation of the total expense among various Contractors will be based on:

          5.3.1. Contractor(s) shall cover the cost of all open enrollment activities. Expenses may include, but
                 are not limited to postage, printing, telephone, temporary staffing, and travel expenses.

     5.4. The ASRS shall not reimburse the Contractor for any enrollment and communication costs.

     5.5. The ASRS reserves the right to conduct a positive enrollment for the initial year of the contract. The
          ASRS will determine in subsequent years if a positive Open Enrollment will be conducted.
          Enrollment meeting will occur at various locations throughout the State.

     5.6. The Contractor shall submit a draft of participant booklets that contain an explanation of how to
          procure care, benefit schedule, and exclusions and limitation to the ASRS for approval at least ninety

                                                                                               Section: Scope of Work
                                                                                                 Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                         Arizona State Retirement System
                                                                                         3300 North Central Avenue
                                      Retiree Dental Benefits Program                             Suite 1300
                                                                                           Phoenix, Arizona 85012
                                                    RT10-022
                                                                                               Page 9 of 154

           (90) days before scheduled beginning of the annual Open Enrollment Period. The Contractor must
           adhere to approval and notification procedures established by authorities including CMS and DOI.

     5.7. The Contractor shall, upon request by the ASRS, provide for Contractor representation at group open
          enrollment meetings for participants. Such meetings will be scheduled throughout the State of Arizona
          and may number anywhere from forty (40) to one hundred (100) meetings. The representative(s) of
          the Contractor shall be responsible for making a brief presentation and answering questions.

     5.8. On a year round basis, the Contractor shall provide for the printing of enrollment forms and guides
          based upon ASRS specifications.

     5.9. Contractor must obtain written approval prior to the release of any communication to any eligible or
          enrolled member of the ASRS program.

     5.10. The Contractor shall ensure that participants receive identification cards no later than the first then (10)
           days following the effective date of coverage. For participants with family coverage, a minimum of
           two cards shall be provided.
     5.11. Provider directories shall be delivered on time and in sufficient quantity for distribution during open
           enrollment or at group meetings. Provider directories shall also be available to members via the
           internet.

     5.12. The Contractor shall provide or pay for all member communications materials, including but not
           limited to: postage, enrollment forms, enrollment brochures, claim forms and checks, certificates of
           insurance, participant booklets, identification cards, provider directories, announcement forms and any
           other forms required for proper administration of coverage. The ASRS must review and approve all
           materials prior to its distribution by the Contractor to participants.

6.   CONTRACTOR PARTICIPATION IS REQUIRED WITH THE FOLLOWING PROGRAM SUPPORT
     FUNCTIONS:

     6.1. Commitment to Participate in the ASRS Health Insurance Advisory Committee.

           6.1.1. The Contractor shall plan to participate in the ASRS-specific member advisory committee
                  directed at issues related to health care delivery and the overall operation of the dental benefits
                  plan. Meetings are held periodically. The Contractor shall host a conference annually for
                  approximately twenty (20) people on an alternating basis.

     6.2. Contractor to Supply Information for Newsletters.

           6.2.1. The Contractor shall supply draft articles for the ASRS retiree newsletters as requested.
                  Contractor will be responsible for all costs associated with the printing and mailing of the
                  newsletter.

                                                                                                   Section: Scope of Work
                                                                                                     Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                       3300 North Central Avenue
                                      Retiree Dental Benefits Program                           Suite 1300
                                                                                         Phoenix, Arizona 85012
                                                     RT10-022
                                                                                             Page 10 of 154

     6.3. If a Contractor is selected for all plans, the Contractor shall work directly with ASRS and fund the
          development and production of all communication materials required for open enrollment and ongoing
          communications throughout the year. The Contractor shall incur the cost of postage expense in
          mailing materials to eligible members.

7.   ELIGIBILITY AND MID-YEAR PLAN ELECTION CHANGES

     7.1 The Contractor shall agree to recognize the rights of the members’ eligibility for enrollment as established
         and documented by ASRS. Contractor shall recognize the rights of members to engage in mid-year plan
         election changes consistent with the following status change rules. Premium rates will be based on the
         status of the participant after the change becomes effective.

     7.1.1       The Contactor shall agree to add Domestic Partners as an eligible retired or disabled class as
                 stated in Arizona Administrative Code.

                          Status Change                     Current Administrative and Election Restrictions
                                                          ASRS will coordinate with Contractor(s) regarding the
                                                          preparation of booklets and forms. ASRS will coordinate
       Annual health plan elections
                                                          the enrollment process. Any eligible Plans may be
                                                          selected. ASRS determines participant eligibility.
                                                          Participant becomes eligible for coverage in ASRS plans.
                                                          Participant elections are processed by ASRS. Any eligible
       Participant retires.
                                                          plan may be selected. ASRS determines participant
                                                          eligibility.
       Participant is determined to be disabled by        Participant becomes eligible for coverage in ASRS plans.
       the ASRS Long Term Disability Program              Participant elections are processed by ASRS. Any eligible
       Administrator or a long-term disability            plan may be selected. ASRS determines participant
       program administered by an ASRS                    eligibility.
       participating employer.
                                                          Participant must notify ASRS. Disabled participant
                                                          becoming Medicare eligible or a retiree attaining age 65
       Participant becomes eligible for Medicare
                                                          may choose any eligible plan available. Other family
       due to disability or reaches age 65 during
                                                          members, not Medicare eligible, shall not change.           If
       plan year and enrolls in Medicare.
                                                          enrolled, no dental change permitted. Participant elections
                                                          are processed by ASRS.
                                                          Participant must notify ASRS. Participant may change to
       Participant moves out of prepaid dental
                                                          any eligible dental plan. Participant elections are processed
       plan service area during plan year.
                                                          by ASRS.
       Participant moves into prepaid dental plan         Participant must notify ASRS. Participant may change to a
                                                                                                  Section: Scope of Work
                                                                                                    Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                    Arizona State Retirement System
                                                                                   3300 North Central Avenue
                                       Retiree Dental Benefits Program                      Suite 1300
                                                                                     Phoenix, Arizona 85012
                                                  RT10-022
                                                                                        Page 11 of 154


                        Status Change                     Current Administrative and Election Restrictions
      service area during plan year.                   prepaid dental plan having appropriate service area.
                                                       Participant elections are processed by ASRS.
      Participant gains dependents through,            Participant must notify ASRS within 31 days. Participant
      marriage, birth or adoption.                     may add new member(s) to current plan. Current
                                                       member(s) may not change plans. Participant elections are
                                                       processed by ASRS.

      Participant loses dependent due to death,         Participant must notify ASRS. Participant may change to
      divorce, dependent reaching maximum               single coverage unless other dependents are covered. No
      age.                                              plan change permitted. Participant elections are processed
                                                        by ASRS.

      Participant dies and surviving dependents         Dependent must notify ASRS. Change becomes effective
      request coverage continuation.                    first of the following month. Dependent may change to
                                                        single coverage unless other dependents are covered. No
                                                        plan change permitted. Participant elections are processed
                                                        ASRS. ASRS determines participant eligibility.

      Participant becomes actively employed           Participant must notify ASRS. Coverage and premium
      with an employer who is not an ASRS             benefits are suspended. Participant termination is processed
      member employer and enrolls for                 by ASRS.
      employer-provided health insurance
      coverage.
                                                      Participant must notify ASRS.         Participant becomes
      Participant becomes actively employed           ineligible for coverage in ASRS plans due to a change to the
      with an employer who is an ASRS member          status of an actively participating member. Participant
      employer and enrolls for employer-              elections are processed by ASRS. ASRS determines
      provided health insurance coverage.             participant eligibility.
      Participant ceases active employment with       Participant must notify ASRS. Participant becomes eligible
      an employer who is an ASRS member               for coverage in ASRS plans due to a change to the status of
      employer and terminates coverage in             retired members. Participant elections are processed by
      employer-provided health insurance              ASRS. ASRS determines participant eligibility.
      coverage.

8.   SPECIFIC RATE REQUIREMENT
     The Contractor must PROVIDE RATES ON BOTH a two (2) tier and a three (3) tier basis. In addition,
     Contractor shall provide rates to include the cost of an on-site representative. See Pricing Schedule.
                                                                                             Section: Scope of Work
                                                                                               Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                        Retiree Dental Benefits Program                        Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                  RT10-022
                                                                                            Page 12 of 154



     8.1.   Dental Rate Structure (2 Tier):

            Retiree only (1) – Single

            Retiree and Dependant(s) – Family

     8.2.   Dental Rate Structure (3 Tier):

            Retiree only (1) – Single

            2 Party Rate (2)

            3 Party Rate (3)

            NOTES:
            (1) Retiree Only could be Retiree (Single) or Spouse (Single)
            (2) 2 Party could be Retiree & Spouse or Retiree & Child
            (3) 3 Party could be Retiree & Children or Retiree / Spouse / Child(ren)

9.   CLAIMS PAYMENT
     The Contractor must pay claims in a timely manner. To facilitate timely payment, the Contractor shall take the
     following steps:
     9.1. Provide claim processing instructions which are clear and complete.

     9.2.   Clearly state the mailing address for claims on the forms. Pre-addressed claim envelopes for claim
            submission are optional. If envelopes are provided, the address must be printed on the forms.

     9.3.   Qualified clinical personnel shall make all denials of claims and all denial notices are to include the
            reason for denial.

     9.4.   When a claim has been denied, or paid in part, the Contractor shall notify the participant of a right to
            appeal. A response to an appeal shall be issued within 60 days of receipt of appeal in accordance with
            the DOL and/or Patient’s Bill of Rights or any other industry standards approved by ASRS.

     9.5.   Payment of claim means the actual preparation and mailing of the amount due the participant or
            provider of services.

10. AUDIT AND ACCOUNTING
    10.1. The Contractor shall determine benefits payable, make any necessary investigations or obtain any
          supplemental dental verification, issue claim drafts to participants and maintain client files.
                                                                                                 Section: Scope of Work
                                                                                                   Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                     Retiree Dental Benefits Program                           Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                  RT10-022
                                                                                           Page 13 of 154



    10.2. The Contractor shall recover any overpayments.

    10.3. The Contractor shall update coverage records upon receipt of the monthly listings of covered
          participants, noting additions, changes and deletions. The Contractor shall also update coverage
          records upon receipt of corrections of information printed on the monthly computer reports and/or
          magnetic media provided to the Contractor by the ASRS. The Contractor shall also accept update of
          coverage information any time the ASRS provides it. Failure to identify a discrepancy within sixty
          (60) days after the receipt of payment shall be considered as acceptance of ASRS calculations and
          records.

    10.4. The Contractor shall provide a monthly discrepancy report after comparing ASRS eligibility
          information.

    10.5. A full annual accounting shall be furnished by the Contractor ,if experience rated, to the ASRS within
          sixty (60) days of the end of the policy year, and shall show premium, paid claims, retention,
          beginning and ending reserves, pooled premiums, and pooled claims, if applicable.

    10.6. The Contractor will complete a final accounting of all premiums and reserves within fifteen (15)
          months of policy termination. Any remaining surplus shall be refunded whether or not cancellation
          was on the anniversary date.

    10.7. A dedicated audit team shall be provided by the Contractor to assist the ASRS with the resolution of
          discrepancies. THIS TEAM NEED NOT BE DEDICATED SOLELY FOR ASRS BUSINESS,
          BUT MAY CONSIST OF CONTRACTOR EMPLOYEES CONDUCTING OTHER
          BUSINESS FOR THE CONTRACTOR OUTSIDE OF ASRS AUDIT PERIODS. THE TEAM
          MAY CONSIST OF ONE OR MORE INDIVIDUALS ENSURING AN APPROPRIATE
          NUMBER TO COMPLETE THE AUDIT IN A TIMELY FASHION.

    10.8. The contractor shall agree to an external Audit of all claims by Plan, annually at the expense of the
          Contractor. ASRS reserve the right to approve the external audit firm selected to conduct the external
          audit. The Contractor also shall conduct internal audits at the request of ASRS should member service
          issues, regulatory changes, or failure to meet performance guarantees require ASRS to seek
          intermittent audit of process or procedures.

11. CLAIMS ADMINISTRATION SYSTEM
    The Contractor shall provide the following administrative services for Dental Plans pursuant to this contract:
    11.1. Creating and maintaining claims files.

    11.2. Evaluating claims to determine if they have been properly filed and advising claimants in meeting the
          requirements for additional information and proper completion of claim forms.


                                                                                                Section: Scope of Work
                                                                                                  Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                         Arizona State Retirement System
                                                                                    3300 North Central Avenue
                                  Retiree Dental Benefits Program                            Suite 1300
                                                                                      Phoenix, Arizona 85012
                                               RT10-022
                                                                                         Page 14 of 154

11.3. Computing the benefits due in accordance with then current benefit plan document and/or
      documentation.

11.4. Issuing drafts to the person or assignee entitled thereto, if applicable.

11.5. Discussing claims, where appropriate, with physicians and other providers of service.

11.6. Obtaining and furnishing information regarding coordination of benefits.

11.7. Applying claims control procedures necessary for the effective administration of the Plan.

11.8. Investigating claims in which the charges appear higher than usual per individual claim.

11.9. Timely notification to participants of delayed claim payments which are caused by the presence of
      duplicate coverage or an error of omission in claim payment documentation.

11.10. Verifying eligibility to provider of service.

11.11. Establishment of dedicated customer service and claim units for the ASRS is preferred. The ASRS
       feels a dedicated unit is necessary to assure prompt and accurate service that is essential to the specific
       needs of retirees.

11.12. The Contractor will have the ability to accept all overflow calls from the ASRS during and throughout
       the ASRS’ normal business hours.

11.13. SHOULD THE CONTRACTOR’S ASRS ENROLLMENT MEET OR EXCEED 3000 LIVES
       (LIVES INCLUDES MEMBERS, DEPENDENTS AND / OR ENROLLED SURVIVORS), the
       Contractor WILL provide a full time customer service representative at the ASRS’ place of business
       in Phoenix, Arizona. The ASRS will provide office space, supplies, and equipment (with the
       exception of a personal computer, which will be the responsibility of the Contractor.)

11.14. Establishment of quality assurance standards and control mechanism for assurance of compliance
       with such standards.

11.15. Print checks or drafts and corresponding explanation of benefits.

11.16. Provide for monthly billing for, and premium collection of, direct pay members. No direct pay
       member should have an outstanding balance greater than three (3) months.

11.17. The Contractor shall make personnel available to any officer or participant for consultation on matters
       regarding this program. The Contractor shall honor the right of the policyholder to question the
       Contractor in any case where the participant's rights under the contract are in question.
                                                                                              Section: Scope of Work
                                                                                                Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                        3300 North Central Avenue
                                       Retiree Dental Benefits Program                           Suite 1300
                                                                                          Phoenix, Arizona 85012
                                                    RT10-022
                                                                                             Page 15 of 154



      11.18. The Contractor shall set up a toll-free telephone line to the claim paying facility for eligible members
             located within or outside the State of Arizona. This telephone line will be in place by the Contract
             effective date. Collect calls may be required.

      11.19. For Indemnity claims, the Contractor shall honor claims in the United States and, for emergency
             claims, worldwide

      11.20. The Contractor agrees that ASRS will pay the premiums on a self-billed basis.

11.21. Indemnity dental plan(s) shall be on an experience rated basis. Pre-paid dental plan(s) may be written on an
      experience rated basis or fully insured basis.

       11.22. The Indemnity/PPO Contractor’s claim payment system shall contain, at a minimum, the
             following data and system edits to assure proper determination of eligibility, proper application of
             required deductibles and copy as, and availability of data required by ASRS and as required by CMS
             for all reporting:

            11.22 .1 Retiree and dependent names and dates of birth.

               11.22.2 Effective dates - Original effective date and termination date - of coverage, for participants
                       and dependents.

               11.22.3 Dollars paid towards maximum benefit payment levels.

               11.22.4 Deductible fulfilled or not; or amount paid to date per person and per family towards
                       deductible.

               11.22.5 Maximum calendar year benefit met or amount paid to date per person and per family
                       towards dental coinsurance
                       Requirements

               11.22.6 Coordination of benefits information on other insurance available.

               11.22.7 Separation of type of participant claim (i.e., member, spouse, dependent child).

               11.22.8 Claim incurred date.

               11.22.9 Claim paid date.



                                                                                                  Section: Scope of Work
                                                                                                    Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                       3300 North Central Avenue
                                     Retiree Dental Benefits Program                            Suite 1300
                                                                                         Phoenix, Arizona 85012
                                                  RT10-022
                                                                                             Page 16 of 154

          11.22.10       A detailed listing of dental codes and identifying categories, number of
        occurrences/visits/procedures, billed charges, disallowed amounts, deductible, co-payments and paid
        amounts.
12. ADMINISTRATIVE SERVICES PROVIDED BY THE ASRS

     12.1. Initial and ongoing enrollment of participants and their dependents.

     12.2. Review and approve of the draft of the contracts and evidence of coverage (booklet) and enrollment
           materials.

     12.3. Determine procedures and eligibility for enrollment.

     12.4. Determine cancellation of coverage protocol.

     12.5. The ASRS will have a degree of supervisory responsibility over the on-site representatives to include,
           but not be limited to, establishing workdays, hours and functions as well as providing input to the
           Contractor for the representative’s performance appraisals.

13. PERFORMANCE GUARANTEES
    13.1. Performance guarantees for the INDEMNITY DENTAL and PREPAID DENTAL PLANS shall be
          monitored by the Contractor on an account specific basis for the ASRS. Such performance shall be
          documented on a quarterly basis and shall be subject to periodic independent audits at the request of
          the ASRS. If a violation of standards is found, the Contractor will accept financial responsibility for
          the audit expenses.

    13.2. When applicable, payment of eighty percent (80%) of all claims within fourteen (14) working days of
          receipt during the initial year of the contract. This standard shall be raised to eighty-five percent (85%)
          in the first renewal term and ninety percent (90%) in the final renewal year of the contract.

    13.3. Where applicable, payment error rate of five percent (5%) or less. The sample size for such
          calculation shall be 200 claims if the error rate is five percent (5%) or less and 300 claims if it is more
          than five percent (5%). An average gross dollar error rate (overpayment and underpayment) of one
          percent (1%) or less. Overpayments and underpayments shall be immediately adjusted with the proper
          charges and credits given to the ASRS’s account.

     13.4. Quality of Service and Responsiveness to Members

           13.4.1. An average of eighty percent (80%) of ASRS members written inquiries are responded to
                   within ten (10) working days (14 calendar days).

           13.4.2. An average of ninety-five percent (95%) of ASRS member written inquiries are responded to
                   within twenty-two working days (30 calendar days).
                                                                                                 Section: Scope of Work
                                                                                                   Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                     3300 North Central Avenue
                                     Retiree Dental Benefits Program                          Suite 1300
                                                                                       Phoenix, Arizona 85012
                                                 RT10-022
                                                                                          Page 17 of 154



           13.4.3. On a calculated median basis, no more than thirty (30) seconds elapse before a member's
                   telephone call is connected to a Plan representative.

           13.4.4. On average, callers receive a busy signal no more than five percent (5%) of the time.

           13.4.5. On average, no more than four percent (4%) of calls are abandoned.

           13.4.6. For one hundred percent (100%) of written ASRS disputed claim requests received for the
                   given time period, within thirty (30) days after receipt by the Plan, the Plan must affirm the
                   denial in writing to the ASRS members, pay the claim, provide the service, or request
                   additional information reasonably necessary to make a determination.

     13.5. All quarterly reports are due within forty-five (45) days from the end of the quarter, semi-annual
           reports are due within 45 days from the end of each six (6) months and annual reports are due within
           forty-five (45) days from the end of the calendar year.

     13.6. Respond within one working day to any inquiry from ASRS benefits supervisor or designated staff
           regarding the disposition of pending or problem claim.

14. REPORTING
    14.1. Reports to be provided: (Please provide sample copies of all reports requested.)
    14.2. All reports will be broken down by plan – Indemnity, PPO, Pre-paid, etc.; by participant; by claimant –
          participant, spouse or dependent child. The following reports shall be provided by the Contractor:

            REPORTS                                         FREQUENCY
            14.2.1. Premium dollars; Total billed           Quarterly
                    claims; Total number of claims;
                    Provider Discounts; Ineligible
                    charges broken down as follows:
                        Over UCR or allowable
                    amount, no plan benefit or plan
                    provision, not eligible for
                    coverage     Total;  allowable
                    expenses; Deductible dollars;
                    COB payments broken down as
                    follows: Other plan payments
                    Other; Total plan payments;
                    Total members’ co-insurance
                    payments; IBNR; Loss ratio
                    percentage       (INDEMNITY
                    CARRIERS ONLY)

                                                                                               Section: Scope of Work
                                                                                                 Form#RFP.02/03/10
                                   REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                 3300 North Central Avenue
                                Retiree Dental Benefits Program                           Suite 1300
                                                                                   Phoenix, Arizona 85012
                                             RT10-022
                                                                                       Page 18 of 154

       14.2.2. DEMOGRAPHICS ON ASRS                     Annually
               GROUP (by Age; Plan selected
               (i.e., single, retiree plus one,
               retiree plus two; and number of
               enrollees); by AZ county.
       14.2.3. Direct        pay        member          Quarterly, or as appropriate
               DELINQUENT REPORT
       14.2.4. Performance report to reflect the        Quarterly
               information requested in the
               Scope of Work, , Items 13.1
               through 13.4
       14.2.5. Utilization   reports,     where         Monthly
               applicable

14.3. Contractors not meeting performance standards as detailed in this section, Items 13.2 through
      13.4 may be assessed liquidated damages sufficient to overcome deficiencies. Damages are not
      to exceed five percent (5%) of premiums as calculated on a quarterly basis. The reports prepared
      by the Contractor, as detailed in this section, Item 14.1, may be used to determine if appropriate levels
      are being met. An audit of services provided by the Contractor may be undertaken at the request of
      the ASRS. If a violation of standards is found, the Contractor will accept financial responsibility for
      the audit expenses.




                                                                                            Section: Scope of Work
                                                                                              Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL                  Arizona State Retirement System
                                                                            3300 North Central Avenue
                                  Retiree Dental Benefits Program                    Suite 1300
                                                                              Phoenix, Arizona 85012
                                            RT10-022
                                                                                 Page 19 of 154


                                           PRICING SCHEDULE

1.   DENTAL
     Proposed Monthly Premium in Accordance with Scope of Work Items 3.1 and 8.1:
                                                   Single
                  PLAN                                                          Family Rate
                                                Party Rate
      1.1. Indemnity Plan
           Maximums
           1.1.1. $1,000                          [Price]                         [Price]
           1.1.2.    $2,000                          [Price]                          [Price]
           1.1.3.    $2,500                          [Price]                          [Price]
      1.2. Pre-Paid Dental Plan                      [Price]                          [Price]
           1.2.1.    Arizona                         [Price]                          [Price]
           1.2.2.     Elsewhere                      [Price]                          [Price]
                    (specify)




       Authorized Signature                     Carrier                             Date

2.   DENTAL
     Proposed Monthly Premium in Accordance with Scope of Work Items 3.1 and 8.2:
                                             Single
                  PLAN                                       Two Party Rate           Three Party Rate
                                           Party Rate
      2.1. Indemnity Plan
           Maximums
           2.1.1. $1,000                     [Price]              [Price]                   [Price]
           2.1.2.    $2,000                    [Price]              [Price]                 [Price]
           2.1.3.    $2,500                    [Price]              [Price]                 [Price]
      2.2. Pre-Paid Dental Plan
           2.2.1.    Arizona                   [Price]              [Price]                 [Price]
           2.2.2.     Elsewhere                [Price]              [Price]                 [Price]
                    (specify)



                                                                                           Section: Pricing Schedule
                                                                                                Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                   Arizona State Retirement System
                                                                              3300 North Central Avenue
                                  Retiree Dental Benefits Program                      Suite 1300
                                                                                Phoenix, Arizona 85012
                                              RT10-022
                                                                                   Page 20 of 154




       Authorized Signature                      Carrier                             Date

Please make duplicates of this page and make corrections to reflect other plan designs and respective price quotes
being offered.



3.   DENTAL
     Proposed Monthly Premium in Accordance with Scope of Work Items 4 and 8.1:

                                                      Single
                    PLAN                                                            Family Rate
                                                    Party Rate

      3.1. Indemnity Plan
           Maximums
           3.1.1. $1,000                              [Price]                          [Price]
          3.1.2.    $2,000                            [Price]                          [Price]
          3.1.3.    $2,500                            [Price]                          [Price]
      3.2. Pre-Paid Dental Plan                       [Price]                          [Price]
          3.2.1.    Arizona                           [Price]                          [Price]
          3.2.2.     Elsewhere                        [Price]                          [Price]
                   (specify)




       Authorized Signature                      Carrier                             Date



4.   DENTAL
     Proposed Monthly Premium in Accordance with Scope of Work Items 4 and 8.2:




                                                                                             Section: Pricing Schedule
                                                                                                  Form#RFP.02/03/10
                                             REQUEST FOR PROPOSAL                             Arizona State Retirement System
                                                                                                3300 North Central Avenue
                                          Retiree Dental Benefits Program                                Suite 1300
                                                                                                  Phoenix, Arizona 85012
                                                        RT10-022
                                                                                                      Page 21 of 154

                                                           Single
                       PLAN                                                      Two Party Rate            Three Party Rate
                                                         Party Rate

      4.1. Indemnity Plan
           Maximums
           4.1.1. $1,000                                   [Price]                    [Price]                     [Price]
             4.1.2.     $2,000                             [Price]                    [Price]                     [Price]
             4.1.3.     $2,500                             [Price]                    [Price]                     [Price]
      4.2. Pre-Paid Dental Plan
             4.2.1.     Arizona                            [Price]                    [Price]                     [Price]
             4.2.2.     Elsewhere                          [Price]                    [Price]                     [Price]
                      (specify)




        Authorized Signature                                Carrier                                     Date

Please make duplicates of this page and make corrections to reflect other plan designs and respective price quotes
being offered.

For the commodities and/or services specified herein, the following apply:

If payment is made within [Number of days]calendar days after acceptance of commodities and/or services, the above quoted price, excluding
sales tax (only for Arizona businesses), shall be discounted by [Percentage].

If payment is made by the Arizona State Purchasing Card Program, after acceptance of commodities and/or services and an accepted invoice
has been provided, the above prices, excluding sales tax, shall be discounted by [Percentage].




                                                                                                                 Section: Pricing Schedule
                                                                                                                      Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                     3300 North Central Avenue
                                            Retiree Dental Benefits Program                                   Suite 1300
                                                                                                       Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                           Page 22 of 154


                       UNIFORM INSTRUCTIONS TO OFFERORS (05-01-03)
                                                                Version 7

A. Definition of Terms. As used in these Instructions, the terms listed below are defined as follows:
    1.    “Attachment” means any item the Solicitation requires an Offeror to submit as part of the Offer.
    2.    “Contract” means the combination of the Solicitation, including the Uniform and Special Instructions to Offerors, the
          Uniform and Special Terms and Conditions, and the Specifications and Statement or Scope of Work; the Offer and any
          Best and Final Offers; and any Solicitation Amendments or Contract Amendments.
    3.    "Contract Amendment" means a written document signed by the Procurement Officer that is issued for the purpose of
          making changes in the Contract.
    4.    “Contractor” means any person who has a Contract with the State.
    5.    “Days” means calendar days unless otherwise specified.
    6.    “Exhibit” means any item labeled as an Exhibit in the Solicitation or placed in the Exhibits section of the Solicitation.
    7.    “Offer” means bid, proposal or quotation.
    8.    “Offeror” means a vendor who responds to a Solicitation.
    9.    “Procurement Officer” means the person, or his or her designee, duly authorized by the State to enter into and administer
          Contracts and make written determinations with respect to the Contract.
    10.   ”Solicitation” means an Invitation for Bids (“IFB”), a Request for Proposals (“RFP”), or a Request for Quotations
          (“RFQ”).
    11.   "Solicitation Amendment" means a written document that is signed by the Procurement Officer and issued for the purpose
          of making changes to the Solicitation.
    12.   “Subcontract” means any Contract, express or implied, between the Contractor and another party or between a
          subcontractor and another party delegating or assigning, in whole or in part, the making or furnishing of any material or
          any service required for the performance of the Contract.
    13.   “State” means the State of Arizona and Department or Agency of the State that executes the Contract.

B. Inquiries
    1.    Duty to Examine. It is the responsibility of each Offeror to examine the entire Solicitation, seek clarification in writing
          (inquiries), and examine its’ Offer for accuracy before submitting the Offer. Lack of care in preparing an Offer shall not be
          grounds for modifying or withdrawing the Offer after the Offer due date and time, nor shall it give rise to any Contract
          claim.
    2.    Solicitation Contact Person. Any inquiry related to a Solicitation, including any requests for or inquiries regarding
          standards referenced in the Solicitation shall be directed solely to the Solicitation contact person. The Offeror shall not
          contact or direct inquiries concerning this Solicitation to any other State employee unless the Solicitation specifically
          identifies a person other than the Solicitation contact person as a contact.
    3.    Submission of Inquiries. The Procurement Officer or the person identified in the Solicitation as the contact for inquiries
          except at the Pre-Offer Conference, require that an inquiry be submitted in writing. Any inquiry related to a Solicitation
          shall refer to the appropriate Solicitation number, page and paragraph. Do not place the Solicitation number on the outside
          of the envelope containing that inquiry, since it may then be identified as an Offer and not be opened until after the Offer
          due date and time. The State shall consider the relevancy of the inquiry but is not required to respond in writing.
    4.    Timeliness. Any inquiry or exception to the solicitation shall be submitted as soon as possible and should be submitted at
          least seven days before the Offer due date and time for review and determination by the State. Failure to do so may result
          in the inquiry not being considered for a Solicitation Amendment.
    5.    No Right to Rely on Verbal Responses. An offeror shall not rely on verbal responses to inquiries. A verbal reply to an
          inquiry does not constitute a modification of the solicitation.
    6.    Solicitation Amendments. The Solicitation shall only be modified by a Solicitation Amendment.



                                                                                               Section: Uniform Instructions to Offerors
                                                                                                                   Form#RFP.02/03/10
                                                  REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                        3300 North Central Avenue
                                              Retiree Dental Benefits Program                                    Suite 1300
                                                                                                          Phoenix, Arizona 85012
                                                             RT10-022
                                                                                                               Page 23 of 154

    7.   Pre-Offer Conference. If a pre-Offer conference has been scheduled under this Solicitation, the date, time and location shall
         appear on the Solicitation cover sheet or elsewhere in the Solicitation. Offerors should raise any questions about the
         Solicitation or the procurement at that time. An Offeror may not rely on any verbal responses to questions at the
         conference. Material issues raised at the conference that result in changes to the Solicitation shall be answered solely
         through a written Solicitation Amendment.
    8.   Persons With Disabilities. Persons with a disability may request a reasonable accommodation, such as a sign language
         interpreter, by contacting the Solicitation contact person. Requests shall be made as early as possible to allow time to
         arrange the accommodation.

C. Offer Preparation
    1    Forms: No Facsimile, Telegraphic or Electronic Mail Offers. An Offer shall be submitted either on the forms provided in
         this Solicitation or their substantial equivalent. Any substitute document for the forms provided in this Solicitation must be
         legible and contain the same information requested on the forms, unless the solicitation indicates otherwise. A facsimile,
         telegraphic, mailgram or electronic mail Offer shall be rejected if submitted in response to requests for proposals or
         invitations for bids.
    2    Typed or Ink; Corrections. The Offer shall be typed or in ink. Erasures, interlineations or other modifications in the Offer
         shall be initialed in ink by the person signing the Offer. Modifications shall not be permitted after Offers have been opened
         except as otherwise provided under applicable law.
    3    Evidence of Intent to be Bound. The Offer and Acceptance form within the Solicitation shall be submitted with the Offer
         and shall include a signature (or acknowledgement for electronic submissions, when authorized) by a person authorized to
         sign the Offer. The signature shall signify the Offeror’s intent to be bound by the Offer and the terms of the Solicitation
         and that the information provided is true, accurate and complete. Failure to submit verifiable evidence of an intent to be
         bound, such as an original signature, shall result in rejection of the Offer.
    4    Exceptions to Terms and Conditions. All exceptions included with the Offer shall be submitted in a clearly identified
         separate section of the Offer in which the Offeror clearly identifies the specific paragraphs of the Solicitation where the
         exceptions occur. Any exceptions not included in such a section shall be without force and effect in any resulting Contract
         unless such exception is specifically accepted by the Procurement Officer in a written statement. The Offeror’s preprinted
         or standard terms will not be considered by the State as a part of any resulting Contract.
               i. Invitation for Bids. An Offer that takes exception to a material requirement of any part of the Solicitation, including
               terms and conditions, shall be rejected.
               ii. Request for Proposals. All exceptions that are contained in the Offer may negatively affect the State’s proposal
               evaluation based on the evaluation criteria stated in the Solicitation or result in rejection of the Offer. An offer that takes
               exception to any material requirement of the solicitation may be rejected.
    5    Subcontracts. Offeror shall clearly list any proposed subcontractors and the subcontractor’s proposed responsibilities in the
         Offer.
    6    Cost of Offer Preparation. The State will not reimburse any Offeror the cost of responding to a Solicitation.
    7    Solicitation Amendments. Each Solicitation Amendment shall be signed with an original signature by the person signing
         the Offer, and shall be submitted no later than the Offer due date and time. Failure to return a signed copy of a Solicitation
         Amendment may result in rejection of the Offer.
    8    Federal Excise Tax. The State of Arizona is exempt from certain Federal Excise Tax on manufactured goods. Exemption
         Certificates will be provided by the State.
    9    Provision of Tax Identification Numbers. Offerors are required to provide their Arizona Transaction Privilege Tax Number
         and/or Federal Tax Identification number in the space provided on the Offer and Acceptance Form.
         9.1      Employee Identification. Offeror agrees to provide an employee identification number or social security number to
                  the Department for the purposes of reporting to appropriate taxing authorities, monies paid by the Department

                                                                                                  Section: Uniform Instructions to Offerors
                                                                                                                      Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                      3300 North Central Avenue
                                            Retiree Dental Benefits Program                                    Suite 1300
                                                                                                        Phoenix, Arizona 85012
                                                            RT10-022
                                                                                                              Page 24 of 154

                 under this contract. If the federal identifier of the offeror is a social security number, this number is being requested
                 solely for tax reporting purposes and will be shared only with appropriate state and federal officials. This
                 submission is mandatory under 26 U.S.C. § 6041A.
    10 Identification of Taxes in Offer. The State of Arizona is subject to all applicable state and local transaction privilege taxes.
       All applicable taxes shall be included in the pricing offered in the solicitation. At all times, payment of taxes and the
       determination of applicable taxes are the sole responsibility of the contractor.
    11 Disclosure. If the firm, business or person submitting this Offer has been debarred, suspended or otherwise lawfully
       precluded from participating in any public procurement activity, including being disapproved as a subcontractor with any
       Federal, state or local government, or if any such preclusion from participation from any public procurement activity is
       currently pending, the Offeror shall fully explain the circumstances relating to the preclusion or proposed preclusion in the
       Offer. The Offeror shall include a letter with its Offer setting forth the name and address of the governmental unit, the
       effective date of this suspension or debarment, the duration of the suspension or debarment, and the relevant circumstances
       relating to the suspension or debarment. If suspension or debarment is currently pending, a detailed description of all
       relevant circumstances including the details enumerated above shall be provided.
    12 Solicitation Order of Precedence. In the event of a conflict in the provisions of this Solicitation, the following shall prevail
       in the order set forth below:
        12.1      Special Terms and Conditions;
        12.2      Uniform Terms and Conditions;
        12.3      Statement or Scope of Work;
        12.4      Specifications;
        12.5      Attachments;
        12.6      Exhibits;
        12.7      Special Instructions to Offerors;
        12.8      Uniform Instructions to Offerors.
        12.9      Other documents referenced or included in the Solicitation.
    13 Delivery. Unless stated otherwise in the Solicitation, all prices shall be F.O.B. Destination and shall include all freight,
       delivery and unloading at the destination(s).

D. Submission of Offer
    1   Sealed Envelope or Package. Each Offer shall be submitted to the submittal location identified in this Solicitation. Offers
        should be submitted in a sealed envelope or container. The envelope or container should be clearly identified with name of
        the Offeror and Solicitation number. The State may open envelopes or containers to identify contents if the envelope or
        container is not clearly identified.
    2   Offer Amendment or Withdrawal. An Offer may not be amended or withdrawn after the Offer due date and time except as
        otherwise provided under applicable law.
    3   Public Record. All Offers submitted and opened are public records and must be retained by the State. Offers shall be open
        to public inspection after Contract award, except for such Offers deemed to be confidential by the State. If an Offeror
        believes that information in its Offer should remain confidential, it shall indicate as confidential the specific information
        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. The State shall determine whether the identified information is
        confidential pursuant to the Arizona Procurement Code.
    4   Non-collusion, Employment, and Services. By signing the Offer and Acceptance Form or other official contract form, the
        Offeror certifies that:
        i.    The Offeror did not engage in collusion or other anti-competitive practices in connection with the preparation or
             submission of its Offer; and



                                                                                                Section: Uniform Instructions to Offerors
                                                                                                                    Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                     3300 North Central Avenue
                                            Retiree Dental Benefits Program                                   Suite 1300
                                                                                                       Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                           Page 25 of 154

         ii.   The Offeror does not discriminate against any employee or applicant for employment or person to whom it provides
               services because of race, color, religion, sex, national origin, or disability, and that it complies with all applicable
               Federal, state and local laws and executive orders regarding employment.

E. Evaluation
    1 Unit Price Prevails. In the case of discrepancy between the unit price or rate and the extension of that unit price or rate, the
      unit price or rate shall govern.
    2 Prompt Payment Discount. Prompt payment discounts of thirty (30) days or more set forth in an Offer shall be deducted
      from the offer for the purposes of evaluating that price.
    3 Late Offers. An Offer submitted after the exact Offer due date and time shall be rejected.
    4 Disqualification. A Offeror (including each of its’ principals) who is currently debarred, suspended or otherwise lawfully
      prohibited from any public procurement activity shall have its offer rejected.
    5 Offer Acceptance Period. An Offeror submitting an Offer under this Solicitation shall hold its Offer open for the number of
      days from the Offer due date that is stated in the Solicitation. If the Solicitation does not specifically state a number of days
      for Offer acceptance, the number of days shall be one hundred-twenty (120). If a Best and Final Offer is requested pursuant
      to a Request for Proposals, an Offeror shall hold its Offer open for one hundred-twenty (120) days from the Best and Final
      Offer due date.
        5.1        Waiver and Rejection Rights. Notwithstanding any other provision of the Solicitation, the State reserves the right
                           to:
                   5.1.1   Waive any minor informality;
                   5.1.2   Reject any and all Offers or portions thereof; or
                   5.1.3   Cancel the Solicitation

F. Award
    1    Number or Types of Awards. The State reserves the right to make multiple awards or to award a Contract by individual
         line items or alternatives, by group of line items or alternatives, or to make an aggregate award, or regional awards,
         whichever is most advantageous to the State. If the Procurement Officer determines that an aggregate award to one Offeror
         is not in the State’s best interest, “all or none” Offers shall be rejected.
    2    Contract Inception. An Offer does not constitute a Contract nor does it confer any rights on the Offeror to the award of a
         Contract. A Contract is not created until the Offer is accepted in writing by the Procurement Officer’s signature on the
         Offer and Acceptance Form. A notice of award or of the intent to award shall not constitute acceptance of the Offer.
    3    Effective Date. The effective date of this Contract shall be the date that the Procurement Officer signs the Offer and
         Acceptance form or other official contract form, unless another date is specifically stated in the Contract.

G. Protests.
    1    A protest shall comply with and be resolved according to Arizona Revised Statutes Title 41, Chapter 23, Article 9 and rules
         adopted thereunder. Protests shall be in writing and be filed with both the Procurement Officer of the purchasing agency
         and with the State Procurement Administrator. A protest of a Solicitation shall be received by the Procurement Officer
         before the Offer due date. A protest of a proposed award or of an award shall be filed within ten (10) days after the
         protester knows or should have known the basis of the protest. A protest shall include:
         1.1       The name, address and telephone number of the protester;
         1.2       The signature of the protester or its representative;
         1.3       Identification of the purchasing agency and the Solicitation or Contract number;
         1.4       A detailed statement of the legal and factual grounds of the protest including copies of relevant documents; and
         1.5       The form of relief requested.


                                                                                              Section: Uniform Instructions to Offerors
                                                                                                                  Form#RFP.02/03/10
                                           REQUEST FOR PROPOSAL                           Arizona State Retirement System
                                                                                            3300 North Central Avenue
                                        Retiree Dental Benefits Program                              Suite 1300
                                                                                              Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                  Page 26 of 154

H. Comments Welcome
The State Procurement Office periodically reviews the Uniform Instructions to Offerors and welcomes any comments you may have.
Please submit your comments to: State Procurement Administrator, State Procurement Office, 100 North 15th Avenue, Suite 104,
Phoenix, Arizona, 85007.




                                                                                      Section: Uniform Instructions to Offerors
                                                                                                          Form#RFP.02/03/10
                                                 REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                      3300 North Central Avenue
                                             Retiree Dental Benefits Program                                   Suite 1300
                                                                                                        Phoenix, Arizona 85012
                                                            RT10-022
                                                                                                             Page 27 of 154


                             SPECIAL INSTRUCTIONS TO OFFERORS
1.   Purpose
     Pursuant to provisions of the Arizona Procurement Code, ARS 41-2501 et seq., the State of Arizona, the ASRS intends to
     establish a Contract for the commodities or services as listed herein.

2.   Offeror's Contacts
     A. All questions regarding this Request for Proposal (RFP), including technical specifications, Offer process, etc., must be in writing
         and directed to the email address as indicated on the first page of this document.
     B. Offerors must not contact the employees of the Arizona State Retirement System (ASRS) concerning this procurement while the
         solicitation and evaluation are in process.

3.   Suspension or Debarment Status
     A. If the firm, business or person submitting this Offer has been debarred, suspended or otherwise lawfully precluded from
         participating in any public procurement activity with any federal, state or local government, the Offeror must include a letter
         with its Offer, setting forth the name and address of the governmental unit, the effective date of the suspension or debarment,
         the duration of the suspension or debarment.
     B. Failure to supply the letter or to disclose in the letter all pertinent information regarding a suspension or debarment shall
         result in rejection of the offer or cancellation of a contract. The State also may exercise any other remedy available by law.

4.   Suspension or Debarment Certification
     A. By signing the offer section of the Offer and Acceptance page, SPO Form 203, the Offeror certifies that the firm, business or
        person submitting the Offer has not been debarred, suspended or otherwise lawfully precluded from participating in any
        public procurement activity with any federal, state or local government.
     B. Signing the offer section without disclosing all pertinent information about a debarment or suspension shall result in rejection
        of the Offer or cancellation of a contract. The State also may exercise any other remedy available by law.

5.   IT 508 Compliance
     Any electronic or information technology offered to the State of Arizona under this solicitation shall comply with A.R.S. §§ 41-
     2531 and 2532 and Section 508 of the Rehabilitation Act of 1973, which requires that employees and members of the public shall
     have access to and use of information technology that is comparable to the access and use by employees and members of the
     public who are not individuals with disabilities. Any exceptions shall be declared in writing in the offer.

6.   Offshore Performance of Work Prohibited
     Due to security and identity protection concerns, direct services under this Contract shall be performed within the borders of the
     United States. Any services that are described in the Specifications or Scope of Work that directly serve the State of Arizona or
     its clients and may involve access to secure or sensitive data or personal client data or development or modification of software
     for the State shall be performed within the borders of the United States. Unless specifically stated otherwise in the Specifications,
     this definition does not apply to indirect or “overhead” services, redundant back-up services or services that are incidental to the
     performance of the Contract. This provision applies to work performed by subcontractors at all tiers. Offerors shall declare all
     anticipated offshore services in the proposal.

7.   Brand Name or Equal
     Any manufacturer’s name, trade name, brand name or catalog designations used in the Specifications are for the purpose of
     describing and establishing the general quality level, design, and performance desired. Such references are not intended to limit
     or restrict offers from other vendors, but are intended to approximate the quality, design, or performance which is desired. Any
     offer which proposes like quality, design, or performance will be considered. If the description in the Offeror’s proposal differs in
     any way, the Offeror must give complete detailed descriptions in the offer including pictures and literature, where applicable.
     Unless a specific exception is made, the assumption will be that the offer will be exactly as specified in this solicitation.

8.   Offer and Acceptance


                                                                                                 Section: Special Instructions to Offerors
                                                                                                                     Form#RFP.02/03/10
                                                 REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                                     3300 North Central Avenue
                                            Retiree Dental Benefits Program                                   Suite 1300
                                                                                                       Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                            Page 28 of 154

     In order to allow for an adequate evaluation, the ASRS requires an Offer in response to this Solicitation to be valid and
     irrevocable for 180 days after the opening time and date.

9.   Proposal Submittals
     The proposal shall contain the following:

     A. One (1) original hard copy and one (1) electronic copy in the form of a CD, DVD, and seven (&) copies of each proposal
        (*NOTE* No flashdrives will be accepted) should be submitted on the forms and in the format specified in the RFP. The
        original copy of the proposal should be clearly labeled “ORIGINAL.” The material should be in sequence and related to the
        RFP. The ASRS will not provide any reimbursement for the cost of developing or presenting proposals in response to this
        RFP. Failure to include the requested information may have a negative impact on the evaluation of the Offeror.

     B. Complete response to all items contained in the Offeror Questionnaire. Questionnaire form is attached for Offeror’s
        convenience. If an Offeror fails to respond to each question on the Questionnaire, it may have a negative impact on the
        evaluation of the Offeror.

     C. A minimum of three (3) business references, government references are preferred. References shall be verifiable and shall be
        able to comment on the Offeror’s related experience and past performance, particularly on the team assigned to this contract.
        Offeror shall provide the name, address, phone, contact person, and a brief description of the services provided for each
        reference. Attachment B is attached for Offeror’s convenience. Should subcontractors be anticipated, Attachment C is
        attached for Offeror’s convenience to provide proposed subcontractor’s experience.

     D. Price Proposals. Price proposals shall be submitted on the pricing schedule or in a format substantially similar to the pricing
        schedule.

     E. Completed “Offer and Acceptance” page.

     F.   One copy of each solicitation amendment, with signed acknowledgement, if any.

     G. The entire proposal should be completed in number 10 font or larger.

     H. Exceptions page to be completed, if applicable. Attachment A has been attached for Offeror’s convenience.

10. Pricing
    Price contained herein shall be firm for the specified commodity and/or service and shall include shipping FOB destination,
    insurance, delivery, and all other incidental costs. List any optional items separately on the quote in addition to the prices that do
    not pertain to the Scope of Work requirements. Any optional items listed will not be included in the Offer tabulation.

11. Delivery and Payment Discounts
    Offer must indicate promised delivery schedule, prompt payment terms, and applicable local sales tax percentage in the areas
    provided on the pricing schedule.

12. Shipping Prices – F.O.B. Destination/Installation
    Prices shall be F.O.B. destination/installation to the delivery location designated herein. Contractor shall retain title and control
    of all commodities until they are delivered/installed and the Contract of Coverage has been completed. All risk of transportation
    and all related charges shall be the responsibility of the Contractor. All claims for visible or concealed damage shall be filed by
    the Contractor. The ASRS will notify the Contractor promptly of any damaged commodities and shall assist the Contractor in
    arranging for inspection.

13. Proposal Opening
    Proposals shall be opened on the date and time, and at the place designated on the cover page of this document, unless amended in
    writing by the ASRS. The name of each Offeror shall be read at this time. Proposals, modifications, and all other information


                                                                                                Section: Special Instructions to Offerors
                                                                                                                    Form#RFP.02/03/10
                                                                REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                                     3300 North Central Avenue
                                                           Retiree Dental Benefits Program                                    Suite 1300
                                                                                                                       Phoenix, Arizona 85012
                                                                                 RT10-022
                                                                                                                            Page 29 of 154

    received in response to the RFP shall be shown only to authorized ASRS personnel having a legitimate interest in the evaluation.
    After a contract award, the RFPs and evaluation documentation shall be open for public inspection.

14. Evaluation
    A. The ASRS will determine responsibility of an Offeror prior to awarding a contract. Any information regarding the past
       performance, reliability, and capability of the Offeror may be considered to determine responsibility. If an Offeror is
       determined to be non-responsible, the ASRS will notify the Offeror of the determination and cite the reasons for the
       determination.

    B. Proposals shall be evaluated in accordance with A.R.S. §41-2534 (The Arizona Procurement Code). If an award is made, the
       contract will be awarded to the responsible Offeror whose proposal is determined to be most advantageous to the ASRS,
       based on the criteria listed below. Evaluation factors are listed below in their relative order of importance, starting with the
       most important.

    C.Evaluation Criteria: Evaluation criteria are listed in the relative order of importance. The award will be made to the responsible
        offeror(s) whose proposal(s) is (are) determined to be advantageous to the State based on the following criteria:

             Cost..........................................................................................30%
             Quality or Value of Benefit Plan .............................................25%
             Experience/Expertise/Resources ............................................25%
             Method of Approach/Implementation Plan ............................20%

             C.1.                Cost Proposal: The cost proposal shall be submitted on the Pricing Schedule attached to the RFP.

             C.2. Quality or Value of the Benefit Plan. The offeror shall provide a plan that offers identifiable value to the retiree.
             The quality of the benefits offered and the “richness” of the plan presented shall be considered in evaluation.

             C.3.                Method of Approach (Implementation Plan)

                          C.3.1.        The offeror(s) must present a proposed method of satisfying the requirements of the Scope of Work
                          as specified herein. The narrative must be point-by-point in the order listed in the Scope of Work.

                          C.3.2.          The offeror may utilize a written narrative or project management chart to demonstrate his/her
                          ability to satisfy the Scope of Work. A narrative should describe a logical progression of tasks and efforts starting
                          with the initial steps or tasks to be accomplished and continuing until all proposed tasks are fully described. The
                          language or the narrative should be straightforward and limited to facts, solutions to problems, and plans of
                          proposed action. The usage of technical language should be minimized and used only to describe a technical
                          process.

                          C.3.3.         The offeror(s) shall provide a complete description of benefits and limitations and/or exclusions
                          relative to benefits requested in the Scope of Work.

                          C.3.4.               The offeror(s) will complete the Questionnaire, as it relates to the offeror's Method of Approach.

                          C.3.5.        The offeror(s) should state whether coverage will encompass any of the following: locally,
                          statewide, national, international or a combination of all areas.


             C.4. Experience/Expertise/Resources of the Offeror: The proposal should contain the following:



                                                                                                                 Section: Special Instructions to Offerors
                                                                                                                                     Form#RFP.02/03/10
                                                 REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                      3300 North Central Avenue
                                             Retiree Dental Benefits Program                                   Suite 1300
                                                                                                        Phoenix, Arizona 85012
                                                            RT10-022
                                                                                                             Page 30 of 154

                       C.4.1.        Information on the offeror's related experience. This shall include specific information on the
                       type of services provided, the dates of performance, demonstrated timeliness of similar work completion, and
                       experience.

                       C.4.2.        A list of client references in accordance with the Questionnaire. The State reserves the right to
                       contact references and other sources capable of commenting on offeror’s past performance.

                       C.4.3.       The offeror(s) shall complete the Questionnaire, attached, as it relates to the offeror's
                       Experience, Expertise and Resources.

                       C.4.4.        The offeror(s) shall list all subcontractors, if applicable.

                       C.4.5.        The offeror(s) should state if there are any services necessary for the operation of their
                       organization provided by a third party (e.g., management contract). If so, describe the services and identify
                       the third party subcontractor(s).

                       C.4.6.       The offeror should provide an organizational chart showing the staffing and lines of authority
                       for the key personnel to be used in the project. The relationship of the project leader to management and to
                       support personnel should be clearly illustrated.

                       C.4.7.         The offeror should provide a resume and data related to previous work assignments as may
                       relate to this RFP for each of the key personnel to be assigned to the project.

                       C.4.8.       The offeror should indicate the relationship between specific key personnel for which resumes
                       have been submitted and the specific tasks or assignments proposed in the method of approach to accomplish
                       the Scope of Work.

                       C.4.9.        The offeror shall comment on their provider breadth and depth.

                       C.4.10.       The offeror should comment on their financial design (e.g., experience rating or pooled, etc.).

                       C.4.11       The proposal may include any additional information that reflects on the offeror's ability to
                       perform the required services.

15. Minimum Qualifications and Requirements
    Listed under Attachment D, Minimum Requirements, section A below are the minimum qualifications an offeror must meet or
    exceed in order for the ASRS to designate a proposal as acceptable. Each offeror must provide a written explanation as to how it
    meets each minimum qualification by answering all questions supplied on the Questionnaire form attached to this solicitation and
    fulfill other requirements in this RFP. Additional information can be provided on the Narrative form Attachment D or F, if
    needed. If the ASRS determines from the response that an offeror does not meet any one of the minimum qualifications, the
    proposal may be considered unacceptable and disqualified from further consideration.

16. Discussions
    In accordance with A.R.S. Section 41-2534, after the initial receipt of proposals, the ASRS reserves the option to conduct
    discussions with those offerors who submit proposals determined by the ASRS to be reasonably susceptible of being selected for
    award.

17. Contract Award
    The State intends to award a firm-fixed price contract or contracts, unless otherwise indicated, resulting from this solicitation to
    the responsible offeror(s) whose proposal represents the best value after evaluation in accordance with the factors and subfactors
    identified in the solicitation. The State may reject any or all proposals if such action is in the State's best interest. The State may
    waive informalities and minor irregularities on proposals received. The offeror's initial proposal should contain the offeror's best
                                                                                                 Section: Special Instructions to Offerors
                                                                                                                       Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                    3300 North Central Avenue
                                           Retiree Dental Benefits Program                                   Suite 1300
                                                                                                      Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                           Page 31 of 154

    terms from a price or cost and technical standpoint. The State reserves the right to conduct discussions (negotiations) if the
    procurement officer determines them to be necessary. If the procurement officer determines that the number of proposals that
    would otherwise be in the competitive range exceeds the number at which an efficient competition can be conducted, the
    procurement officer may limit the number of proposals in the competitive range to the greatest number that will permit an
    efficient competition among the most highly rated proposals. The State reserves the right to make an award on any item for any
    quantity less than the quantity offered, at unit costs or prices offered, unless the offeror specifies otherwise in the proposal. The
    State reserves the right to make multiple awards if, after considering the additional administrative costs, it is in the State's best
    interest to do so. Any exchanges with offerors after receipt of a proposal does not constitute a rejection of counteroffer by the
    State.

18. Insurance
    The State requires a complete and valid Certificate of Insurance prior to the commencement of any service or activity specified in
    this solicitation. The ASRS will notify the successful Contractor(s) of the intent to issue a Contract award. The coverages shall
    be maintained in full force and effect during the term of the Contract and shall not serve to limit any liabilities or any other
    Contractor obligations.

19. Employee Sanctions A.R.S. 41-4401:
    FINA Requirement
    By entering into the Contract, the Contractor warrants compliance with the Federal Immigration and Nationality Act (FINA) and
    all other Federal immigration laws and regulations related to the immigration status of its employees. 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 U.S. Department of Labor’s Immigration and Control
    Act, for all employees performing work under the Contract. I-9 forms are available for download at http://www.USCIS.GOV.

    The State may request verification of compliance for any Contractor or subcontractor performing work under the Contract.
    Should the State suspect or find that the Contractor or any of its subcontractors are not in compliance, the State 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 Contract. All costs necessary to verify compliance are the responsibility of the Contractor.

20. Compliance Requirements for A.R.S. § 41-4401, Government Procurement:
    E-Verify Requirement

    A. The contractor warrants compliance with all Federal immigration laws and regulations relating to employees and warrants its
       compliance with Section A.R.S. § 23-214, Subsection A, which reads “After December 31, 2007, every employer, after
       hiring an employee, shall verify the employment eligibility of the employee through the E-Verify program.”
    B. A breach of a warranty regarding compliance with immigration laws and regulations shall be deemed a material breach of the
       contract and the contractor may be subject to penalties up to and including termination of the contract.
    C. Failure to comply with a State audit process to randomly verify the employment records of contractors and subcontractors
       shall be deemed a material breach of the contract and the contractor may be subject to penalties up to and including
       termination of the contract.
    D. The State Agency retains the legal right to inspect the papers of any employee who works on the contract to ensure that the
       contractor or subcontractor is complying with the warranty under paragraph 1.

21. Definitions
    “May” denotes the permissive; “Shall” denotes the imperative, “Must” denotes the imperative.

    Participant: Means all eligible members of the Arizona State Retirement System (ASRS), Public Safety Personnel Retirement
    System (PSPRS), Elected Officials' Retirement Plan (EORP), Corrections Officers' Retirement Plan (CORP), their dependents,
    and surviving dependents pursuant to A.R.S. § 38-651.01. All those receiving Long Term Disability income benefits, their
    dependents, and surviving dependents pursuant to A.R.S. § 38-651.03 or § 38-782. All former employees of the State of
    Arizona University System who belong to the Optional Retirement Plans (ORP) namely the Variable Annuity Life Insurance


                                                                                               Section: Special Instructions to Offerors
                                                                                                                   Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                     3300 North Central Avenue
                                      Retiree Dental Benefits Program                         Suite 1300
                                                                                       Phoenix, Arizona 85012
                                                       RT10-022
                                                                                            Page 32 of 154

Company (VALIC) or Teachers Insurance Annuity Association-College Retirement Fund (TIAA-CREF), their dependents, and
surviving dependents.


Glossary of Abbreviations
AAPCC:              Average Area Per Capitation Cost

ADL:                 Activities of Daily Living

ASRS:                Arizona State Retirement System

CD:                  Chemical Dependency

COB:                 Coordination of Benefits

CORP:                Corrections Officer Retirement Plan

DRG:                 Diagnosis Related Groups

DXL:                 Diagnostic, X-ray, and Lab

EORP:                Elected Officials’ Retirement Plan

GHAA:                Group Health Association of America

HEDIS:               Healthplan Employer Data Information Set

HMO:                 Health Maintenance Organization

IBNR:                Incurred But Not Reported

KQC:                 Key Quality Characteristics

LPN:                 Licensed Practical Nurse

LTC:                 Long Term Care

NCQA:                National Commission for Quality Assurance

UORP:                University Optional Retirement Plan

PCP:                 Primary Care Physician

PMPM:                Per Member Per Month

PPO:                 Preferred Provider Organization

PSPRS:               Public Safety Personnel Retirement System

R + C:               Reasonable and Customary

RFP:                 Request for Proposal

                                                                                 Section: Special Instructions to Offerors
                                                                                                     Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                            Arizona State Retirement System
                                                                                                 3300 North Central Avenue
                                          Retiree Dental Benefits Program                                 Suite 1300
                                                                                                   Phoenix, Arizona 85012
                                                         RT10-022
                                                                                                        Page 33 of 154

    RN:                   Registered Nurse

    RX:                   Prescription Drugs

    TIAA-CREF:            Teachers Insurance Annuity Association - College Retirement Fund

    UCR:                  Usual, Customary, and Reasonable

    VALIC:                Variable Annuity Life Insurance Company


22. Uniform Instructions to Offerors
    The Contractor shall be subject to the Arizona State Procurement Office (SPO) Uniform Instructions to Offerors currently in force
    and effect, which may be found at the SPO website http://www.azdoa.gov/spo/agency-resources-1/documents-
    forms/procurement-documents. Said instructions are hereby incorporated by reference as though set forth in full herein and shall
    supersede any contract or other form of agreement supplied by Offeror.




                                                                                             Section: Special Instructions to Offerors
                                                                                                                 Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                    3300 North Central Avenue
                                           Retiree Dental Benefits Program                                   Suite 1300
                                                                                                      Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                           Page 34 of 154



                             UNIFORM TERMS & CONDITIONS (05-01-03)
                                                              Version 7
1       Definition of Terms. As used in this Solicitation and any resulting Contract, the terms listed below are defined as follows:
    1.1 “Attachment” means any item the Solicitation requires the Offeror to submit as part of the Offer.
    1.2 “Contract” means the combination of the Solicitation, including the Uniform and Special Instructions to Offerors, the
        Uniform and Special Terms and Conditions, and the Specifications and Statement or Scope of Work; the Offer and any Best
        and Final Offers; and any Solicitation Amendments or Contract Amendments.
    1.3 "Contract Amendment" means a written document signed by the Procurement Officer that is issued for the purpose of making
        changes in the Contract.
    1.4 “Contractor” means any person who has a Contract with the State.
    1.5 “Days” means calendar days unless otherwise specified.
    1.6 “Exhibit” means any item labeled as an Exhibit in the Solicitation or placed in the Exhibits section of the Solicitation.
    1.7 “Gratuity” means a payment, loan, subscription, advance, deposit of money, services, or anything of more than nominal
        value, present or promised, unless consideration of substantially equal or greater value is received.
    1.8 “Materials” means all property, including equipment, supplies, printing, insurance and leases of property but does not
        include land, a permanent interest in land or real property or leasing space.
    1.9 “Procurement Officer” means the person, or his or her designee, duly authorized by the State to enter into and administer
        Contracts and make written determinations with respect to the Contract.
    1.10 “Services” means the furnishing of labor, time or effort by a contractor or subcontractor which does not involve the delivery
         of a specific end product other than required reports and performance, but does not include employment agreements or
         collective bargaining agreements.
    1.11 “Subcontract” means any Contract, express or implied, between the Contractor and another party or between a subcontractor
         and another party delegating or assigning, in whole or in part, the making or furnishing of any material or any service
         required for the performance of the Contract.
    1.12 “State” means the State of Arizona and Department or Agency of the State that executes the Contract.
    1.13 “State Fiscal Year” means the period beginning with July 1 and ending June 30.

2       Contract Interpretation
    2.1 Arizona Law. The Arizona law applies to this Contract including, where applicable, the Uniform Commercial Code as
        adopted by the State of Arizona and the Arizona Procurement Code, Arizona Revised Statutes (A.R.S.) Title 41, Chapter 23,
        and its implementing rules, Arizona Administrative Code (A.A.C.) Title 2, Chapter 7.
    2.2 Implied Contract Terms. Each provision of law and any terms required by law to be in this Contract are a part of this Contract
        as if fully stated in it.
    2.3 Contract Order of Precedence. In the event of a conflict in the provisions of the Contract, as accepted by the State and as they
        may be amended, the following shall prevail in the order set forth below:
        2.3.1    Special Terms and Conditions;
        2.3.2    Uniform Terms and Conditions;
        2.3.3    Statement or Scope of Work;
        2.3.4    Specifications;
        2.3.5    Attachments;
        2.3.6    Exhibits;

                                                                                                 Section: Uniform Terms & Conditions
                                                                                                                 Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                                 Arizona State Retirement System
                                                                                                       3300 North Central Avenue
                                            Retiree Dental Benefits Program                                     Suite 1300
                                                                                                         Phoenix, Arizona 85012
                                                            RT10-022
                                                                                                              Page 35 of 154

        2.3.7     Documents referenced or included in the Solicitation.
    2.4 Relationship of Parties. The Contractor under this Contract is an independent Contractor. Neither party to this Contract shall
        be deemed to be the employee or agent of the other party to the Contract.
    2.5 Severability. The provisions of this Contract are severable. Any term or condition deemed illegal or invalid shall not affect
        any other term or condition of the Contract.
    2.6 No Parol Evidence. This Contract is intended by the parties as a final and complete expression of their agreement. No course
        of prior dealings between the parties and no usage of the trade shall supplement or explain any terms used in this document
        and no other understanding either oral or in writing shall be binding.
    2.7 No Waiver. Either party’s failure to insist on strict performance of any term or condition of the Contract shall not be deemed
        a waiver of that term or condition even if the party accepting or acquiescing in the nonconforming performance knows of the
        nature of the performance and fails to object to it.

3       Contract administration and operation.
    3.1 Records. Under A.R.S. § 35-214 and § 35-215, the Contractor shall retain and shall contractually require each subcontractor
        to retain all data and other “records” relating to the acquisition and performance of the Contract for a period of five years
        after the completion of the Contract. All records shall be subject to inspection and audit by the State at reasonable times.
        Upon request, the Contractor shall produce a legible copy of any or all such records.
    3.2 Non-Discrimination. The Contractor shall comply with State Executive Order No. 99-4 and all other applicable Federal and
        State laws, rules and regulations, including the Americans with Disabilities Act.
    3.3 Audit. Pursuant to ARS § 35-214, at any time during the term of this Contract and five (5) years thereafter, the Contractor’s
        or any subcontractor’s books and records shall be subject to audit by the State and, where applicable, the Federal
        Government, to the extent that the books and records relate to the performance of the Contract or Subcontract.
    3.4 Facilities Inspection and Materials Testing. The Contractor agrees to permit access to its facilities, subcontractor facilities and
        the Contractor’s processes or services, at reasonable times for inspection of the facilities or materials covered under this
        Contract. The State shall also have the right to test, at its own cost, the materials to be supplied under this Contract. Neither
        inspection of the Contractor’s facilities nor materials testing shall constitute final acceptance of the materials or services. If
        the State determines noncompliance of the materials, the Contractor shall be responsible for the payment of all costs incurred
        by the State for testing and inspection.
    3.5 Notices. Notices to the Contractor required by this Contract shall be made by the State to the person indicated on the Offer
        and Acceptance form submitted by the Contractor unless otherwise stated in the Contract. Notices to the State required by the
        Contract shall be made by the Contractor to the Solicitation Contact Person indicated on the Solicitation cover sheet, unless
        otherwise stated in the Contract. An authorized Procurement Officer and an authorized Contractor representative may change
        their respective person to whom notice shall be given by written notice to the other and an amendment to the Contract shall
        not be necessary.
    3.6 Advertising, Publishing and Promotion of Contract. The Contractor shall not use, advertise or promote information for
        commercial benefit concerning this Contract without the prior written approval of the Procurement Officer.
    3.7 Property of the State. Any materials, including reports, computer programs and other deliverables, created under this Contract
        are the sole property of the State. The Contractor is not entitled to a patent or copyright on those materials and may not
        transfer the patent or copyright to anyone else. The Contractor shall not use or release these materials without the prior
        written consent of the State.
    3.8 Ownership of Intellectual Property. Any and all intellectual property, including but not limited to copyright, invention,
        trademark, trade name, service mark, and/or trade secrets created or conceived pursuant to or as a result of this contract and
        any related subcontract (“Intellectual Property”), shall be work made for hire and the State shall be considered the creator of
        such Intellectual Property. The agency, department, division, board or commission of the State of Arizona requesting the
        issuance of the contract shall own (for and on behalf of the State) the entire right, title and interest to the Intellectual Property
        throughout the world. Contractor shall notify the State, within thirty (30) days, of the creation of any Intellectual Property by
        it or its subcontractor(s). Contractor, on behalf of itself and any subcontractor (s), agrees to execute any and all document(s)
                                                                                                    Section: Uniform Terms & Conditions
                                                                                                                    Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                    3300 North Central Avenue
                                           Retiree Dental Benefits Program                                   Suite 1300
                                                                                                      Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                           Page 36 of 154

        necessary to assure ownership of the Intellectual Property vests in the State and shall take no affirmative actions that might
        have the effect of vesting all or part of the Intellectual Property in any entity other than the State. The Intellectual Property
        shall not be disclosed by contractor or its subcontractor(s) to any entity not the State without the express written authorization
        of the agency, department, division, board or commission of the State of Arizona requesting the issuance of this contract.

4       Costs and Payments
    4.1 Payments. Payments shall comply with the requirements of A.R.S. Titles 35 and 41, Net 30 days. Upon receipt and
        acceptance of goods or services, the Contractor shall submit a complete and accurate invoice for payment from the State
        within thirty (30) days.
    4.2 Delivery. Unless stated otherwise in the Contract, all prices shall be F.O.B. Destination and shall include all freight delivery
        and unloading at the destination.
    4.3 Applicable Taxes.
        4.3.1    Payment of Taxes. The Contractor shall be responsible for paying all applicable taxes.
        4.3.2    State and Local Transaction Privilege Taxes. The State of Arizona is subject to all applicable state and local
                 transaction privilege taxes. Transaction privilege taxes apply to the sale and are the responsibility of the seller to
                 remit. Failure collect such taxes from the buyer does not relieve the seller from its obligation to remit taxes.
        4.3.3    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 the
                 State 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.
        4.3.4    IRS W9 Form. In order to receive payment the Contractor shall have a current IRS W9 Form on file with the State
                 of Arizona, unless not required by law.
    4.4 Availability of Funds for the Next State fiscal year. Funds may not presently be available for performance under this Contract
        beyond the current state fiscal year. No legal liability on the part of the State for any payment may arise under this Contract
        beyond the current state fiscal year until funds are made available for performance of this Contract.
    4.5 Availability of Funds for the current State fiscal year. Should the State Legislature enter back into session and reduce the
        appropriations or for any reason and these goods or services are not funded, the State may take any of the following actions:
        4.5.1   Accept a decrease in price offered by the, contractor
        4.5.2   Cancel the Contract
        4.5.3   Cancel the contract and re-solicit the requirements.

5       Contract changes
    5.1 Amendments. This Contract is issued under the authority of the Procurement Officer who signed this Contract. The Contract
        may be modified only through a Contract Amendment within the scope of the Contract. Changes to the Contract, including
        the addition of work or materials, the revision of payment terms, or the substitution of work or materials, directed by a person
        who is not specifically authorized by the procurement officer in writing or made unilaterally by the Contractor are violations
        of the Contract and of applicable law. Such changes, including unauthorized written Contract Amendments shall be void and
        without effect, and the Contractor shall not be entitled to any claim under this Contract based on those changes.
    5.2 Subcontracts. The Contractor shall not enter into any Subcontract under this Contract for the performance of this contract
        without the advance written approval of the Procurement Officer. The Contractor shall clearly list any proposed
        subcontractors and the subcontractor’s proposed responsibilities. The Subcontract shall incorporate by reference the terms
        and conditions of this Contract.
    5.3 Assignment and Delegation. The Contractor shall not assign any right nor delegate any duty under this Contract without the
        prior written approval of the Procurement Officer. The State shall not unreasonably withhold approval.

                                                                                                  Section: Uniform Terms & Conditions
                                                                                                                  Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                                 Arizona State Retirement System
                                                                                                      3300 North Central Avenue
                                            Retiree Dental Benefits Program                                    Suite 1300
                                                                                                        Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                              Page 37 of 154


6       Risk and Liability
    6.1 Risk of Loss. The Contractor shall bear all loss of conforming material covered under this Contract until received by
        authorized personnel at the location designated in the purchase order or Contract. Mere receipt does not constitute final
        acceptance. The risk of loss for nonconforming materials shall remain with the Contractor regardless of receipt.
    6.2 Indemnification
        6.2.1    Contractor/Vendor Indemnification (Not Public Agency) The parties to this contract agree that the State of Arizona,
                 its’ departments, agencies, boards and commissions shall be indemnified and held harmless by the contractor for the
                 vicarious liability of the State as a result of entering into this contract. However, the parties further agree that the
                 State of Arizona, its’ departments, agencies, boards and commissions shall be responsible for its’ own negligence.
                 Each party to this contract is responsible for its’ own negligence.
        6.2.2    Public Agency Language Only Each party (as 'indemnitor') agrees to indemnify, defend, and hold harmless the other
                 party (as 'indemnitee'') from and against any and all claims, losses, liability, costs, or expenses (including reasonable
                 attorney's fees) (hereinafter collectively referred to as 'claims') arising out of bodily injury of any person (including
                 death) or property damage but only to the extent that such claims which result in vicarious/derivative liability to the
                 indemnitee, are caused by the act, omission, negligence, misconduct, or other fault of the indemnitor, its’ officers,
                 officials, agents, employees, or volunteers."
    6.3 Indemnification - Patent and Copyright. The Contractor shall indemnify and hold harmless the State against any liability,
        including costs and expenses, for infringement of any patent, trademark or copyright arising out of Contract performance or
        use by the State of materials furnished or work performed under this Contract. The State shall reasonably notify the
        Contractor of any claim for which it may be liable under this paragraph. If the contractor is insured pursuant to A.R.S. § 41-
        621 and § 35-154, this section shall not apply.
    6.4 Force Majeure.
        6.4.1    Except for payment of sums due, neither party shall be liable to the other nor deemed in default under this Contract
                 if and to the extent that such party’s performance of this Contract is prevented by reason of force majeure. The term
                 “force majeure” means an occurrence that is beyond the control of the party affected and occurs without its fault or
                 negligence. Without limiting the foregoing, force majeure includes acts of God; acts of the public enemy; war; riots;
                 strikes; mobilization; labor disputes; civil disorders; fire; flood; lockouts; injunctions-intervention-acts; or failures or
                 refusals to act by government authority; and other similar occurrences beyond the control of the party declaring
                 force majeure which such party is unable to prevent by exercising reasonable diligence.
        6.4.2    Force Majeure shall not include the following occurrences:
                 6.4.2.1 Late delivery of equipment or materials caused by congestion at a manufacturer’s plant or elsewhere, or an
                      oversold condition of the market;
                 6.4.2.2 Late performance by a subcontractor unless the delay arises out of a force majeure occurrence in
                      accordance with this force majeure term and condition; or
                 6.4.2.3 Inability of either the Contractor or any subcontractor to acquire or maintain any required insurance, bonds,
                      licenses or permits.
        6.4.3    If either party is delayed at any time in the progress of the work by force majeure, the delayed party shall notify the
                 other party in writing of such delay, as soon as is practicable and no later than the following working day, of the
                 commencement thereof and shall specify the causes of such delay in such notice. Such notice shall be delivered or
                 mailed certified return receipt and shall make a specific reference to this article, thereby invoking its provisions. The
                 delayed party shall cause such delay to cease as soon as practicable and shall notify the other party in writing when
                 it has done so. The time of completion shall be extended by Contract Amendment for a period of time equal to the
                 time that results or effects of such delay prevent the delayed party from performing in accordance with this Contract.




                                                                                                    Section: Uniform Terms & Conditions
                                                                                                                    Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                    3300 North Central Avenue
                                           Retiree Dental Benefits Program                                   Suite 1300
                                                                                                      Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                           Page 38 of 154

        6.4.4    Any delay or failure in performance by either party hereto shall not constitute default hereunder or give rise to any
                 claim for damages or loss of anticipated profits if, and to the extent that such delay or failure is caused by force
                 majeure.
    6.5 Third Party Antitrust Violations. The Contractor assigns to the State any claim for overcharges resulting from antitrust
        violations to the extent that those violations concern materials or services supplied by third parties to the Contractor, toward
        fulfillment of this Contract.

7       Warranties
    7.1 Liens. The Contractor warrants that the materials supplied under this Contract are free of liens and shall remain free of liens.
    7.2 Quality. Unless otherwise modified elsewhere in these terms and conditions, the Contractor warrants that, for one year after
        acceptance by the State of the materials, they shall be:
        7.2.1    Of a quality to pass without objection in the trade under the Contract description;
        7.2.2    Fit for the intended purposes for which the materials are used;
        7.2.3    Within the variations permitted by the Contract and are of even kind, quantity, and quality within each unit and
                 among all units;
        7.2.4    Adequately contained, packaged and marked as the Contract may require; and
        7.2.5    Conform to the written promises or affirmations of fact made by the Contractor.
7.3    Fitness. The Contractor warrants that any material supplied to the State shall fully conform to all requirements of the Contract
       and all representations of the Contractor, and shall be fit for all purposes and uses required by the Contract.
7.4    Inspection/Testing. The warranties set forth in subparagraphs 7.1 through 7.3 of this paragraph are not affected by inspection
       or testing of or payment for the materials by the State.
7.5    Year 2000.
        7.5.1    Notwithstanding any other warranty or disclaimer of warranty in this Contract, the Contractor warrants that all
                 products delivered and all services rendered under this Contract shall comply in all respects to performance and
                 delivery requirements of the specifications and shall not be adversely affected by any date-related data Year 2000
                 issues. This warranty shall survive the expiration or termination of this Contract. In addition, the defense of force
                 majeure shall not apply to the Contractor’s failure to perform specification requirements as a result of any date-
                 related data Year 2000 issues.
        7.5.2    Additionally, notwithstanding any other warranty or disclaimer of warranty in this Contract, the Contractor warrants
                 that each hardware, software, and firmware product delivered under this Contract shall be able to accurately process
                 date/time data (including but not limited to calculation, comparing, and sequencing) from, into, and between the
                 twentieth and twenty-first centuries, and the years 1999 and 2000 and leap year calculations, to the extent that other
                 information technology utilized by the State in combination with the information technology being acquired under
                 this Contract properly exchanges date-time data with it. If this Contract requires that the information technology
                 products being acquired perform as a system, or that the information technology products being acquired perform as
                 a system in combination with other State information technology, then this warranty shall apply to the acquired
                 products as a system. The remedies available to the State for breach of this warranty shall include, but shall not be
                 limited to, repair and replacement of the information technology products delivered under this Contract. In addition,
                 the defense of force majeure shall not apply to the failure of the Contractor to perform any specification
                 requirements as a result of any date-related data Year 2000 issues.
    7.6 Compliance With Applicable Laws. The materials and services supplied under this Contract shall comply with all applicable
        Federal, state and local laws, and the Contractor shall maintain all applicable licenses and permit requirements.
    7.7 Survival of Rights and Obligations after Contract Expiration or Termination.
        7.7.1    Contractor's Representations and Warranties. All representations and warranties made by the Contractor under this
                 Contract shall survive the expiration or termination hereof. In addition, the parties hereto acknowledge that pursuant
                                                                                                  Section: Uniform Terms & Conditions
                                                                                                                  Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                     3300 North Central Avenue
                                            Retiree Dental Benefits Program                                   Suite 1300
                                                                                                       Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                            Page 39 of 154

                 to A.R.S. § 12-510, except as provided in A.R.S. § 12-529, the State is not subject to or barred by any limitations of
                 actions prescribed in A.R.S., Title 12, Chapter 5.
        7.7.2    Purchase Orders. The Contractor shall, in accordance with all terms and conditions of the Contract, fully perform
                 and shall be obligated to comply with all purchase orders received by the Contractor prior to the expiration or
                 termination hereof, unless otherwise directed in writing by the Procurement Officer, including, without limitation,
                 all purchase orders received prior to but not fully performed and satisfied at the expiration or termination of this
                 Contract.

8       State's Contractual Remedies
    8.1 Right to Assurance. If the State in good faith has reason to believe that the Contractor does not intend to, or is unable to
        perform or continue performing under this Contract, the Procurement Officer may demand in writing that the Contractor give
        a written assurance of intent to perform. Failure by the Contractor to provide written assurance within the number of Days
        specified in the demand may, at the State’s option, be the basis for terminating the Contract under the Uniform Terms and
        Conditions or other rights and remedies available by law or provided by the contract.
    8.2 Stop Work Order.
        8.2.1    The State 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 period(s) of days indicated by the State after the order is delivered to the
                 Contractor. 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.
        8.2.2    If a stop work order issued under this clause is canceled or the period of the order or any extension expires, the
                 Contractor shall resume work. The Procurement Officer shall make an equitable adjustment in the delivery schedule
                 or Contract price, or both, and the Contract shall be amended in writing accordingly.
    8.3 Non-exclusive Remedies. The rights and the remedies of the State under this Contract are not exclusive.
    8.4 Nonconforming Tender. Materials or services supplied under this Contract shall fully comply with the Contract. The delivery
        of materials or services or a portion of the materials or services that do not fully comply constitutes a breach of contract. On
        delivery of nonconforming materials or services, the State may terminate the Contract for default under applicable
        termination clauses in the Contract, exercise any of its rights and remedies under the Uniform Commercial Code, or pursue
        any other right or remedy available to it.
    8.5 Right of Offset. The State shall be entitled to offset against any sums due the Contractor, any expenses or costs incurred by
        the State, or damages assessed by the State concerning the Contractor’s non-conforming performance or failure to perform
        the Contract, including expenses, costs and damages described in the Uniform Terms and Conditions.

9       Contract Termination
    9.1 Cancellation for Conflict of Interest. Pursuant to A.R.S. § 38-511, the State may cancel this Contract within three (3) years
        after Contract execution without penalty or further obligation if any person significantly involved in initiating, negotiating,
        securing, drafting or creating the Contract on behalf of the State is or becomes at any time while the Contract or an extension
        of the Contract is in effect an employee of or a consultant to any other party to this Contract with respect to the subject matter
        of the Contract. The cancellation shall be effective when the Contractor receives written notice of the cancellation unless the
        notice specifies a later time. If the Contractor is a political subdivision of the State, it may also cancel this Contract as
        provided in A.R.S. § 38-511.
    9.2 Gratuities. The State may, by written notice, terminate this Contract, in whole or in part, if the State determines that
        employment or a Gratuity was offered or made by the Contractor or a representative of the Contractor to any officer or
        employee of the State for the purpose of influencing the outcome of the procurement or securing the Contract, an amendment
        to the Contract, or favorable treatment concerning the Contract, including the making of any determination or decision about
        contract performance. The State, in addition to any other rights or remedies, shall be entitled to recover exemplary damages
        in the amount of three times the value of the Gratuity offered by the Contractor.

                                                                                                  Section: Uniform Terms & Conditions
                                                                                                                  Form#RFP.02/03/10
                                            REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                  3300 North Central Avenue
                                         Retiree Dental Benefits Program                                   Suite 1300
                                                                                                    Phoenix, Arizona 85012
                                                        RT10-022
                                                                                                         Page 40 of 154

 9.3 Suspension or Debarment. The State may, by written notice to the Contractor, immediately terminate this Contract if the
     State determines that the Contractor has been debarred, suspended or otherwise lawfully prohibited from participating in any
     public procurement activity, including but not limited to, being disapproved as a subcontractor of any public procurement
     unit or other governmental body. Submittal of an offer or execution of a contract shall attest that the contractor is not
     currently suspended or debarred. If the contractor becomes suspended or debarred, the contractor shall immediately notify the
     State.
 9.4 Termination for Convenience. The State reserves the right to terminate the Contract, in whole or in part at any time, when in
     the best interests of the State without penalty or recourse. Upon receipt of the written notice, the Contractor shall stop all
     work, as directed in the notice, notify all subcontractors of the effective date of the termination and minimize all further costs
     to the State. In the event of termination under this paragraph, all documents, data and reports prepared by the Contractor
     under the Contract shall become the property of and be delivered to the State upon demand. The Contractor shall be entitled
     to receive just and equitable compensation for work in progress, work completed and materials accepted before the effective
     date of the termination. The cost principles and procedures provided in A.A.C. R2-7-701 shall apply.
 9.5 Termination for Default.
     9.5.1    In addition to the rights reserved in the contract, the State may terminate the Contract in whole or in part due to the
              failure of the Contractor to comply with any term or condition of the Contract, to acquire and maintain all required
              insurance policies, bonds, licenses and permits, or to make satisfactory progress in performing the Contract. The
              Procurement Officer shall provide written notice of the termination and the reasons for it to the Contractor.
     9.5.2    Upon termination under this paragraph, all goods, materials, documents, data and reports prepared by the Contractor
              under the Contract shall become the property of and be delivered to the State on demand.
     9.5.3    The State may, upon termination of this Contract, procure, on terms and in the manner that it deems appropriate,
              materials or services to replace those under this Contract. The Contractor shall be liable to the State for any excess
              costs incurred by the State in procuring materials or services in substitution for those due from the Contractor.
 9.6 Continuation of Performance Through Termination. The Contractor shall continue to perform, in accordance with the
     requirements of the Contract, up to the date of termination, as directed in the termination notice.

10   Contract Claims. All contract claims or controversies under this Contract shall be resolved according to A.R.S. Title 41,
     Chapter 23, Article 9, and rules adopted thereunder.

11   Arbitration. The parties to this Contract agree to resolve all disputes arising out of or relating to this contract through
     arbitration, after exhausting applicable administrative review, to the extent required by A.R.S. § 12-1518, except as may be
     required by other applicable statutes (Title 41).
12   Comments Welcome. The State Procurement Office periodically reviews the Uniform Terms and Conditions and welcomes
     any comments you may have. Please submit your comments to: State Procurement Administrator, State Procurement Office,
     100 North 15th Avenue, Suite 104, Phoenix, Arizona, 85007.




                                                                                               Section: Uniform Terms & Conditions
                                                                                                               Form#RFP.02/03/10
                                                 REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                       3300 North Central Avenue
                                             Retiree Dental Benefits Program                                    Suite 1300
                                                                                                         Phoenix, Arizona 85012
                                                            RT10-022
                                                                                                              Page 41 of 154



                                     SPECIAL TERMS & CONDITIONS

I           INSURANCE TERMS


INDEMNIFICATION CLAUSE:
Contractor shall indemnify, defend, save and hold harmless the State of Arizona, its departments, agencies, boards, commissions,
universities and its officers, officials, agents, and employees (hereinafter referred to as “Indemnitee”) from and against any and all
claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys’ fees, and costs of claim processing,
investigation and litigation) (hereinafter referred to as “Claims”) for bodily injury or personal injury (including death), or loss or
damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or
omissions of Contractor or any of its owners, officers, directors, agents, employees or subcontractors. This indemnity includes any
claim or amount arising out of or recovered under the Workers’ Compensation Law or arising out of the failure of such contractor to
conform to any federal, state or local law, statute, ordinance, rule, regulation or court decree. It is the specific intention of the parties
that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the
Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that Contractor will be responsible for
primary loss investigation, defense and judgment costs where this indemnification is applicable. In consideration of the award of this
contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents and
employees for losses arising from the work performed by the Contractor for the State of Arizona.

This indemnity shall not apply if the contractor or sub-contractor(s) is/are an agency, board, commission or university of the State of
Arizona.


INSURANCE REQUIREMENTS:
Contractor and subcontractors shall procure and maintain until all of their obligations have been discharged, including any warranty
periods under this Contract, are satisfied, insurance against claims for injury to persons or damage to property which may arise from
or in connection with the performance of the work hereunder by the Contractor, his agents, representatives, employees or
subcontractors.

The insurance requirements herein are minimum requirements for this Contract and in no way limit the indemnity covenants
contained in this Contract. The State of Arizona in no way warrants that the minimum limits contained herein are sufficient to protect
the Contractor from liabilities that might arise out of the performance of the work under this contract by the Contractor, its agents,
representatives, employees or subcontractors, and Contractor is free to purchase additional insurance.



A.     MINIMUM SCOPE AND LIMITS OF INSURANCE: Contractor shall provide coverage with limits of liability not less
       than those stated below.


       1.    Commercial General Liability – Occurrence Form

             Policy shall include bodily injury, property damage, personal injury and broad form contractual liability
             coverage.

                General Aggregate                                                            $2,000,000
                Products – Completed Operations Aggregate                                    $1,000,000

                                                                                                     Section: Special Terms & Conditions
                                                                                                                     Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                              3300 North Central Avenue
                                     Retiree Dental Benefits Program                                   Suite 1300
                                                                                                Phoenix, Arizona 85012
                                                    RT10-022
                                                                                                     Page 42 of 154

         Personal and Advertising Injury                                            $1,000,000
         Blanket Contractual Liability – Written and Oral                           $1,000,000
         Fire Legal Liability                                                       $ 50,000
         Each Occurrence                                                            $1,000,000
     a.     The policy shall be endorsed to include the following additional insured language: “The State of
            Arizona, its departments, agencies, boards, commissions, universities and its officers, officials,
            agents, and employees shall be named as additional insureds with respect to liability arising out of
            the activities performed by or on behalf of the Contractor".
     b.     Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies,
            boards, commissions, universities and its officers, officials, agents, and employees for losses arising
            from work performed by or on behalf of the Contractor.


2.   Business Automobile Liability

     Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance
     of this Contract.
     Combined Single Limit (CSL)                                                    $1,000,000
     a.   The policy shall be endorsed to include the following additional insured language: “The State of
          Arizona, its departments, agencies, boards, commissions, universities and its officers, officials,
          agents, and employees shall be named as additional insureds with respect to liability arising out
          of the activities performed by or on behalf of the Contractor, involving automobiles owned,
          leased, hired or borrowed by the Contractor".
     b.   Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies,
          boards, commissions, universities and its officers, officials, agents, and employees for losses arising
          from work performed by or on behalf of the Contractor.


3.   Worker's Compensation and Employers' Liability

            Workers' Compensation                                                    Statutory

            Employers' Liability

                         Each Accident                                               $ 500,000

                         Disease – Each Employee                                     $ 500,000

                         Disease – Policy Limit                                      $1,000,000
     a.     Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies,
            boards, commissions, universities and its officers, officials, agents, and employees for losses arising
            from work performed by or on behalf of the Contractor.

     b.     This requirement shall not apply to: Separately, EACH contractor or subcontractor exempt under
            A.R.S. 23-901, AND when such contractor or subcontractor executes the appropriate waiver (Sole
            Proprietor/Independent Contractor) form.



                                                                                            Section: Special Terms & Conditions
                                                                                                            Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                                  3300 North Central Avenue
                                           Retiree Dental Benefits Program                                 Suite 1300
                                                                                                    Phoenix, Arizona 85012
                                                         RT10-022
                                                                                                         Page 43 of 154

     4.   Professional Liability (Errors and Omissions Liability)

                              Each Claim                                                 $1,000,000

                              Annual Aggregate                                           $2,000,000
          a.    In the event that the professional liability insurance required by this Contract is written on a claims-
                made basis, Contractor warrants that any retroactive date under the policy shall precede the effective
                date of this Contract; and that either continuous coverage will be maintained or an extended
                discovery period will be exercised for a period of two (2) years beginning at the time work under this
                Contract is completed.
          b.    The policy shall cover professional misconduct or lack of ordinary skill for those positions defined in
                the Scope of Work of this contract.



B.   ADDITIONAL INSURANCE REQUIREMENTS: The policies shall include, or be endorsed to include, the following
     provisions:
     1.   The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and
          employees wherever additional insured status is required. Such additional insured shall be covered to the full limits of
          liability purchased by the Contractor, even if those limits of liability are in excess of those required by this Contract.
     2.   The Contractor's insurance coverage shall be primary insurance with respect to all other available sources.
     3.   Coverage provided by the Contractor shall not be limited to the liability assumed under the indemnification provisions of
          this Contract.



C.   NOTICE OF CANCELLATION: Each insurance policy required by the insurance provisions of this Contract shall provide
     the required coverage and shall not be suspended, voided, canceled, or reduced in coverage or in limits except after thirty (30)
     days prior written notice has been given to the State of Arizona. Such notice shall be sent directly to procurement officer listed
     on the first page of this contract and shall be sent by certified mail, return receipt requested.



D.   ACCEPTABILITY OF INSURERS: Insurance is to be placed with duly licensed or approved non-admitted insurers in the
     state of Arizona with an “A.M. Best” rating of not less than A- VII. The State of Arizona in no way warrants that the above-
     required minimum insurer rating is sufficient to protect the Contractor from potential insurer insolvency.



E.   VERIFICATION OF COVERAGE: Contractor shall furnish the State of Arizona with certificates of insurance (ACORD
     form or equivalent approved by the State of Arizona) as required by this Contract. The certificates for each insurance policy
     are to be signed by a person authorized by that insurer to bind coverage on its behalf.

     All certificates and endorsements are to be received and approved by the State of Arizona before work commences. Each
     insurance policy required by this Contract must be in effect at or prior to commencement of work under this Contract and
     remain in effect for the duration of the project. Failure to maintain the insurance policies as required by this Contract, or to
     provide evidence of renewal, is a material breach of contract.


                                                                                                 Section: Special Terms & Conditions
                                                                                                                 Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                   3300 North Central Avenue
                                          Retiree Dental Benefits Program                                   Suite 1300
                                                                                                     Phoenix, Arizona 85012
                                                         RT10-022
                                                                                                          Page 44 of 154

     All certificates required by this Contract shall be sent directly to procurement officer listed on the first page of this contract.
     The State of Arizona project/contract number and project description shall be noted on the certificate of insurance. The State of
     Arizona reserves the right to require complete, certified copies of all insurance policies required by this Contract at any time.
     DO NOT SEND CERTIFICATES OF INSURANCE TO THE STATE OF ARIZONA'S RISK MANAGEMENT
     DIVISION.



F.   SUBCONTRACTORS: Contractors’ certificate(s) shall include all subcontractors as insureds under its policies or Contractor
     shall furnish to the State of Arizona separate certificates and endorsements for each subcontractor. All coverages for
     subcontractors shall be subject to the minimum requirements identified above.



G.   APPROVAL: Any modification or variation from the insurance requirements in this Contract shall be made by the
     Department of Administration, Risk Management Division, whose decision shall be final. Such action will not require a formal
     Contract amendment, but may be made by administrative action.



H.   EXCEPTIONS: In the event the Contractor or sub-contractor(s) is/are a public entity, then the Insurance Requirements shall
     not apply. Such public entity shall provide a Certificate of Self-Insurance. If the contractor or sub-contractor(s) is/are a State
     of Arizona agency, board, commission, or university, none of the above shall apply.




                                                                                                 Section: Special Terms & Conditions
                                                                                                                 Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                                    3300 North Central Avenue
                                            Retiree Dental Benefits Program                                  Suite 1300
                                                                                                      Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                           Page 45 of 154



II       OTHER SPECIAL TERMS & CONDITIONS

1.   Authority to Contract
     This Contract activity is issued under the authority of the State Procurement Administrator, through the Arizona State Retirement
     System. No alteration of any portion of the Contract, any commodities and/or services awarded, or any other agreement that is
     based upon this Contract may be made without express written approval of the ASRS Chief Procurement Officer in the form of an
     official Contract Amendment. Any attempt to alter any documents on the part of the ASRS or any Contractor or any
     subcontractor is a violation of the Contract and the Arizona Procurement Code. Any such action is subject to the legal and
     contractual remedies available to the State inclusive of, but not limited to, Contract cancellation, suspension, and/or debarment of
     the Contractor.

2.   Contract Applicability
     Any Contract resulting from this Solicitation shall be for the exclusive use of the Arizona State Retirement System.

3.   General Information
     The Contractor may not make any changes to the Specifications, delivery schedule, or price without prior written approval by the
     ASRS.

4.   Term of Contract
     The term of the contract shall commence upon award and shall remain in effect for a period of one (1) year thereafter unless
     terminated, canceled or extended as otherwise provided herein.

5.   Contract Renewal
     The Contract shall not bind nor purport to bind the ASRS for any contractual commitment in excess of the original Contract
     period, which is January 1, through December 31. The ASRS shall have the right, as its sole option, to renew the contract for four
     (4) one-year periods or a portion thereof. If the ASRS exercises such rights, all terms, conditions, and provisions of the original
     Contract shall remain the same and apply during the renewal period. The Contractor shall agree that the prices stated in the
     original contract shall not be increased unless otherwise negotiated. Any extension beyond a maximum of five (5) years may
     only be made at the sole discretion of the ASRS with approval by the Director of the Arizona Department of Administration.

     The Contractor shall provide the State of Arizona with a preliminary renewal on or before May 15, for any first renewal period and a
     firm renewal offer no later than June 15. Preliminary renewals for any subsequent years shall be provided on or before May 15
     and firm renewal offers no later than June 15. Any request shall be accompanied by supporting documentation. Similarly, the
     Contractor shall provide the State of Arizona with one hundred ninety-five (195) day advance notice of program/operation changes or
     modifications of any type.

6.   Licenses
     The Contractor shall maintain in current status all federal, state, and local licenses and permits required for the operation of the
     business conducted by the Contractor.

7.   IT 508 Compliance
     Any electronic or information technology offered to the State of Arizona under this solicitation shall comply with A.R.S. §§ 41-
     2531 and 2532 and Section 508 of the Rehabilitation Act of 1973, which requires that employees and members of the public shall
     have access to and use of information technology that is comparable to the access and use by employees and members of the
     public who are not individuals with disabilities. Any exceptions shall be declared in writing in the offer.

8.   Confidentiality of Records
     A. The Contractor shall establish and maintain procedures and controls that are acceptable to the ASRS for the purpose of
        assuring that no information contained in its records or obtained from the ASRS or from others in carrying out its functions
        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. Persons requesting such information shall be referred to the ASRS. The Contractor also

                                                                                                   Section: Special Terms & Conditions
                                                                                                                   Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                     3300 North Central Avenue
                                            Retiree Dental Benefits Program                                   Suite 1300
                                                                                                       Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                            Page 46 of 154

         agrees that any information pertaining to individual persons shall not be divulged other than to employees or officers of the
         Contractor as needed for the performance of duties under the Contract, unless otherwise agreed to in writing by the ASRS.

     B. The Contractor shall treat all information, and in particular, information relating to recipients and providers, which is
        obtained by it through its performance under the Contract, as confidential information to the extent that confidential treatment
        is provided under state and federal law, and shall not use any information so obtained in any manner except as necessary for
        the proper discharge of its obligations and protection of its rights hereunder.

9.   Shipping Prices – F.O.B. Destination/Installation
     Prices shall be F.O.B. destination/installation to the delivery location designated herein. Contractor shall retain title and control
     of all commodities until they are delivered/installed and the Contract of Coverage has been completed. All risk of transportation
     and all related charges shall be the responsibility of the Contractor. All claims for visible or concealed damage shall be filed by
     the Contractor. The ASRS will notify the Contractor promptly of any damaged commodities and shall assist the Contractor in
     arranging for inspection.

10. Shipping Instructions –
    If the ASRS directs the Contractor to make a delivery to the ASRS facility, trucks must have a vertical clearance of less than 12
    feet and horizontal clearance of 27 feet to enter the loading dock. The building is closed to deliveries during the hours of 7:30
    a.m. to 8:30 a.m., 11:30 a.m. to 1:00 p.m., and 4:30 p.m. to 5:30 p.m. Delivery shall be completed during regular building
    delivery hours, unless the ASRS directs the Contractor to the contrary. Twenty-four hour notice prior to delivery must be
    provided to the Contract Manager so that security clearance can be authorized. Deliveries are to be placed inside the building as
    directed by the ASRS.

11. Key Personnel
    It is essential the Contractor provide an adequate staff of experienced personnel capable of and devoted to the successful
    accomplishment of work to be performed under this Contract. The Contractor must assign specific individuals to the key
    positions. Once key personnel are assigned to work under the Contract, the ASRS shall have the opportunity to review the
    qualifications and approve the assignment of additional or replacement key personnel.

12. Billing
    All billing notices should be identified by the name, and list the purchase order number, Contract number, line item number, and
    serial number, if applicable. Any Contract release order issued by the ASRS shall refer to the Contract number.

13. Taxes
    A. Applicable Taxes. The ASRS will pay only the rate and/or amount of taxes identified in the Offer and in any resulting
       Contract.

     B. Tax Indemnification. The Contractor and all subcontractors shall pay all federal, state, and local taxes applicable to its
        operation and persons employed by the Contractor. The Contractor shall, and require all subcontractors to, hold the ASRS
        harmless from any responsibility for taxes, penalties, 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.

     C. IRS W9 Form. In order to receive payment under any resulting Contract, the Contractor must have a current IRS W9 Form
        on file with the State of Arizona, Department of Administration, General Accounting Office.

14. Discounts
    Payment discount periods shall be computed from the date of receipt of commodities and/or services or correct invoice,
    whichever is later, to the date the ASRS’s warrant is mailed. Unless freight and other charges are itemized, any discount provided
    shall be taken on full amount of invoice. The ASRS shall be entitled to take advantage of any payment discount offered by the
    Contractor provided payment is made within the discount period.

 15. Tax Exemptions. Federal Excise Tax: The ASRS is exempt from Federal Excise Tax on manufactured goods. Exemption
     Certificates will be prepared upon request.
                                                                                    Section: Special Terms & Conditions
                                                                                                    Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                     3300 North Central Avenue
                                           Retiree Dental Benefits Program                                    Suite 1300
                                                                                                       Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                           Page 47 of 154

   A. State and Local Transaction Privilege Taxes: The ASRS is subject to all applicable state and local transaction privilege taxes.
      Transaction privilege taxes apply to the sale and are the responsibility of the seller to remit. Failure to collect taxes from the
      buyer does not relieve the seller from his obligation to remit taxes. Offerors are required to provide their Arizona Transaction
      Privilege Tax Number, if applicable, in the space provided on the Offer and Acceptance Form and provide the tax rate and
      amount, if applicable, on the Pricing Schedule.
   B. Evaluation of Offers: All applicable taxes will be considered by the ASRS when determining the lowest offeror evaluating
      proposals; except when a responsive offeror which is otherwise reasonably susceptible for award is located outside of
      Arizona and is not subject to a transaction privilege or use tax of a political subdivision of this state. In that event all
      applicable taxes which are the obligation of offerors in-state and out-of-state, offerors shall be disregarded in the Contract
      Award. At all times, payment of taxes and the determination of applicable taxes and rates are the sole responsibility of the
      Contractor.

16. Price Adjustments
   Unless otherwise addressed in the Pricing Schedule, the ASRS may review a fully documented request for a price increase only
   after the Contract has been in effect for one (1) year. The ASRS shall determine whether the requested price increase or an
   alternate option is in the best interest of the State.

   The Contractor may offer the State a price reduction on the Contract services and commodities at any time.

17. Contract Default
   The ASRS, by written notice of default to the Contractor, may terminate the whole or any part of this Contract in any one of the
   following circumstances:
   A. If the Contractor fails to make delivery of the commodities or to perform the services within the time specified; or
   B. If the Contractor fails to perform any of the other provisions of this Contract and fails to remedy the situations within a period
        of ten (10) days after receipt of notice.

18. Equitable Adjustments
   If the Contractor fails to perform satisfactorily under this Contract, or with any requirement under the Scope of Work and Terms
   & Conditions of this Contract, the ASRS may, at its sole discretion, request the Contractor make an equitable adjustment in the
   payment for that specific deficit. Such request for an equitable adjustment may be made in addition to any other remedies
   provided for under this Contract.

19. Contract Cancellation
   This Contract is critical to the State of Arizona and the state reserves the right to immediately cancel the whole or any part of this
   contract due to failure of the Contractor to carry out any material obligation, term, or condition of the Contract. The ASRS may
   issue a written notice of default effective at once and not deferred by any interval of time. Default shall be for acting or failing to
   act on in any of the following:
   A. The Contractor provides services that do not meet the Scope of Work of the Contract;
   B. The Contractor provides personnel that do not meet the requirements of the Contract;
   C. The Contractor attempts to impose on the State, personnel which are of an unacceptable quality;
   D. The Contractor fails to complete the work required or furnish the commodities required within the time stipulated in the
        Contract;
   E. The Contractor fails to make progress in the performance of the Contract and/or gives the ASRS reason to believe the
        Contractor will not or cannot perform to the requirements of the Contract.

20. Disputes
    The contract is not subject to arbitration. The State and the Contractor shall meet to discuss and attempt to resolve any dispute.
    However, should the dispute go unresolved to the satisfaction of both parties, the Contractor shall have the right to pursue the
    Arizona Procurement Code/Administrative Appeal Process for Claims, prior to an appeal to the judicial system.

21. Liquidated Damages Requirements
    In order to satisfactorily adjust the damages which the State of Arizona may suffer on goods and/or services according to the
    performance standards specified in the contract, the Contractor hereby covenants and agrees to pay the State of Arizona, as

                                                                                                   Section: Special Terms & Conditions
                                                                                                                   Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                                Arizona State Retirement System
                                                                                                      3300 North Central Avenue
                                             Retiree Dental Benefits Program                                   Suite 1300
                                                                                                        Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                             Page 48 of 154

     and for liquidated damages, without proof of actual or specified loss, in accordance with the following schedule:

     It is agreed by the State and the Contractor that a failure to meet the performance standards contained in this contract will
     cause damage to the State. In the event that such failure is attributable to the performance or lack of performance by the
     Contractor, the Contractor agrees to pay damages to the State therefore. The State and the Contractor further agree that it may
     be impractical and difficult to ascertain and determine the actual damages sustained by the State in the event of a failure to
     perform; it is therefore agreed that the Contractor shall, at the option of the State, have deducted no more than five percent
     (5%) of the premiums in a quarter.

     Assessment of Liquidated Damages: In the event of a claim by the State that the Contractor has failed to perform any of the
     requirements as defined in the Scope of Work, and the State decides to assess liquidated damages, the State shall notify the
     Contractor in writing of the claim and the assessment. If the Contractor agrees with the State’s claim assessment, the
     Contractor shall have any amount of liquidated damages deducted from the State’s Payment.

     Liquidated damages shall not be imposed or assessed if the failure to perform is a direct result of the State’s action or failure to
     act in accordance with its responsibility under this contract.

 22. Contract Termination
    Any Contract entered into as a result of this Solicitation is for the convenience of the ASRS and as such may be terminated
    without default by the ASRS by providing a written thirty (30) day notice of termination. The ASRS may resort to any single or
    combination of the following remedies:
    A. Cancel any Contract;
    B. Reserve all rights or claims to damage for breach of any covenants of the Contract;
    C. In case of default, the ASRS reserves the right to purchase commodities or to complete the required work in accordance with
         the Arizona Procurement Code. The ASRS may recover reasonable excess costs from the Contractor by:
         1) Deduction from an unpaid balance;
         2) Collection against the offer and/or performance bond; or
         3) Any combination of the above or any other remedies as provided by law.
23. Changes to the Contract
    The Contractor understands and agrees the needs of the ASRS may change during the life of the contract and the ASRS may
    propose changes to any part of this Contract with a commensurate, fair, and equitable adjustment in price. Any such changes
    shall be made in accordance with the Amendments clause of this contract.

24. Notices
    All notices, requests, demands, consents, approvals, and other communications which may or are required to be served or given
    hereunder (for the purposes of this Contract collectively called “NOTICES”), shall be in writing and shall be sent by registered or
    certified United States mail, return receipt requested, postage prepaid, addressed to the party or parties to receive such notice as
    follows:
    A. If intended for the ASRS, to:               Shireen Boone
                                                   Arizona State Retirement System
                                                   3300 North Central Avenue
                                                   Suite 1300 – Procurement Office
                                                   Phoenix, AZ 85012

    B. If intended for the Contractor, to:        [Contact's Name]
                                                  [Contractor Company Name]
                                                  [Company Address]
                                                  [Floor/Suite]
                                                  [City, State Zip]

    Or to such other address as either party may from time to time furnish in writing to the other by notice hereunder. Any notice so
    mailed shall be deemed to have been given as of the date such notice is received as shown on the return receipt. Furthermore,
    such notice may be given by delivering personally such notice. If intended for the ASRS and, if intended for the Contractor, to
                                                                                                    Section: Special Terms & Conditions
                                                                                                                    Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                                   3300 North Central Avenue
                                           Retiree Dental Benefits Program                                  Suite 1300
                                                                                                     Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                          Page 49 of 154

    the person named in the Offer of this Contract, or to such other person as either party may from time to time furnish in writing to
    the other by notice hereunder. Any notice so delivered shall be deemed to have been given as of the date such notice is personally
    delivered to the other party.

25. Offshore Performance of Work Prohibited
    Due to security and identity protection concerns, direct services under this contract shall be performed within the borders of the
    United States. Any services that are described in the Scope of Work that directly serve the State of Arizona or its clients and may
    involve access to secure or sensitive data or personal client data or development or modification of software for the State shall be
    performed within the borders of the United States. Unless specifically stated otherwise in the Specifications, this definition does
    not apply to indirect or “overhead” services, redundant back-up services, or services that are incidental to the performance of the
    Contract. This provision applies to work performed by subcontractors at all tiers. Offerors shall declare all anticipated offshore
    services in the proposal.

26. Compliance Requirements for A.R.S. § 41-4401, Government Procurement:
    E-Verify Requirement
    A. The contractor warrants compliance with all Federal immigration laws and regulations relating to employees and warrants its
       compliance with Section A.R.S. § 23-214, Subsection A, which reads “After December 31, 2007, every employer, after
       hiring an employee, shall verify the employment eligibility of the employee through the E-Verify program”.
    B. A breach of a warranty regarding compliance with immigration laws and regulations shall be deemed a material breach of the
       contract and the contractor may be subject to penalties up to and including termination of the contract.
    C. Failure to comply with a State audit process to randomly verify the employment records of contractors and subcontractors
       shall be deemed a material breach of the contract and the contractor may be subject to penalties up to and including
       termination of the contract.
    D. The State Agency retains the legal right to inspect the papers of any employee who works on the contract to ensure that the
       contractor or subcontractor is complying with the warranty under paragraph A.

25. Federal Immigration and Nationality Act 2
    The contractor shall comply with all federal, state and local immigration laws and regulations relating to the immigration status of
    their employees during the term of the contract. Further, the contractor shall flow down this requirement to all subcontractors
    utilized during the term of the contract. The State shall retain the right to perform random audits of contractor and subcontractor
    records or to inspect papers of any employee thereof to ensure compliance. Should the State determine that the contractor and/or
    any subcontractors be found noncompliant, the State may pursue 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.
26 Employee Sanctions A.R.S. § 41-4401
   By entering into the Contract, the Contractor warrants compliance with the Federal Immigration and Nationality Act (FINA) and
   all other Federal immigration laws and regulations related to the immigration status of its employees. 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 U.S. Department of Labor's Immigration and Control Act, for
   all employees performing work under the Contract. I-9 forms are available for download at http://www.USCIS.GOV .
    The State may request verification of compliance for any Contractor or subcontractor performing work under the Contract.
    Should the State suspect or find that the Contractor or any of its subcontractors are not in compliance, the State 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 Contract. All costs necessary to verify compliance are the responsibility of the Contractor.
27. Uniform Terms and Conditions
    The Contractor shall be subject to the Arizona State Procurement Office (SPO) Uniform Terms and Conditions currently in force
    and effect, which may be found at the SPO website http://www.azdoa.gov/spo/agency-resources-1/documents-
    forms/procurement-documents. Said instructions are hereby incorporated by reference as though set forth in full herein and shall
    supersede any Contract or other form of agreement supplied by Offeror.




                                                                                                  Section: Special Terms & Conditions
                                                                                                                  Form#RFP.02/03/10
   REQUEST FOR PROPOSAL            Arizona State Retirement System
                                     3300 North Central Avenue
 Retiree Dental Benefits Program              Suite 1300
                                       Phoenix, Arizona 85012
           RT10-022
                                          Page 50 of 154




 Exhibit A

DEMOGRAPHIC
INFORMATION




                                                   Section: Exhibit A
                                                 Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                     3300 North Central Avenue
                                       Retiree Dental Benefits Program                        Suite 1300
                                                                                       Phoenix, Arizona 85012
                                                   RT10-022
                                                                                             Page 51 of 154



                                                             Arizona State Retirement System
                                                              History of Retiree Enrollments
                                                                Calendar Years 2006 - 2010




                                          Retiree Only                                    Retiree +1                              Retiree +2 or more
Dental Plans

                          2006        2007     2008      2009     2010    2006    2007       2008       2009     2010    2006    2007     2008       2009    2010

High Option               7,710       8,483    9,213   10,004    11,050   4,282   4,844      5,561      6,265    7,358    393     500       591       657    1006

Low Option                1,359       1,492    1,683     1,810    1,963    522     616        703        786      887      42      50           70     79     117

Prepaid - AZ              5,192       5,366    5,412     5,558    5,752   3,131   3,307      3,387      3,504    3,525    419     410       422       422     570

Prepaid - Other States      n/a         n/a     170       163      159      n/a     n/a         93        85       83     n/a     n/a           12     11      11

                         14,261      15,341   16,478   17,535    18,924   7,935   8,767      9,744     10,640   11,853    854     960    1,095       1,169   1,704

Total Enrollment by Calendar Year:
                  2006    23,050
                  2007    25,068
                  2008    27,317
                  2009    29,344
                  2010    32,481




                                                                                                                           Section: Exhibit A
                                                                                                                         Form#RFP.02/03/10
                    REQUEST FOR PROPOSAL                    Arizona State Retirement System
                                                              3300 North Central Avenue
                 Retiree Dental Benefits Program                       Suite 1300
                                                                Phoenix, Arizona 85012
                              RT10-022
                                                                    Page 52 of 154

                        Arizona State Retirement System
                         History of Dental Plan Premiums
                        Calendar Years 2006 through 2010


                                                                  Retire &
                                                      Retire &    2 or more
                                         Retire       1
Effective 1-1-2006                       Only         Dependent   Dependents
Freedom Advance (High Option)                $36.61        $73.06     $103.39
Freedom Basic (Low Option)                   $17.18        $36.34      $66.54
Prepaid (Arizona)                            $10.61        $17.41      $26.90
Prepaid (other states where available)       $10.45        $17.64      $27.87

                                                                    Retire &
                                                    Retire &        2 or more
                                         Retire     1
Effective 1-1-2007                       Only       Dependent   Dependents
Freedom Advance (High Option)                $36.61      $73.06    $103.39
Freedom Basic (Low Option)                   $17.18      $36.34     $66.54
Prepaid (Arizona)                            $10.61      $17.41     $26.90
Prepaid (other states where available)       $10.45      $17.64     $27.87

                                                                    Retire &
                                                    Retire &        2 or more
                                         Retire     1
Effective 1-1-2008                       Only       Dependent   Dependents
Freedom Advance (High Option)                $36.61      $73.06    $103.39
Freedom Basic (Low Option)                   $17.18      $36.34     $66.54
Prepaid (Arizona)                            $10.61      $17.41     $26.90
Prepaid (other states where available)       $10.45      $17.64     $27.87

                                                                Retire &
                                                    Retire &    2 or more
                                         Retire     1
Effective 1-1-2009                       Only       Dependent   Dependents
Freedom Advance (High Option)                $36.61      $73.06     $103.39
Freedom Basic (Low Option)                   $17.18      $36.34      $66.54
Prepaid (Arizona)                            $10.61      $17.41      $26.90
Prepaid (other states where available)       $10.45        $17.64        $27.87



                                                                             Section: Exhibit A
                                                                           Form#RFP.02/03/10
                    REQUEST FOR PROPOSAL                  Arizona State Retirement System
                                                            3300 North Central Avenue
                 Retiree Dental Benefits Program                     Suite 1300
                                                              Phoenix, Arizona 85012
                              RT10-022
                                                                 Page 53 of 154



                                                                Retire &
                                                    Retire &    2 or more
                                         Retire     1
Effective 1-1-2010                       Only       Dependent   Dependents
Freedom Advance (High Option)                $36.61      $73.06    $103.39
Freedom Basic (Low Option)                   $17.18      $36.34     $66.54
Prepaid (Arizona)                            $10.61      $17.41     $26.90
Prepaid (other states where available)       $10.45      $17.64     $27.87




                                                                          Section: Exhibit A
                                                                        Form#RFP.02/03/10
     REQUEST FOR PROPOSAL            Arizona State Retirement System
                                       3300 North Central Avenue
   Retiree Dental Benefits Program              Suite 1300
                                         Phoenix, Arizona 85012
             RT10-022
                                            Page 54 of 154




   Exhibit B

EXPERIENCE DATA




                                                     Section: Exhibit B
                                                   Form#RFP.02/03/10
                               REQUEST FOR PROPOSAL                 Arizona State Retirement System
                                                                      3300 North Central Avenue
                           Retiree Dental Benefits Program                     Suite 1300
                                                                        Phoenix, Arizona 85012
                                      RT10-022
                                                                           Page 55 of 154


                                              2006
                            Arizona State Retirement System
                 Freedom Advance (high option) / Freedom Basic (low Option)
                                  Indemnity Experience

             No. of         Earned             Paid              PAID
            Insureds       Premiums           Claims              L/R

  Jan-06     15747             $755,344        $568,409           75.25%

  Feb-06     15931             $769,123        $546,275           71.03%

  Mar-06     16016             $772,202        $619,828           80.27% 75.52% 1st Q L/R

  Apr-06     15991             $746,622        $594,530           79.63%

  May-06     16022             $766,924        $662,196           86.34%

  Jun-06     16134             $773,049        $682,640           88.30% 80.16% 2nd Q L/R

   Jul-06    16434             $781,707        $534,870           68.42%

  Aug-06     16631             $810,813        $622,837           76.82%

  Sep-06     16643             $770,751        $663,796           86.12% 79.11% 3rd Q L/R

  Oct-06     16731             $810,981        $690,809           85.18%

  Nov-06     16803             $814,999        $613,899           75.33%

  Dec-06     16854             $812,612        $613,662           75.52%
                       =                  =                  =
Total                        $9,385,127       $7,413,751          78.99%              4th Q L/R


                       Note:                  The above figures are unaudited.




                                                                                    Section: Exhibit B
                                                                                  Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                           3300 North Central Avenue
                                            Retiree Dental Benefits Program                         Suite 1300
                                                                                             Phoenix, Arizona 85012
                                                        RT10-022
                                                                                                Page 56 of 154




                                            Procedure Code Breakdown

                                      ARIZONA STATE RETIREMENT SYSTEM
                                  Claims Paid between 1/1/2006 and 12/31/2006
                                               Procedure   Employee Paid   Dependent Paid        Total Paid           # of
       Paid Procedure Code Desc
                                                 Code         Claims          Claims              Claims           Claimants

Unspecified                                     99999           $0               $0                  $0                 7
Claim Adjustments                              ADJST         -$169,419        -$54,451           -$223,870             866
Not Used On claims                              D0000           $0               $0                  $0                24
Periodic Oral Exam                              D0120        $344,576         $121,176            $465,752           12,879
Limited Oral Evaluation                         D0140         $49,967         $18,393             $68,360             2,898
Comprehensive Oral Evaluation                   D0150         $49,344         $19,530             $68,874             2,083
Detailed Oral Evaluation-Problem
                                                D0160          $646             $186                $831               33
Focused
Re-Evaluation-Problem Focused                   D0170          $391             $37                 $428               45
Comprehensive Periodontal Evaluation            D0180         $6,146           $1,935              $8,081              280
Intraoral-Complete Series (Including
                                                D0210         $85,348         $33,142             $118,490            2,112
Bitewings)
Intraoral-Periapical First Film                 D0220         $69,594         $22,748             $92,342             5,524
Intraoral-Periapical Each Additional Film       D0230         $21,235          $7,286             $28,520             1,959
Intraoral Occlusal Film                         D0240          $129             $64                 $193               10
Extraoral-First Film                            D0250          $133             $166                $299               16
Extraoral-Each Additional Film                  D0260           $12             $12                 $24                 2
Bitewing-Single Film                            D0270         $1,598            $576               $2,174              253
Bitewings-Two Films                             D0272         $25,929         $10,206             $36,135             1,598
Bitewings-Four Films                            D0274        $211,337         $74,242             $285,579            8,447
Vertical Bitewings-7 To 8 Films                 D0277         $3,499           $1,263              $4,762              86
Post/Ant Lateral Skull/Facial Film              D0290           $0               $0                  $0                 1
temporomandibular joint arthrogram,
                                                D0320           $0               $0                  $0                 1
including injection
Other Tmj Films                                 D0321           $0               $0                  $0                 2
Tomographic Survey                              D0322           $0               $0                  $0                 5
Panoramic Film                                  D0330         $27,204         $11,898             $39,103              884
Cephalometric Film                              D0340           $0               $0                  $0                 2
Oral/Facial Images                              D0350           $0               $0                  $0                17
Bacteriologic Studies                           D0415           $0               $0                  $0                 1
Adjunctive Pre-Diagnostic Test                  D0431           $0               $0                  $0                139

                                                                                                            Section: Exhibit B
                                                                                                          Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                            3300 North Central Avenue
                                             Retiree Dental Benefits Program                         Suite 1300
                                                                                              Phoenix, Arizona 85012
                                                         RT10-022
                                                                                                 Page 57 of 154

Pulp Vitality Tests                              D0460          $0               $0                   $0                51
Diagnostic Casts                                 D0470         $621              $86                 $707               65
Diagnostic Photographs                           D0471          $0               $0                   $0                 2
accession of tissue, gross and microscopic
examination, preparation and                     D0473          $68              $0                  $68                 1
transmission of written report
Microscopic Examination By Report                D0474         $136              $0                  $136                1
Consultation on Slides Prepared
                                                 D0484          $0               $0                   $0                 1
Elsewhere
other oral pathology procedures, by
                                                 D0502          $0               $0                   $0                 1
report
unspecified diagnostic procedure, by
                                                 D0999          $0               $0                   $0                19
report
Prophylaxis-Adult                                D1110        $877,097         $308,869           $1,185,966          14,100
Prophylaxis-Child                                D1120         $338             $7,929              $8,268              148
Topical Application of Fluoride-Child            D1203          $0              $1,859              $1,859              719
Topical Application of Fluoride-Adult            D1204          $0               $20                 $20                424
Nutritional Counseling For Control Of
                                                 D1310          $0               $0                   $0                 1
Dental Disease
Oral Hygiene Instructions                        D1330          $0               $0                   $0                35
Training in Preventive Dental Care               D1340          $0               $0                   $0                 4
Sealant-Per Tooth                                D1351          $0              $3,123              $3,123              49
Space Maintainer-Fixed-Unilateral                D1510          $0              $222                 $222                1
amalgam - one surface, primary or
                                                 D2140        $160,691         $70,898             $231,589            2,151
permanent
amalgam - two surfaces, primary or
                                                 D2150        $142,845         $63,474             $206,319            1,761
permanent
amalgam - three surfaces, primary or
                                                 D2160        $79,434          $30,614             $110,047             799
permanent
amalgam - four or more surfaces,
                                                 D2161        $16,030           $5,011             $21,041              152
primary or permanent
resin-based composite - one surface,
                                                 D2330        $178,761         $66,548             $245,309            1,798
anterior
resin-based composite - two surfaces,
                                                 D2331        $53,438          $20,556             $73,994              569
anterior
resin-based composite - three surfaces,
                                                 D2332        $35,428           $9,610             $45,038              264
anterior
Resin-Based Composite-Four Or More
Surfaces Or Involving Incisal Angle              D2335        $45,170          $13,246             $58,416              327
(Anterior)
resin-based composite crown, anterior            D2390          $0              $134                 $134                3
resin-based composite - one surface,
                                                 D2391         $427              $0                  $427                2
posterior

                                                                                                             Section: Exhibit B
                                                                                                           Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                           3300 North Central Avenue
                                            Retiree Dental Benefits Program                         Suite 1300
                                                                                             Phoenix, Arizona 85012
                                                        RT10-022
                                                                                                Page 58 of 154

resin-based composite - two surfaces,
                                                D2392         $153              $0                  $153                1
posterior
resin-based composite - one surface,
                                                D2394         $360              $0                  $360                3
posterior-permanent
Inlay-Metallic-Two Surfaces                     D2520         $916              $0                  $916                3
Inlay-Metallic-Three Surfaces                   D2530         $1,127           $464                $1,591               5
Onlay-Metallic                                  D2540          $0               $0                   $0                 2
Onlay-Metallic -Two Surfaces                    D2542         $1,195            $0                 $1,195               4
Onlay-Metallic-Three Surfaces                   D2543        $11,699           $8,551             $20,250              43
Onlay-Metallic-Four Or More Surfaces            D2544        $16,034           $7,035             $23,069              52
Crown-Resin-Direct                              D2710          $0               $0                   $0                 1
Crown-Resin With High Noble Metal               D2720         $694             $246                 $940                4
Crown-Porcelain/Ceramic Substrate               D2740        $155,683         $57,681             $213,365             362
Crown-Porcelain Fused To
                                                D2751        $924,975         $285,424           $1,210,399           2,706
Predominantly Base Metal
Crown-Porcelain Fused To
                                                D2752         $345              $0                  $345                1
Predominantly Base Metal
Crown-3/4 Cast Predominantly Base
                                                D2781        $13,155           $6,664             $19,820              34
Metal
Crown-Full Cast Predominantly Base
                                                D2791        $113,172         $44,464             $157,636             426
Metal
Provisional Crown                               D2799          $0               $0                   $0                15
Recement Inlay                                  D2910         $491              $84                 $574               32
Recement Cast or PreFab Post/Core               D2915         $161              $0                  $161                5
Recement Crown                                  D2920        $10,453           $3,182             $13,635              600
Prefabricated Stainless Steel Crown-
                                                D2930          $0              $292                 $292                6
Primary Tooth
Prefabricated Stainless Steel Crown-
                                                D2931          $0               $0                   $0                 5
Permanent Tooth
Prefabricated Resin Crown                       D2932          $0               $0                   $0                 3
Prefabricated Stainless Steel Crown With
                                                D2933          $0              $271                 $271                1
Resin Window
Sedative Filling                                D2940          $0               $0                   $0                88
core build-up, including any pins               D2950        $91,221          $32,790             $124,011            1,713
pin retention - per tooth, in addition to
                                                D2951         $568             $402                 $970               33
restoration
Cast Post And Core In Addition To
                                                D2952         $9,334           $1,560             $10,894              88
Crown
Each Additional Post And Core                   D2953          $57              $0                  $57                 1
Prefabricated Post And Core In Addition
                                                D2954        $38,788          $12,287             $51,074              476
To Crown
Post Removal Not In Conjunction With
                                                D2955          $0               $0                   $0                 8
Endodontic Therapy
                                                                                                            Section: Exhibit B
                                                                                                          Form#RFP.02/03/10
                                                REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                            3300 North Central Avenue
                                              Retiree Dental Benefits Program                        Suite 1300
                                                                                              Phoenix, Arizona 85012
                                                          RT10-022
                                                                                                 Page 59 of 154

Each Additional Prefabricated Post-Same
                                                  D2957          $0               $0                  $0                 3
Tooth
Labial Veneer (Resin Laminate)-
                                                  D2960         $841             $223               $1,064               7
Chairside
Labial Veneer (Porcelain Laminate)-
                                                  D2962        $12,246          $2,322             $14,568              28
Laboratory
Temporary Crown (Fractured Tooth)                 D2970          $0               $0                  $0                 9
Additional Crown Procedures for Partial
                                                  D2971          $0               $0                  $0                 5
Denture Framework
Coping                                            D2975          $0               $0                  $0                 1
crown repair, by report                           D2980         $1,478           $788               $2,266              29
unspecified restorative procedure, by
                                                  D2999          $0               $0                  $0                25
report
Pulp Cap - Direct (Excluding Final
                                                  D3110          $0               $0                  $0                28
Restoration)
Pulp Cap - Indirect (Excluding Final
                                                  D3120          $0               $0                  $0                65
Restoration)
Therapeutic Pulpotomy (Excluding Final
                                                  D3220          $0              $80                 $80                11
Restoration)
pulpal debridement, primary and
                                                  D3221          $0               $0                  $0                17
permanent teeth
pulpal therapy (resorbable filling) -
anterior, primary tooth (excluding final          D3230          $0              $309                $309                1
restoration)
pulpal therapy (resorbable filling) -
posterior, primary tooth (excluding final         D3240          $0              $392                $392                1
restoration)
Endodontic Therapy-Anterior Tooth
                                                  D3310        $94,126          $29,434            $123,560             283
(Excluding Final Restoration)
Endodontic Therapy-Bicuspid Tooth
                                                  D3320        $145,186         $50,959            $196,146             393
(Excluding Final Restoration)
Endodontic Therapy-Molar (Excluding
                                                  D3330        $270,290         $84,396            $354,686             551
Final Restoration)
Treatment Of Root Canal Obstruction;
                                                  D3331          $0               $0                  $0                 8
Non-Surgical Access
Incomplete Endodontic Therapy;
                                                  D3332         $169              $0                 $169               24
Inoperable Or Fractured Tooth
Retreatment Of Previous Root Canal
                                                  D3346         $7,685          $1,513              $9,198              17
Therapy-Anterior
Retreatment Of Previous Root Canal
                                                  D3347         $7,858          $2,552             $10,410              16
Therapy-Bicuspid
Retreatment Of Previous Root Canal
                                                  D3348        $24,447          $8,861             $33,307              42
Therapy-Molar
Apexification/Recalcification-Initial Visit       D3351         $628             $414               $1,042               6

                                                                                                             Section: Exhibit B
                                                                                                           Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                           3300 North Central Avenue
                                             Retiree Dental Benefits Program                        Suite 1300
                                                                                             Phoenix, Arizona 85012
                                                         RT10-022
                                                                                                Page 60 of 154

Apexification/Recalcification-Interim
                                                 D3352         $26               $0                 $26                 1
Medication Replacement
Apicoectomy/Periradicular Surgery-
                                                 D3410        $2,779           $3,869              $6,648              18
Anterior
Apicoectomy/Periradicular Surgery-
                                                 D3421        $2,810           $1,451              $4,261               9
Bicuspid (First Root)
Apicoectomy/Periradicular Surgery-
                                                 D3425        $7,460            $982               $8,442              16
Molar (First Root)
Apicoectomy/Periradicular Surgery-Each
                                                 D3426         $908             $556               $1,464              10
Additional Root
Retrograde Filling-Per Root                      D3430        $3,598           $1,874              $5,472              35
Root Amputation-Per Root                         D3450        $1,759           $1,020              $2,779               7
Hemisection (Including Any Root
Removal) Not Including Root Canal                D3920         $781             $502               $1,283               8
Therapy
Canal Preparation And Fitting Of
                                                 D3950          $0               $0                  $0                 2
Preformed Dowel Or Post
unspecified endodontic procedure, by
                                                 D3999          $0               $0                  $0                 1
report
Gingivectomy Or Gingivoplasty-Four Or
                                                 D4210         $128              $0                 $128                3
More Contiguous Teeth Per Quadrant
Gingivectomy Or Gingivoplasty-One To
                                                 D4211        $1,670            $183               $1,853              49
Three Teeth Per Quadrant
Gingival Curettage, Per Quadrant                 D4220          $0               $0                  $0                 1
gingival flap procedure, including root
planing - four or more contiguous teeth          D4240        $3,996             $0                $3,996               8
or bounded teeth spaces per quadrant
gingival flap procedure, including root
                                                 D4241        $1,835            $970               $2,805              15
planing - one to three teeth, per quadrant
Clinical Crown Lengthening-Hard Tissue           D4249        $15,297          $6,311             $21,608              48
Osseous Surgery (Including Flap Entry
And Closure)-Four Or More Contiguous
                                                 D4260        $69,891          $14,751            $84,641              139
Teeth Or Bounded Teeth Spaces Per
Quadrant
Bone Replacement Graft-First Site In
                                                 D4263        $4,286           $1,690              $5,977              47
Quadrant
Guided Tissue Regeneration - Resorbable          D4266        $4,926           $2,416              $7,343              39
Guided Tissue Regeneration - Non-
                                                 D4267        $1,383             $0                $1,383              10
Resorbable
Free Soft Tissue Graft Procedure
                                                 D4271        $10,642          $2,226             $12,868              19
(Including Donor Site Surgery)
Subepithelial Connective Tissue Graft
                                                 D4273        $3,353           $3,085              $6,438              11
Procedures
Distal Or Proximal Wedge Procedure               D4274         $712              $0                 $712                2

                                                                                                            Section: Exhibit B
                                                                                                          Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                          3300 North Central Avenue
                                            Retiree Dental Benefits Program                        Suite 1300
                                                                                            Phoenix, Arizona 85012
                                                        RT10-022
                                                                                               Page 61 of 154

Provisional Splinting - Intracoronal            D4320         $184             $40                 $224                2
Provisional Splinting - Extracoronal            D4321         $1,358           $428               $1,786              17
Periodontal Scaling And Root Planing-
Four Or More Contiguous Teeth Or                D4341        $130,743         $38,296            $169,039             464
Bounded Teeth Spaces Per Quadrant
periodontal scaling and root planing, one
                                                D4342        $22,901          $7,145             $30,047              248
to three teeth, per quadrant
Perio Scaling/Gingival Inflammation             D4345          $0               $0                  $0                21
Periodontics: tooth movement                    D4350          $0               $0                  $0                 1
Full Mouth Debridement                          D4355          $0               $0                  $0                171
Periodontal therapy: re-evaluation              D4380          $0               $0                  $0                 1
Chemotherapeutic Agents                         D4381          $0               $0                  $0                314
Periodontal Maintenance                         D4910        $125,973         $33,101            $159,074            2,196
unspecified periodontal procedure, by
                                                D4999          $0               $0                  $0                91
report
Complete Denture-Maxillary                      D5110        $24,121          $10,538            $34,659              77
Complete Denture-Mandibular                     D5120        $15,101          $1,839             $16,940              33
Immediate Denture-Maxillary                     D5130        $16,232          $3,972             $20,204              46
Immediate Denture-Mandibular                    D5140         $9,165          $5,025             $14,189              28
maxillary partial denture - resin base
(including any conventional clasps, rest        D5211         $5,860           $875               $6,735              23
and teeth)
mandibular partial denture - resin base
(including any conventional clasps, rest        D5212         $1,296           $775               $2,071              15
and teeth)
maxillary partial denture - cast metal
framework with resin denture bases
                                                D5213        $40,272          $14,592            $54,864              150
(including any conventional clasps, rest
and teeth)
mandibular partial denture - cast metal
framework with resin denture bases
                                                D5214        $49,799          $17,707            $67,507              182
(including any conventional clasps, rest
and teeth)
Maxillary Denture-Flexible Base                 D5225         $1,035           $263               $1,297               4
Mandibular Partial Denture-Flexible Base        D5226         $1,897          $1,252              $3,149               9
Removable Unilateral Partial Denture-
One Piece Cast Metal (Including Clasps          D5281         $1,936           $427               $2,363               7
And Teeth)
Adjust Complete Denture-Maxillary               D5410         $217             $38                 $255               13
Adjust Complete Denture-Mandibular              D5411         $128             $15                 $143                8
Adjustments-partial denture compl               D5415          $0               $0                  $0                 1
Adjust Partial Denture-Maxillary                D5421          $85             $71                 $156               10

                                                                                                           Section: Exhibit B
                                                                                                         Form#RFP.02/03/10
                                           REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                         Retiree Dental Benefits Program                       Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                     RT10-022
                                                                                           Page 62 of 154

Adjust Partial Denture-Mandibular            D5422         $181             $92                $273               20
Repair Broken Complete Denture Base          D5510         $588            $442               $1,030              25
Replace Missing Or Broken Teeth-
                                             D5520        $1,345           $631               $1,976              34
Complete Denture (Each Tooth)
Repair Resin Denture Base                    D5610         $697            $189                $885               25
Repair Cast Framework                        D5620         $215            $225                $440                6
Repair Or Replace Broken Clasp               D5630        $2,136           $852               $2,988              42
Replace Broken Teeth-Per Tooth               D5640        $1,713           $1,373             $3,086              55
Add Tooth To Existing Partial Denture        D5650        $7,168           $2,686             $9,854              141
Replace All Teeth And Acrylic On Cast
                                             D5671          $0             $528                $528                2
Metal Framework (Mandibular)
Rebase Complete Maxillary Denture            D5710         $491             $0                 $491                2
Rebase Complete Mandibular Denture           D5711         $80              $0                 $80                 1
Rebase Maxillary Partial Denture             D5720          $0             $200                $200                1
Rebase Mandibular Partial Denture            D5721         $263             $0                 $263                2
Reline Complete Maxillary Denture
                                             D5730         $712            $294               $1,006              10
(Chairside)
Reline Complete Mandibular Denture
                                             D5731         $246             $87                $332                8
(Chairside)
Reline Maxillary Partial Denture
                                             D5740         $482             $0                 $482               10
(Chairside)
Reline Mandibular Partial Denture
                                             D5741         $407            $169                $576                8
(Chairside)
Reline Complete Maxillary Denture
                                             D5750        $6,706           $3,036             $9,741              85
(Laboratory)
Reline Complete Mandibular Denture
                                             D5751        $3,115           $991               $4,106              34
(Laboratory)
Denture reline-upper or lower                D5755          $0              $0                  $0                 1
Reline Maxillary Partial Denture
                                             D5760        $1,029           $576               $1,605              14
(Laboratory)
Reline Mandibular Partial Denture
                                             D5761        $1,906           $1,197             $3,103              22
(Laboratory)
Interim Complete Denture (Maxillary)         D5810          $0              $0                  $0                 2
Interim Complete Denture (Mandibular)        D5811          $0              $0                  $0                 5
Interim Partial Denture (Maxillary)          D5820          $0              $0                  $0                44
Interim Partial Denture (Mandibular)         D5821          $0              $0                  $0                14
tissue conditioning, maxillary               D5850         $197            $266                $462               13
tissue conditioning, mandibular              D5851         $256            $508                $763               10
overdenture - complete, by report            D5860          $0              $0                  $0                 2
precision attachment, by report              D5862          $0              $0                  $0                16
Precision Attachment: Replacement Part       D5867          $0              $0                  $0                 1
Modification Of Removable Prosthesis         D5875          $0              $0                  $0                 1
                                                                                                       Section: Exhibit B
                                                                                                     Form#RFP.02/03/10
                                             REQUEST FOR PROPOSAL                 Arizona State Retirement System
                                                                                    3300 North Central Avenue
                                           Retiree Dental Benefits Program                   Suite 1300
                                                                                      Phoenix, Arizona 85012
                                                       RT10-022
                                                                                         Page 63 of 154

Unspecified Removable Prosthodontic
                                               D5899          $0             $0               $0                 4
Procedure
Facial Augmentation Implant Prosthesis         D5925          $0             $0               $0                 2
trismus appliance (not for TMD
                                               D5937          $0             $0               $0                 1
treatment)
Surgical Stent                                 D5982          $0             $0               $0                12
Fluoride Gel Carrier                           D5986          $0             $0               $0                 4
Unspecified Procedure                          D5999          $0             $0               $0                 1
Surgical Placement Of Implant Body:
                                               D6010          $0             $0               $0                106
Endosteal Implant
Abutment Placement Or Substitution:
                                               D6020          $0             $0               $0                 5
Endosteal Implant
Surgical Placement-Eposteal Implant            D6040          $0             $0               $0                 1
Implant/Abutment Supported
Removable Denture For Completely               D6053          $0             $0               $0                 3
Edentulous Arch
Implant/Abutment Supported
Removable Denture For Partially                D6054          $0             $0               $0                 1
Edentulous Arch
Prefabricated Abutment                         D6056          $0             $0               $0                24
Custom Abutment                                D6057          $0             $0               $0                26
Abutment Supported Porcelain Fused To
Metal Crown (Predom Inately Base               D6060          $0             $0               $0                60
Metal)
Abutment Supported Cast Metal Crown
                                               D6063          $0             $0               $0                 5
(Predominantly Base Metal)
abutment supported metal crown
(titanium, titanium alloy, nigh noble          D6067          $0             $0               $0                38
metal)
Abutment Supported Retainer For
Porcelain Fused To Metal Fpd                   D6070          $0             $0               $0                 4
(Predominantly Base Metal)
Abutment Supported Retainer For Cast
                                               D6073          $0             $0               $0                 1
Metal Fpd (Predominantly Base Metal)
implant supported retainer for porcelain
fused to metal FPD (titanium, titanium         D6076          $0             $0               $0                 1
alloy, nigh noble metal)
Implant/Abutment Supported Fixed
Denture For Completely Edentulous              D6078          $0             $0               $0                 1
Arch
Implant Maintenance Procedures                 D6080          $0             $0               $0                13
repair implant supported prosthesis, be
                                               D6090          $0             $0               $0                 1
report
implant removal, by report                     D6100          $0             $0               $0                 2
                                                                                                     Section: Exhibit B
                                                                                                   Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                          3300 North Central Avenue
                                            Retiree Dental Benefits Program                        Suite 1300
                                                                                            Phoenix, Arizona 85012
                                                        RT10-022
                                                                                               Page 64 of 154

Abutment Supported Retainer Crown for
                                                D6190          $0               $0                  $0                 1
FPD-Titanium
unspecified implant procedure, by report        D6199          $0               $0                  $0                 4
Pontic-Cast Predominantly Base Metal            D6211         $8,925           $755               $9,680              24
Pontic-Cast Predominantly Base Metal            D6241        $135,670         $51,797            $187,466             488
Pontic-Resin With Predominantly Base
                                                D6251         $1,129            $0                $1,129               5
Metal
Provisional Pontic                              D6253          $0               $0                  $0                 2
Inlay-Metallic-Two Surface                      D6520         $117              $0                 $117                1
Retainer-Cast Metal For Resin Bonded
                                                D6545          $0              $98                 $98                 3
Fixed Prosthesis
inlay - cast predominantly base metal,
                                                D6604          $27              $0                 $27                 1
two surfaces
Crown-Porcelain Fused To
                                                D6751        $232,125         $80,208            $312,332             516
Predominantly Base Metal
Crown-Full Cast Predominantly Base
                                                D6791         $4,957           $790               $5,747              10
Metal
Provisional Retainer Crown                      D6793          $0               $0                  $0                 2
Recement Fixed Partial Denture                  D6930         $2,678           $981               $3,659              86
Stress Breaker                                  D6940          $0               $0                  $0                 1
Precision Attachment                            D6950          $0               $0                  $0                 3
Cast Post And Core In Addition To Fixed
                                                D6970         $110             $70                 $180                3
Partial Denture Retainer
Prefabricated Post And Core In Addition
                                                D6972         $238              $0                 $238                4
To Fixed Partial Denture Retainer
core build up for retainer, including any
                                                D6973         $669             $148                $817               11
pins
fixed partial denture repair, by report         D6980         $585              $0                 $585                7
unspecified, fixed prosthodontic
                                                D6999          $0               $0                  $0                27
procedure, by report
Extraction (Single Tooth)                       D7110          $0               $0                  $0                 5
Coronal Remnants-Deciduous Tooth                D7111         $134             $277                $411                5
extraction, erupted tooth or exposed root
                                                D7140        $91,639          $29,198            $120,837             917
(elevation and/or forceps removal)
Surgical Removal Of Erupted Tooth
Requiring Elevation Of Mucoperiosteal
                                                D7210        $59,141          $17,664            $76,806              752
Flap And Removal Of Bone And/Or
Section Of Tooth
Removal Of Impacted Tooth-Soft Tissue           D7220         $645             $605               $1,250              16
Removal Of Impacted Tooth-Partially
                                                D7230         $373            $6,277              $6,650              32
Bony
Removal Of Impacted Tooth-Completely
                                                D7240         $1,304          $6,050              $7,354              32
Bony

                                                                                                           Section: Exhibit B
                                                                                                         Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                          3300 North Central Avenue
                                             Retiree Dental Benefits Program                       Suite 1300
                                                                                            Phoenix, Arizona 85012
                                                         RT10-022
                                                                                               Page 65 of 154

Removal Of Impacted Tooth-Completely
Bony With Unusual Surgical                       D7241          $0             $191                $191                1
Complications
Surgical Removal Of Residual Tooth
                                                 D7250        $10,269          $2,998            $13,267              101
Roots (Cutting Procedure)
Oroantral Fistula Closure                        D7260         $116             $0                 $116                1
Primary Closure Of A Sinus Perforation           D7261          $0              $0                  $0                 1
Surgical Access Of An Unerupted Tooth            D7280          $0             $294                $294                2
Mobilization Of Erupted Or
                                                 D7282          $0              $0                  $0                 1
Malpositioned Tooth To Aid Eruption
biopsy of oral tissue - hard (bone, tooth)       D7285          $0             $875                $875                3
Biopsy Of Oral Tissue-Soft (All Others)          D7286        $1,383           $594               $1,977              20
Brush Biopsy-Transepithelial Sample
                                                 D7288         $31              $29                $60                 3
Collection
Alveoloplasty In Conjunction With
                                                 D7310        $2,739           $709               $3,448              27
Extractions-Per Quadrant
Alveoloplasty In Conjunction with
                                                 D7311         $290             $0                 $290                2
Extractions
Alveoloplasty Not In Conjunction With
                                                 D7320         $494            $127                $621                4
Extractions-Per Quadrant
vestibuloplasty - ridge extension
(including soft tissue grafts, muscle
reattachment, revision of soft tissue            D7350          $0              $0                  $0                 1
attachment and management of
hypertrophied and hyperplastic tissue)
Excision Of Benign Lesion Up To 1.25
                                                 D7410          $0              $0                  $0                 4
Cm
Excision Of Malignant Tumor-Up To 1.25
                                                 D7440          $0              $0                  $0                 1
Cm
Removal Of Benign Odontogenic Cyst Or
                                                 D7450          $0              $0                  $0                 5
Tumor-Lesion Diameter Up To 1.25 Cm
Removal Of Benign Nonodontogenic
Cyst Or Tumor-Lesion Diameter Up To              D7460          $0              $0                  $0                 1
1.25 Cm
Destruction Of Lesion - Physical Or
                                                 D7465          $0              $0                  $0                 2
Chemical
Removal Of Lateral Exostosis-Maxilla Or
                                                 D7471         $706            $125                $831                5
Mandible
Removal Of Torus Palatinus                       D7472         $130            $283                $413                2
Removal Of Torus Mandibularis                    D7473         $400             $0                 $400                1
Surgical Reduction Of Osseous
                                                 D7485         $250             $0                 $250                1
Tuberosity
Surgical Reduction Of Osseous
                                                 D7490          $0              $0                  $0                 1
Tuberosity
                                                                                                           Section: Exhibit B
                                                                                                         Form#RFP.02/03/10
                                             REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                        3300 North Central Avenue
                                           Retiree Dental Benefits Program                       Suite 1300
                                                                                          Phoenix, Arizona 85012
                                                       RT10-022
                                                                                             Page 66 of 154

Incision And Drainage Of Abscess-
                                               D7510         $544             $0                 $544                8
Intraoral Soft Tissue
Removal Of Foreign Body                        D7530         $75              $0                 $75                 3
Maxillary Sinusotomy For Removal Of
                                               D7560          $0              $73                $73                 1
Tooth Fragment
occlusal orthotic device, by report            D7880          $0              $0                  $0                13
Suture Of Recent Small Wound Up To 5
                                               D7910          $0              $0                  $0                 2
Cm
Skin Graft                                     D7920          $0              $0                  $0                 1
Osteotomy - Mandibular Rami With
                                               D7943          $0              $0                  $0                 1
Bone Graft
Osseoperiosteal Graft                          D7950          $0              $0                  $0                16
Bone Replacement Graft for Ridge
                                               D7953          $0              $0                  $0                36
Preservation-Per Site
Repair Of Maxillofacial Tissue Defect          D7955          $0              $0                  $0                 3
Frenulectomy (Frenectomy Or
                                               D7960         $105            $288                $392                3
Frenotomy)-Separate Procedure
Excision Of Hyperplastic Tissue-Per Arch       D7970         $489             $78                $567                4
Excision Of Periocoronal Gingiva               D7971         $180             $30                $210                2
Synthetic Graft - Mandible                     D7995          $0              $0                  $0                 1
Appliance Removal                              D7997          $0              $0                  $0                 1
Unspecified Oral Surgery Procedure By
                                               D7999          $0              $0                  $0                 9
Report
Limited Ortho- Primary                         D8020          $0              $0                  $0                 1
Limited Ortho-Adolescent                       D8040          $0              $0                  $0                 1
Comprehensive Ortho-Transitional               D8070          $0              $0                  $0                 2
Comprehensive Ortho-Adolescent                 D8080          $0              $0                  $0                 1
Comprehensive Ortho-Adult                      D8090          $0              $0                  $0                 4
Removable Appliance Therapy                    D8210          $0              $0                  $0                 2
Periodontic Orthodontic Visit                  D8670          $0              $0                  $0                 4
Orthodontic Retention                          D8680          $0              $0                  $0                 2
Replacement Of Lost Or Broken Retainer         D8692          $0              $0                  $0                 3
Palliative (Emergency) Treatment Of
                                               D9110        $5,820           $1,770             $7,590              187
Dental Pain-Minor Procedure
Miscellaneous Tax                              D9199         $121             $81                $202               10
Nitrous Oxide                                  D9200          $0              $0                  $0                 1
Local Anesthesia                               D9215          $0              $0                  $0                 9
General Anesthesia                             D9220        $4,297           $3,669             $7,966              124
Each Additional 15 Minutes                     D9221         $256            $483                $739               33
analgesia, anxiolysis, inhalation of
                                               D9230          $0              $0                  $0                113
nitrous oxide
Intravenous Sedation                           D9240         $984            $316               $1,300              32
                                                                                                         Section: Exhibit B
                                                                                                       Form#RFP.02/03/10
                                            REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                        3300 North Central Avenue
                                          Retiree Dental Benefits Program                        Suite 1300
                                                                                          Phoenix, Arizona 85012
                                                      RT10-022
                                                                                             Page 67 of 154

Intravenous Conscious
                                              D9241        $1,088             $932              $2,020              33
Sedation/Analgesia-First 30 Minutes
Intravenous Conscious
Sedation/Analgesia-Each Additional 15         D9242          $0                $0                 $0                 1
Minutes
Non-Intravenous Conscious Sedation            D9248          $0                $0                 $0                 5
Consultation (Diagnostic Service
Provided By Dentist Or Physician Other        D9310          $0                $0                 $0                88
Than Practitioner Providing Treatment
House/Extended Care Facility Call             D9410          $0                $0                 $0                 1
Hospital Call                                 D9420          $0                $0                 $0                 1
Office Visit During Regularly Scheduled
                                              D9430          $0                $0                 $0                55
Hours
Office Visit-After Hours                      D9440          $0                $0                 $0                 6
Case Presentation                             D9450          $0                $0                 $0                 1
therapeutic drug injection, by report         D9610        $1,234             $696              $1,930              50
other drugs and/or medicaments, by
                                              D9630          $0                $0                 $0                214
report
Application Of Desensitizing
                                              D9910          $0                $0                 $0                79
Medicament
Application Of Desensitizing Resin            D9911          $0                $0                 $0                10
Behavior Management                           D9920          $0                $0                 $0                 5
occlusal guard, by report                     D9940        $19,163           $9,377            $28,540              140
Fabrication Of Athletic Mouthguard            D9941          $0                $0                 $0                 3
Repair and/or Reline of Occlusal Guard        D9942          $0                $0                 $0                 5
Occlusion Analysis-Mounted Case               D9950          $0                $0                 $0                 7
Occlusal Adjustment - Limited                 D9951         $989              $251              $1,241              52
Occlusal Adjustment - Complete                D9952        $1,771             $160              $1,931              12
Enamel Microabrasion                          D9970          $0                $0                 $0                 3
Odontoplasty 1 - 2 Teeth                      D9971          $0                $0                 $0                 3
External Bleaching - Per Arch                 D9972          $0                $0                 $0                13
External Bleaching - Per Tooth                D9973          $0                $0                 $0                 3
Internal Bleaching - Per Tooth                D9974          $0                $0                 $0                 1
Sterilization                                 D9998          $0                $0                 $0                 9
Unspecified Adjunctive Procedure              D9999          $0                $0                 $0                561
Interest                                     INTRS          $1,949             $675             $2,624              878
                                             Totals       $5,486,489        $1,926,894        $7,413,383




                                                                                                         Section: Exhibit B
                                                                                                       Form#RFP.02/03/10
                             REQUEST FOR PROPOSAL                   Arizona State Retirement System
                                                                      3300 North Central Avenue
                         Retiree Dental Benefits Program                       Suite 1300
                                                                        Phoenix, Arizona 85012
                                    RT10-022
                                                                           Page 68 of 154



                                      2007
                       Arizona State Retirement System
            Freedom Advance (high option) / Freedom Basic (low option)
                             Indemnity Experience


           No. of         Earned             Paid            PAID
          Insureds       Premiums           Claims            L/R

 Jan-07    17593             $834,830        $668,474         80.07%

Feb-07     17690             $858,929        $660,408         76.89%

Mar-07     17782             $865,639        $692,209         79.97%        78.97%       1st Q L/R

Apr-07     17732             $844,637        $684,462         81.04%

May-07     17760             $863,073        $855,914         99.17%

Jun-07     17938             $820,405        $673,369         82.08%        83.24%       2nd Q L/R

 Jul-07    18192             $861,301        $605,886         70.35%

Aug-07     18428             $903,234        $747,845         82.80%

 Sep-07    18502             $895,725        $656,944         73.34%        80.61%       3rd Q L/R

 Oct-07    18574             $903,074        $756,655         83.79%

Nov-07     18647             $905,875        $632,751         69.85%

Dec-07     18681             $904,557        $743,491         82.19%
                     =                  =                =
Total                    $10,461,279        $8,378,408        80.09%                     4th Q L/R

                     Note:       The above figures are unaudited.




                                                                                    Section: Exhibit B
                                                                                  Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                 Arizona State Retirement System
                                                                                 3300 North Central Avenue
                                    Retiree Dental Benefits Program                       Suite 1300
                                                                                   Phoenix, Arizona 85012
                                                RT10-022
                                                                                      Page 69 of 154



                                      Procedure Code Breakdown

                                    ARIZONA STATE RETIREMENT SYSTEM

                                Claims Paid between 1/1/2007 and 12/31/2007

                                Procedure     Employee Paid   Dependent Paid       Total Paid              # of
 Paid Procedure Code Desc
                                  Code           Claims          Claims             Claims              Claimants

Unspecified                       99999            $0               $0                 $0                    6
Claim Adjustments                ADJST          -$203,452        -$80,457          -$283,909                975
Periodic Oral Exam               D0120          $396,401         $145,201           $541,603              14,458
Emergency Oral Exam              D0130             $0               $0                 $0                    1
Limited Oral Evaluation          D0140           $58,418         $20,470            $78,888                3,391
Comprehensive Oral
                                 D0150           $58,755         $23,416            $82,171                2,413
Evaluation
Detailed Oral Evaluation-
                                 D0160            $409             $218               $627                  41
Problem Focused
Re-Evaluation-Problem
                                 D0170           $1,026            $108              $1,134                 58
Focused
Comprehensive Periodontal
                                 D0180           $7,208           $2,141             $9,349                 360
Evaluation
Intraoral-Complete Series
                                 D0210           $92,256         $34,624            $126,881               2,299
(Including Bitewings)
Intraoral-Periapical First
                                 D0220           $79,651         $26,428            $106,079               6,190
Film
Intraoral-Periapical Each
                                 D0230           $25,768          $8,048            $33,816                2,311
Additional Film
Intraoral Occlusal Film          D0240            $214             $323               $538                  26
Extraoral-First Film             D0250             $94             $38                $132                   6
Extraoral-Each Additional
                                 D0260             $66              $0                $66                    2
Film
Bitewing-Single Film             D0270           $1,586            $530              $2,116                 271
Bitewings-Two Films              D0272           $25,463         $11,624            $37,087                1,592
Bitewings-Four Films             D0274          $248,331         $92,944            $341,275               9,774
Vertical Bitewings-7 To 8
                                 D0277           $4,872           $1,556             $6,429                 130
Films
Post/Ant Lateral Skull/Facial
                                 D0290             $0               $0                 $0                    1
Film
Sialography                      D0310             $0              $316               $316                   1
Tomographic Survey               D0322             $0               $0                 $0                    3
Panoramic Film                   D0330           $32,473         $15,832            $48,305                1,194

                                                                                                  Section: Exhibit B
                                                                                                Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                           3300 North Central Avenue
                                   Retiree Dental Benefits Program                  Suite 1300
                                                                             Phoenix, Arizona 85012
                                              RT10-022
                                                                                Page 70 of 154

Cephalometric Film               D0340           $0              $0              $0                    7
Oral/Facial Images               D0350           $0              $0              $0                   39
Cone Beam CT-Craniofacial
Data Capture-Axial, Coronal,     D0360           $0              $0              $0                    2
Sagittal
Cone Beam CT-Two
                                 D0362           $0              $0              $0                    1
Dimensional Image
Cone Beam CT-Three
                                 D0363           $0              $0              $0                    1
Doimensional Image
Bacteriologic Studies            D0415          $427            $189            $616                   6
Genetic Test for
                                 D0421           $0              $0              $0                    1
Susceptibility
Caries Susceptibility Tests      D0425           $0              $0              $0                    4
Adjunctive Pre-Diagnostic
                                 D0431           $0              $0              $0                   186
Test
Pulp Vitality Tests              D0460           $0              $0              $0                   57
Diagnostic Casts                 D0470          $641            $276            $918                  70
Diagnostic Photographs           D0471           $0              $0              $0                    2
accession of tissue, gross
examination, preparation
                                 D0472           $92             $0             $92                    1
and transmission of written
report
accession of tissue, gross and
microscopic examination,
preparation and                  D0473          $129             $0             $129                   2
transmission of written
report
Microscopic Examination By
                                 D0474          $381             $0             $381                   2
Report
Test/Lab Examinations            D0490           $0              $0              $0                    1
Histopathological
                                 D0501           $86             $0             $86                    2
Examination
unspecified diagnostic
                                 D0999           $0              $0              $0                   26
procedure, by report
Prophylaxis-Adult                D1110         $986,006       $359,300       $1,345,305             15,551
Prophylaxis-Child                D1120          $289           $8,059          $8,348                 152
Topical Application of
                                 D1203           $0            $1,803          $1,803                 149
Fluoride-Child
Topical Application of
                                 D1204           $0             $100            $100                  817
Fluoride-Adult
Topical Fluoride Varnish         D1206           $0              $67            $67                   124
Oral Hygiene Instructions        D1330           $0              $0              $0                   64
Training in Preventive           D1340           $0              $0              $0                    7

                                                                                            Section: Exhibit B
                                                                                          Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                             RT10-022
                                                                               Page 71 of 154

Dental Care
Sealant-Per Tooth               D1351           $0            $2,428          $2,428                58
Space Maintainer-Fixed-
                                D1510           $0             $744            $744                  5
Unilateral
Space Maintainer-Fixed-
                                D1515           $0             $458            $458                  2
Bilateral
Re-Cementation Of Space
                                D1550           $0              $0              $0                   1
Maintainer
Preventive procedure;
                                D1999           $0              $0              $0                   6
unspecified
amalgam - one surface,
                                D2140         $170,779        $80,511        $251,290              2,345
primary or permanent
amalgam - two surfaces,
                                D2150         $153,821        $71,516        $225,337              1,889
primary or permanent
amalgam - three surfaces,
                                D2160         $95,775         $34,981        $130,756               907
primary or permanent
amalgam - four or more
surfaces, primary or            D2161         $18,809         $7,165         $25,974                173
permanent
resin-based composite - one
                                D2330         $193,649        $62,487        $256,136              1,947
surface, anterior
resin-based composite - two
                                D2331         $66,141         $21,030        $87,171                703
surfaces, anterior
resin-based composite - three
                                D2332         $32,758         $10,176        $42,934                302
surfaces, anterior
Resin-Based Composite-Four
Or More Surfaces Or
                                D2335         $45,644         $18,813        $64,457                366
Involving Incisal Angle
(Anterior)
resin-based composite
                                D2390           $0              $0              $0                   3
crown, anterior
resin-based composite - one
                                D2391          $151             $0             $151                  2
surface, posterior
resin-based composite - two
                                D2392          $173             $0             $173                  1
surfaces, posterior
resin-based composite - one
                                D2394          $478            $477            $954                  5
surface, posterior-permanent
Inlay-Metallic-Two Surfaces     D2520          $129           $1,870          $1,998                 4
Inlay-Metallic-Three Surfaces   D2530          $526             $51            $577                  3
Onlay-Metallic -Two
                                D2542          $4,843           $0            $4,843                 8
Surfaces
Onlay-Metallic-Three
                                D2543         $10,288         $2,433         $12,721                31
Surfaces
Onlay-Metallic-Four Or          D2544          $9,958         $5,575         $15,533                42

                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                             RT10-022
                                                                               Page 72 of 154

More Surfaces
Crown-Resin-Direct              D2710           $0              $0              $0                    1
Crown-Resin With High
                                D2720           $0             $493            $493                   1
Noble Metal
Crown-Porcelain/Ceramic
                                D2740         $128,810        $38,558        $167,369                303
Substrate
Crown-Porcelain Fused To
                                D2751        $1,020,099      $349,252       $1,369,352              2,937
Predominantly Base Metal
Crown-3/4 Cast
                                D2781          $9,174         $6,099         $15,274                 35
Predominantly Base Metal
Crown-Full Cast High Noble
                                D2790          $409             $0             $409                   1
Metal
Crown-Full Cast
                                D2791         $191,793        $63,210        $255,004                638
Predominantly Base Metal
Provisional Crown               D2799           $0              $0              $0                   12
Recement Inlay                  D2910          $567             $78            $644                  23
Recement Cast or PreFab
                                D2915           $53            $100            $153                   5
Post/Core
Recement Crown                  D2920          $9,715         $3,232         $12,947                 613
Prefabricated Stainless Steel
                                D2930           $0             $170            $170                   2
Crown-Primary Tooth
Prefabricated Stainless Steel
                                D2931           $0              $0              $0                    3
Crown-Permanent Tooth
Prefabricated Resin Crown       D2932           $0              $0              $0                    2
Sedative Filling                D2940           $0              $0              $0                   89
core build-up, including any
                                D2950         $97,466         $37,077        $134,544               1,949
pins
pin retention - per tooth, in
                                D2951          $475            $234            $710                  26
addition to restoration
Cast Post And Core In
                                D2952          $6,711         $2,444          $9,155                 80
Addition To Crown
Each Additional Post And
                                D2953          $140             $0             $140                   1
Core
Prefabricated Post And Core
                                D2954         $38,203         $15,743        $53,946                 485
In Addition To Crown
Post Removal Not In
Conjunction With                D2955           $0              $0              $0                    9
Endodontic Therapy
Each Additional
Prefabricated Post-Same         D2957           $0              $0              $0                    2
Tooth
Labial Veneer (Resin
                                D2960          $1,017          $245           $1,262                  8
Laminate)-Chairside
Labial Veneer (Porcelain        D2962         $10,398         $2,031         $12,428                 24
                                                                                           Section: Exhibit B
                                                                                         Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                             RT10-022
                                                                               Page 73 of 154

Laminate)-Laboratory
Temporary Crown
                                D2970           $0              $0              $0                   8
(Fractured Tooth)
Additional Crown
Procedures for Partial          D2971           $0              $0              $0                  10
Denture Framework
Coping                          D2975           $61             $0             $61                   1
crown repair, by report         D2980          $1,384          $489           $1,873                30
unspecified restorative
                                D2999           $0              $0              $0                  22
procedure, by report
Pulp Cap - Direct (Excluding
                                D3110           $0              $0              $0                  31
Final Restoration)
Pulp Cap - Indirect
                                D3120           $0              $0              $0                  56
(Excluding Final Restoration)
Therapeutic Pulpotomy
                                D3220           $0             $161            $161                 15
(Excluding Final Restoration)
pulpal debridement, primary
                                D3221           $0              $0              $0                  26
and permanent teeth
pulpal therapy (resorbable
filling) - anterior, primary
                                D3230           $0              $0              $0                   1
tooth (excluding final
restoration)
pulpal therapy (resorbable
filling) - posterior, primary
                                D3240           $0              $0              $0                   2
tooth (excluding final
restoration)
Endodontic Therapy-
Anterior Tooth (Excluding       D3310         $110,661        $31,358        $142,019               325
Final Restoration)
Endodontic Therapy-
Bicuspid Tooth (Excluding       D3320         $160,777        $57,957        $218,734               425
Final Restoration)
Endodontic Therapy-Molar
                                D3330         $283,421       $112,819        $396,240               621
(Excluding Final Restoration)
Treatment Of Root Canal
Obstruction; Non-Surgical       D3331           $0              $0              $0                   8
Access
Incomplete Endodontic
Therapy; Inoperable Or          D3332           $0              $0              $0                  32
Fractured Tooth
Retreatment Of Previous
                                D3346         $11,078         $2,684         $13,762                22
Root Canal Therapy-Anterior
Retreatment Of Previous
                                D3347         $15,803         $6,587         $22,389                35
Root Canal Therapy-

                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL           Arizona State Retirement System
                                                                          3300 North Central Avenue
                                   Retiree Dental Benefits Program                 Suite 1300
                                                                            Phoenix, Arizona 85012
                                              RT10-022
                                                                               Page 74 of 154

Bicuspid
Retreatment Of Previous
                                 D3348         $31,040         $9,251        $40,292               54
Root Canal Therapy-Molar
Apexification/Recalcification-
                                 D3351          $320            $216           $536                 3
Initial Visit
Apicoectomy/Periradicular
                                 D3410         $4,004          $1,264         $5,268               12
Surgery-Anterior
Apicoectomy/Periradicular
                                 D3421         $6,618          $2,187         $8,805               16
Surgery-Bicuspid (First Root)
Apicoectomy/Periradicular
                                 D3425         $12,764         $2,622        $15,386               22
Surgery-Molar (First Root)
Apicoectomy/Periradicular
Surgery-Each Additional          D3426         $1,579           $685          $2,264                9
Root
Retrograde Filling-Per Root      D3430         $5,062          $1,960         $7,022               39
Root Amputation-Per Root         D3450          $618           $1,382         $2,000                7
Surgical Procedure For
Isolation Of Tooth With          D3910           $0              $0             $0                  1
Rubber Dam
Hemisection (Including Any
Root Removal) Not
                                 D3920           $0              $0             $0                  1
Including Root Canal
Therapy
Canal Preparation And
Fitting Of Preformed Dowel       D3950           $0              $0             $0                  2
Or Post
Bleaching                        D3960           $0              $0             $0                  5
unspecified endodontic
                                 D3999           $0              $0             $0                  1
procedure, by report
Gingivectomy Or
Gingivoplasty-Four Or More
                                 D4210         $1,582           $616          $2,198               12
Contiguous Teeth Per
Quadrant
Gingivectomy Or
Gingivoplasty-One To Three       D4211         $1,918          $2,023         $3,941               69
Teeth Per Quadrant
gingival flap procedure,
including root planing - four
or more contiguous teeth or      D4240         $4,651          $1,148         $5,799               12
bounded teeth spaces per
quadrant
gingival flap procedure,
including root planing - one     D4241         $1,483           $710          $2,193               11
to three teeth, per quadrant

                                                                                         Section: Exhibit B
                                                                                       Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                         3300 North Central Avenue
                                 Retiree Dental Benefits Program                  Suite 1300
                                                                           Phoenix, Arizona 85012
                                            RT10-022
                                                                              Page 75 of 154

Clinical Crown Lengthening-
                               D4249         $22,430         $5,234         $27,664                66
Hard Tissue
Osseous Surgery (Including
Flap Entry And Closure)-
Four Or More Contiguous        D4260         $69,664         $22,007        $91,671                121
Teeth Or Bounded Teeth
Spaces Per Quadrant
osseous surgery (including
flap entry and closure)-one    D4261         $17,632         $1,696         $19,327                29
to three teeth, per quadrant
Bone Replacement Graft-
                               D4263          $4,679         $2,556          $7,235                84
First Site In Quadrant
Guided Tissue Regeneration
                               D4266          $2,005         $1,812          $3,817                32
- Resorbable
Guided Tissue Regeneration
                               D4267          $2,890          $940           $3,830                14
- Non-Resorbable
Free Soft Tissue Graft
Procedure (Including Donor     D4271          $6,290         $2,550          $8,839                14
Site Surgery)
Subepithelial Connective
                               D4273          $8,934         $2,401         $11,335                18
Tissue Graft Procedures
Distal Or Proximal Wedge
                               D4274          $1,284           $0            $1,284                 3
Procedure
Soft Tissue Allograft          D4275           $0             $302            $302                  1
Combined Connective Tissue
                               D4276           $0             $495            $495                  1
And Double Pedicle Graft
Provisional Splinting -
                               D4320          $395            $218            $613                  6
Intracoronal
Provisional Splinting -
                               D4321          $1,274          $782           $2,056                11
Extracoronal
Periodontal Scaling And
Root Planing-Four Or More
Contiguous Teeth Or            D4341         $150,658        $48,106        $198,764               517
Bounded Teeth Spaces Per
Quadrant
periodontal scaling and root
planing, one to three teeth,   D4342         $29,475         $9,117         $38,592                296
per quadrant
Perio Scaling/Gingival
                               D4345           $0              $0              $0                  37
Inflammation
Full Mouth Debridement         D4355           $0              $0              $0                  212
Periodontal therapy: re-
                               D4380           $0              $0              $0                   1
evaluation
Chemotherapeutic Agents        D4381           $0              $0              $0                  333

                                                                                         Section: Exhibit B
                                                                                       Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                             RT10-022
                                                                               Page 76 of 154

Periodontal Maintenance         D4910         $153,124        $42,182        $195,306              2,561
unspecified periodontal
                                D4999           $0              $0              $0                  126
procedure, by report
Complete Denture-Maxillary      D5110         $29,451         $13,637        $43,088                97
Complete Denture-
                                D5120         $12,333         $7,084         $19,417                46
Mandibular
Immediate Denture-
                                D5130         $22,164         $5,405         $27,569                65
Maxillary
Immediate Denture-
                                D5140         $13,790         $4,844         $18,633                40
Mandibular
maxillary partial denture -
resin base (including any
                                D5211          $5,356          $779           $6,135                20
conventional clasps, rest and
teeth)
mandibular partial denture -
resin base (including any
                                D5212          $4,511         $1,200          $5,711                18
conventional clasps, rest and
teeth)
maxillary partial denture -
cast metal framework with
resin denture bases             D5213         $53,743         $22,116        $75,859                177
(including any conventional
clasps, rest and teeth)
mandibular partial denture -
cast metal framework with
resin denture bases             D5214         $66,728         $14,904        $81,632                191
(including any conventional
clasps, rest and teeth)
Maxillary Denture-Flexible
                                D5225          $4,261         $3,695          $7,955                23
Base
Mandibular Partial Denture-
                                D5226          $1,612           $0            $1,612                 9
Flexible Base
Removable Unilateral Partial
Denture-One Piece Cast
                                D5281          $830            $175           $1,005                 5
Metal (Including Clasps And
Teeth)
New clasps                      D5310           $0              $0              $0                   1
Adjust Complete Denture-
                                D5410          $139             $46            $185                 15
Maxillary
Adjust Complete Denture-
                                D5411          $123             $40            $162                 15
Mandibular
Adjustments-partial denture
                                D5415           $0              $0              $0                   2
compl
Adjust Partial Denture-
                                D5421          $180            $110            $290                 13
Maxillary
                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL           Arizona State Retirement System
                                                                      3300 North Central Avenue
                               Retiree Dental Benefits Program                 Suite 1300
                                                                        Phoenix, Arizona 85012
                                          RT10-022
                                                                           Page 77 of 154

Adjust Partial Denture-
                             D5422          $418             $70           $488                37
Mandibular
Repair Broken Complete
                             D5510          $584            $290           $873                22
Denture Base
Replace Missing Or Broken
Teeth-Complete Denture       D5520         $1,759           $346          $2,105               35
(Each Tooth)
Repair Resin Denture Base    D5610         $1,069           $347          $1,416               34
Repair Cast Framework        D5620          $292             $19           $310                 9
Repair Or Replace Broken
                             D5630         $2,731           $808          $3,539               53
Clasp
Replace Broken Teeth-Per
                             D5640         $2,784           $636          $3,420               64
Tooth
Add Tooth To Existing
                             D5650         $9,536          $2,920        $12,456               165
Partial Denture
Replace All Teeth And
Acrylic On Cast Metal        D5671          $38              $0            $38                  1
Framework (Mandibular)
Rebase Complete Maxillary
                             D5710         $1,020           $244          $1,263                6
Denture
Rebase Complete
                             D5711           $0             $125           $125                 1
Mandibular Denture
Rebase Maxillary Partial
                             D5720          $468            $196           $663                 4
Denture
Rebase Mandibular Partial
                             D5721          $275            $225           $500                 4
Denture
Reline Complete Maxillary
                             D5730         $1,123           $327          $1,450               17
Denture (Chairside)
Reline Complete Mandibular
                             D5731          $470            $238           $708                10
Denture (Chairside)
Reline Maxillary Partial
                             D5740          $681             $0            $681                 7
Denture (Chairside)
Reline Mandibular Partial
                             D5741          $713            $114           $827                12
Denture (Chairside)
Reline Complete Maxillary
                             D5750         $5,456          $1,853         $7,308               66
Denture (Laboratory)
Reline Complete Mandibular
                             D5751         $2,886          $1,450         $4,336               36
Denture (Laboratory)
Denture reline-upper or
                             D5755           $0              $0             $0                  1
lower
Reline Maxillary Partial
                             D5760         $1,643           $503          $2,146               17
Denture (Laboratory)
Reline Mandibular Partial
                             D5761         $1,578           $438          $2,015               18
Denture (Laboratory)

                                                                                     Section: Exhibit B
                                                                                   Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL          Arizona State Retirement System
                                                                      3300 North Central Avenue
                                Retiree Dental Benefits Program                Suite 1300
                                                                        Phoenix, Arizona 85012
                                           RT10-022
                                                                           Page 78 of 154

Interim Complete Denture
                              D5810           $0              $0            $0                 3
(Maxillary)
Interim Complete Denture
                              D5811           $0              $0            $0                 2
(Mandibular)
Interim Partial Denture
                              D5820           $0              $0            $0                62
(Maxillary)
Interim Partial Denture
                              D5821           $0              $0            $0                13
(Mandibular)
tissue conditioning,
                              D5850          $247             $0           $247               10
maxillary
tissue conditioning,
                              D5851          $321             $89          $410                9
mandibular
overdenture - complete, by
                              D5860           $0              $0            $0                 4
report
overdenture - partial, by
                              D5861           $0              $0            $0                 1
report
precision attachment, by
                              D5862           $0              $0            $0                10
report
Precision Attachment:
                              D5867           $0              $0            $0                 8
Replacement Part
Unspecified Removable
                              D5899           $0              $0            $0                11
Prosthodontic Procedure
Surgical Stent                D5982           $0              $0            $0                 7
Fluoride Gel Carrier          D5986           $0              $0            $0                 4
Unspecified Procedure         D5999           $0              $0            $0                10
Surgical Placement Of
Implant Body: Endosteal       D6010           $0              $0            $0                137
Implant
Abutment Placement Or
Substitution: Endosteal       D6020           $0              $0            $0                 3
Implant
Surgical Placement-Eposteal
                              D6040           $0              $0            $0                 1
Implant
Implant/Abutment
Supported Removable
                              D6053           $0              $0            $0                 7
Denture For Completely
Edentulous Arch
Dental Implant Supported
                              D6055           $0              $0            $0                 1
Connecting Bar
Prefabricated Abutment        D6056           $0              $0            $0                52
Custom Abutment               D6057           $0              $0            $0                30
Abutment Supported
Porcelain Fused To Metal      D6060           $0              $0            $0                64
Crown (Predom Inately Base

                                                                                    Section: Exhibit B
                                                                                  Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                         3300 North Central Avenue
                                 Retiree Dental Benefits Program                  Suite 1300
                                                                           Phoenix, Arizona 85012
                                            RT10-022
                                                                              Page 79 of 154

Metal)
Abutment Supported Cast
Metal Crown                    D6063           $0              $0              $0                   2
(Predominantly Base Metal)
abutment supported metal
crown (titanium, titanium      D6067           $0              $0              $0                  50
alloy, nigh noble metal)
Abutment Supported
Retainer For Porcelain Fused
                               D6070           $0              $0              $0                   7
To Metal Fpd
(Predominantly Base Metal)
Abutment Supported
Retainer For Cast Metal Fpd    D6073           $0              $0              $0                   3
(Predominantly Base Metal)
implant supported retainer
for porcelain fused to metal
                               D6076           $0              $0              $0                   2
FPD (titanium, titanium
alloy, nigh noble metal)
Implant/Abutment
Supported Fixed Denture For    D6078           $0              $0              $0                   2
Completely Edentulous Arch
Implant/Abutment
Supported Fixed Denture For    D6079           $0              $0              $0                   1
Partially Edentulous Arch
Implant Maintenance
                               D6080           $0              $0              $0                  11
Procedures
repair implant supported
                               D6090           $0              $0              $0                   1
prosthesis, be report
Recement Implant/Abutment
Supported Fixed Partial        D6093           $0              $0              $0                   1
Denture
implant removal, by report     D6100           $0              $0              $0                   4
Abutment Supported
Retainer Crown for FPD-        D6190           $0              $0              $0                   2
Titanium
unspecified implant
                               D6199           $0              $0              $0                   6
procedure, by report
Pontic-Cast Predominantly
                               D6211          $3,985         $2,586          $6,570                25
Base Metal
Pontic-Cast Predominantly
                               D6241         $123,808        $43,358        $167,165               492
Base Metal
Pontic-Resin With
                               D6251          $466            $518            $983                  3
Predominantly Base Metal
Retainer-Cast Metal For
                               D6545          $1,925           $0            $1,925                 6
Resin Bonded Fixed
                                                                                         Section: Exhibit B
                                                                                       Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                             RT10-022
                                                                               Page 80 of 154

Prosthesis
onlay - cast predominantly
base metal, three or more       D6613           $0              $0              $0                   1
surfaces
Crown-Porcelain Fused To
                                D6751         $246,124        $80,107        $326,231               525
Predominantly Base Metal
Crown-3/4 Cast
                                D6781           $0              $0              $0                   1
Predominantly Noble Metal
Crown-Full Cast
                                D6791          $6,557         $1,856          $8,412                18
Predominantly Base Metal
Provisional Retainer Crown      D6793           $0              $0              $0                   2
Recement Fixed Partial
                                D6930          $1,511         $1,025          $2,535                73
Denture
Stress Breaker                  D6940           $0              $0              $0                   2
Precision Attachment            D6950           $0              $0              $0                   6
Prefabricated Post And Core
In Addition To Fixed Partial    D6972          $673             $0             $673                  4
Denture Retainer
core build up for retainer,
                                D6973          $270             $0             $270                 10
including any pins
Coping - Metal                  D6975           $0              $0              $0                   1
fixed partial denture repair,
                                D6980          $923            $231           $1,154                13
by report
unspecified, fixed
prosthodontic procedure, by     D6999           $0              $25            $25                  26
report
Extraction (Single Tooth)       D7110           $0              $0              $0                   6
Coronal Remnants-
                                D7111           $0             $435            $435                  5
Deciduous Tooth
extraction, erupted tooth or
exposed root (elevation         D7140         $112,392        $37,934        $150,326              1,013
and/or forceps removal)
Surgical Removal Of Erupted
Tooth Requiring Elevation
Of Mucoperiosteal Flap And      D7210         $79,616         $26,980        $106,596               888
Removal Of Bone And/Or
Section Of Tooth
Removal Of Impacted Tooth-
                                D7220          $870           $1,969          $2,839                21
Soft Tissue
Removal Of Impacted Tooth-
                                D7230          $1,156         $5,642          $6,798                39
Partially Bony
Removal Of Impacted Tooth-
                                D7240          $520           $7,136          $7,655                29
Completely Bony
Removal Of Impacted Tooth-      D7241          $335             $0             $335                  1

                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL           Arizona State Retirement System
                                                                        3300 North Central Avenue
                                 Retiree Dental Benefits Program                 Suite 1300
                                                                          Phoenix, Arizona 85012
                                            RT10-022
                                                                             Page 81 of 154

Completely Bony With
Unusual Surgical
Complications
Surgical Removal Of
Residual Tooth Roots           D7250         $10,547         $2,478        $13,026               131
(Cutting Procedure)
Oroantral Fistula Closure      D7260          $275             $0            $275                 1
Primary Closure Of A Sinus
                               D7261           $0              $0             $0                  3
Perforation
Surgical Access Of An
                               D7280           $0              $92           $92                  1
Unerupted Tooth
Placement of Device to
Facilitate Eruption of         D7283           $0              $0             $0                  1
Impacted Tooth
biopsy of oral tissue - hard
                               D7285          $365             $0            $365                 4
(bone, tooth)
Biopsy Of Oral Tissue-Soft
                               D7286         $1,032           $143          $1,175               19
(All Others)
Brush Biopsy-Transepithelial
                               D7288          $28              $0            $28                  1
Sample Collection
Alveoloplasty In Conjunction
With Extractions-Per           D7310         $2,605          $2,313         $4,918               22
Quadrant
Alveoloplasty Not In
Conjunction With               D7320          $506            $121           $627                 4
Extractions-Per Quadrant
Alveoloplasty Not In
                               D7321          $88              $0            $88                  1
Conjunction with Extractions
Excision Of Benign Lesion
                               D7410           $0              $0             $0                  6
Up To 1.25 Cm
Excision Of Benign Lesion
                               D7411           $0              $0             $0                  1
Greater Than 1.25 Cm
Removal Of Benign
Odontogenic Cyst Or
                               D7450           $0              $0             $0                  3
Tumor-Lesion Diameter Up
To 1.25 Cm
Removal Of Benign
Odontogenic Cyst Or
                               D7451           $0              $0             $0                  1
Tumor-Lesion Diameter
Greater Than 1.25 Cm
Removal Of Lateral
Exostosis-Maxilla Or           D7471          $673             $0            $673                 4
Mandible
Removal Of Torus Palatinus     D7472          $213             $0            $213                 1


                                                                                       Section: Exhibit B
                                                                                     Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL          Arizona State Retirement System
                                                                        3300 North Central Avenue
                                  Retiree Dental Benefits Program                Suite 1300
                                                                          Phoenix, Arizona 85012
                                             RT10-022
                                                                             Page 82 of 154

Removal Of Torus
                                D7473          $789            $150          $939                 3
Mandibularis
Incision And Drainage Of
                                D7510         $1,970            $28         $1,998               19
Abscess-Intraoral Soft Tissue
Incision and Drainage of
Abscess-Intraoral Soft          D7511          $438             $0           $438                 1
Tissue-Complicated
Sequestrectomy For
                                D7550           $0              $0            $0                  1
Osteomyelitis
Malar And/Or Zygomatic
                                D7750           $0              $0            $0                  1
Arch - Open Reduction
Non-Arthoscopic Lysis And
                                D7871           $0              $0            $0                  1
Lavage
occlusal orthotic device, by
                                D7880           $0              $0            $0                 11
report
Unspecified Tmj Therapy By
                                D7899           $0              $0            $0                  1
Report
Suture Of Recent Small
                                D7910           $0              $0            $0                  1
Wound Up To 5 Cm
Osteotomy - Mandibular
                                D7943           $0              $0            $0                  3
Rami With Bone Graft
Osseoperiosteal Graft           D7950           $0              $0            $0                 19
Sinus Augmentation With
                                D7951           $0              $0            $0                  2
Bone or Bone Substitutes
Bone Replacement Graft for
                                D7953           $0              $0            $0                 54
Ridge Preservation-Per Site
Repair Of Maxillofacial
                                D7955           $0              $0            $0                  4
Tissue Defect
Frenulectomy (Frenectomy
Or Frenotomy)-Separate          D7960          $296            $123          $418                 4
Procedure
Frenuloplasty                   D7963           $0             $228          $228                 1
Excision Of Hyperplastic
                                D7970           $0              $50          $50                  2
Tissue-Per Arch
Surgical Reduction Of
                                D7972          $30              $0           $30                  1
Fibrous Tuberosity
Unspecified Oral Surgery
                                D7999           $0              $0            $0                  4
Procedure By Report
Limited Ortho- Primary          D8020           $0              $0            $0                  1
Limited Ortho-Adolescent        D8030           $0              $0            $0                  1
Limited Ortho-Adolescent        D8040           $0              $0            $0                  2
Comprehensive Ortho-
                                D8070           $0              $0            $0                  2
Transitional
Comprehensive Ortho-Adult       D8090           $0              $0            $0                  4

                                                                                       Section: Exhibit B
                                                                                     Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL           Arizona State Retirement System
                                                                         3300 North Central Avenue
                                  Retiree Dental Benefits Program                 Suite 1300
                                                                           Phoenix, Arizona 85012
                                             RT10-022
                                                                              Page 83 of 154

Removable Appliance
                                D8210           $0              $0             $0                  1
Therapy
Pre-Orthodontic Visit           D8660           $0              $0             $0                  1
Periodontic Orthodontic
                                D8670           $0              $0             $0                  3
Visit
Orthodontic Retention           D8680           $0              $0             $0                  3
Repair Of Orthodontic
                                D8691           $0              $0             $0                  1
Appliances
Replacement Of Lost Or
                                D8692           $0              $0             $0                  2
Broken Retainer
Rebonding, Recementing
and/orRepair, as required, of   D8693           $0              $0             $0                  1
Fixed Retainers
Palliative (Emergency)
Treatment Of Dental Pain-       D9110         $7,483          $2,168         $9,650               228
Minor Procedure
Fixed Partial Denture
                                D9120           $0              $0             $0                  8
Sectioning
Miscellaneous Tax               D9199          $185             $93           $278                18
Local Anesthesia                D9210           $0              $0             $0                  2
Regional Block Anesthesia       D9211           $0              $0             $0                  1
Local Anesthesia                D9215           $0              $0             $0                  6
General Anesthesia              D9220         $5,374          $4,755        $10,129               150
Each Additional 15 Minutes      D9221          $627            $685          $1,311               40
analgesia, anxiolysis,
                                D9230           $0              $0             $0                 126
inhalation of nitrous oxide
Intravenous Conscious
Sedation/Analgesia-First 30     D9241         $2,790           $235          $3,024               72
Minutes
Intravenous Conscious
Sedation/Analgesia-Each         D9242           $0              $0             $0                  2
Additional 15 Minutes
Non-Intravenous Conscious
                                D9248           $0              $0             $0                  9
Sedation
Consultation (Diagnostic
Service Provided By Dentist
Or Physician Other Than         D9310           $0              $0             $0                 146
Practitioner Providing
Treatment
House/Extended Care
                                D9410           $0              $0             $0                  5
Facility Call
Office Visit During Regularly
                                D9430           $0              $0             $0                 52
Scheduled Hours
Office Visit-After Hours        D9440           $0              $0             $0                  8
                                                                                        Section: Exhibit B
                                                                                      Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                               3300 North Central Avenue
                                   Retiree Dental Benefits Program                      Suite 1300
                                                                                 Phoenix, Arizona 85012
                                              RT10-022
                                                                                    Page 84 of 154

Case Presentation               D9450            $0              $0                  $0                  1
therapeutic drug injection,
                                D9610           $978            $136               $1,114               43
by report
Irrigation                      D9611            $0              $0                  $0                  2
Therapeutic Prenteral Drugs-
2                               D9612           $129             $0                 $129                 4
Administrations/Medications
other drugs and/or
                                D9630            $0              $0                  $0                 196
medicaments, by report
Application Of Desensitizing
                                D9910            $0              $0                  $0                 69
Medicament
Application Of Desensitizing
                                D9911            $0              $0                  $0                 19
Resin
Behavior Management             D9920            $0              $0                  $0                  2
occlusal guard, by report       D9940          $33,056         $11,792            $44,848               205
Fabrication Of Athletic
                                D9941            $0              $0                  $0                  3
Mouthguard
Repair and/or Reline of
                                D9942            $0              $0                  $0                  3
Occlusal Guard
Occlusal Adjustment -
                                D9951          $1,166           $325               $1,491               58
Limited
Occlusal Adjustment -
                                D9952           $732             $0                 $732                 3
Complete
Enamel Microabrasion            D9970            $0              $0                  $0                  3
Odontoplasty 1 - 2 Teeth        D9971            $0              $0                  $0                  3
External Bleaching - Per Arch   D9972            $0              $0                  $0                  9
External Bleaching - Per
                                D9973            $0              $0                  $0                  1
Tooth
Internal Bleaching - Per
                                D9974            $0              $0                  $0                  2
Tooth
Sterilization                   D9998            $0              $0                  $0                  6
Unspecified Adjunctive
                                D9999            $0              $0                  $0                 610
Procedure
Interest                        INTRS           $930            $332               $1,262               849
                                Totals           $6,167,834     $2,210,663           $8,378,497




                                                                                              Section: Exhibit B
                                                                                            Form#RFP.02/03/10
                         REQUEST FOR PROPOSAL                   Arizona State Retirement System
                                                                  3300 North Central Avenue
                     Retiree Dental Benefits Program                       Suite 1300
                                                                    Phoenix, Arizona 85012
                                 RT10-022
                                                                       Page 85 of 154




                                      2008
                       Arizona State Retirement System
            Freedom Advance (high option) / Freedom Basic (low option)
                             Indemnity Experience

           No. of         Earned             Paid            PAID
          Insureds       Premiums           Claims            L/R

Jan-08     19506             $950,209        $629,301        66.23%

Feb-08     19603             $953,984        $949,452        99.52%

Mar-08     19671             $962,477        $714,432        74.23%     79.99%       1st Q L/R

Apr-08     19770             $967,918        $871,573        90.05%

May-08     19552             $834,465        $753,747        90.33%

Jun-08     19671             $968,720        $793,378        81.90%     83.58%       2nd Q L/R

 Jul-08    19914             $975,958        $722,882        74.07%

Aug-08     20103             $947,543        $768,117        81.06%

Sep-08     20138             $982,025        $759,550        77.35%     81.50%       3rd Q L/R

Oct-08     20186             $986,051        $875,280        88.77%

Nov-08     20229             $990,846        $751,181        75.81%

Dec-08     20277             $999,909        $854,278        85.44%
                     =                  =                =
Total                    $11,520,105        $9,443,171       81.97%                  4th Q L/R

                     Note:       The above figures are unaudited.



                                                                                Section: Exhibit B
                                                                              Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL                   Arizona State Retirement System
                                                                                3300 North Central Avenue
                                     Retiree Dental Benefits Program                     Suite 1300
                                                                                  Phoenix, Arizona 85012
                                               RT10-022
                                                                                     Page 86 of 154



                                       Procedure Code Breakdown

                                     ARIZONA STATE RETIREMENT SYSTEM

                                  Claims Paid between 1/1/2008 and 12/31/2008

                                  Procedure    Employee      Dependent Paid                                 # of
  Paid Procedure Code Desc                                                      Total Paid Claims
                                    Code      Paid Claims       Claims                                   Claimants

Unspecified                         99999         $0               $0                   $0                    3
Claim Adjustments                  ADJST       -$201,225        -$90,650            -$291,875               1,135
Periodic Oral Exam                 D0120        $457,410        $169,765             $627,175              16,301
Limited Oral Evaluation            D0140        $67,839          $24,833             $92,672                3,954
Comprehensive Oral
                                   D0150        $64,810          $27,497             $92,307                2,688
Evaluation
Detailed Oral Evaluation-
                                   D0160         $823             $399                $1,221                 35
Problem Focused
Re-Evaluation-Problem
                                   D0170         $942             $138                $1,079                 68
Focused
Comprehensive Periodontal
                                   D0180         $7,813          $2,483              $10,296                 389
Evaluation
Intraoral-Complete Series
                                   D0210        $112,984         $41,909             $154,893               2,615
(Including Bitewings)
Intraoral-Periapical First Film    D0220        $90,515          $31,284             $121,799               6,954
Intraoral-Periapical Each
                                   D0230        $29,797          $11,007             $40,804                2,768
Additional Film
Intraoral Occlusal Film            D0240         $197             $38                  $234                  14
Extraoral-First Film               D0250         $114             $50                  $165                   7
Extraoral-Each Additional
                                   D0260          $12              $0                  $12                    1
Film
Bitewing-Single Film               D0270         $1,752           $806                $2,559                 283
Bitewings-Two Films                D0272        $27,787          $12,496             $40,283                1,713
Bitewings-Four Films               D0274        $287,029        $109,308             $396,337              11,041
Vertical Bitewings-7 To 8 Films    D0277         $4,583          $1,432               $6,015                 121
Post/Ant Lateral Skull/Facial
                                   D0290          $0               $0                   $0                    2
Film
Tomographic Survey                 D0322          $0               $0                   $0                    7
Panoramic Film                     D0330        $38,998          $17,339             $56,337                1,306
Cephalometric Film                 D0340          $0               $0                   $0                    4
Oral/Facial Images                 D0350          $0               $0                   $0                   29
Cone Beam CT-Craniofacial
                                   D0360          $0               $0                   $0                   10
Data Capture-Axial, Coronal,
                                                                                                 Section: Exhibit B
                                                                                               Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                            RT10-022
                                                                               Page 87 of 154

Sagittal
Cone Beam CT-Two
                                 D0362         $0               $0                $0                    2
Dimensional Image
Cone Beam CT-Three
                                 D0363         $0               $0                $0                    6
Doimensional Image
Bacteriologic Studies            D0415        $366             $227              $593                   6
Caries Susceptibility Tests      D0425         $0               $0                $0                    1
Adjunctive Pre-Diagnostic Test   D0431         $0               $0                $0                   299
Pulp Vitality Tests              D0460         $0               $0                $0                   73
Diagnostic Casts                 D0470        $678             $293              $971                  76
Diagnostic Photographs           D0471         $0               $0                $0                    2
accession of tissue, gross
examination, preparation and     D0472        $280              $0               $280                   1
transmission of written report
accession of tissue, gross and
microscopic examination,
                                 D0473        $978             $249             $1,227                 11
preparation and transmission
of written report
Microscopic Examination By
                                 D0474        $159              $0               $159                   1
Report
Special Stains for
                                 D0476        $100             $20               $120                   5
Microorganisms
Direct Immunofluorescence        D0482         $0               $0                $0                    1
Test/Lab Examinations            D0490         $0               $0                $0                    2
Histopathological Examination    D0501         $6               $0                $6                    4
other oral pathology
                                 D0502         $0               $0                $0                    1
procedures, by report
unspecified diagnostic
                                 D0999         $0               $0                $0                    4
procedure, by report
Prophylaxis-Adult                D1110      $1,118,810       $418,426         $1,537,236             17,316
Prophylaxis-Child                D1120        $403            $8,368            $8,771                 157
Topical Application of
                                 D1203         $0             $2,148            $2,148                 162
Fluoride-Child
Topical Application of
                                 D1204         $0               $0                $0                   854
Fluoride-Adult
Topical Fluoride Varnish         D1206         $0              $27               $27                   267
Nutritional Counseling For
                                 D1310         $0               $0                $0                    1
Control Of Dental Disease
Oral Hygiene Instructions        D1330         $0               $0                $0                   43
Training in Preventive Dental
                                 D1340         $0               $0                $0                    2
Care
Sealant-Per Tooth                D1351         $0             $2,841            $2,841                 48
amalgam - one surface,           D2140       $196,048         $87,919          $283,966               2,568
                                                                                           Section: Exhibit B
                                                                                         Form#RFP.02/03/10
                                   REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                         3300 North Central Avenue
                                 Retiree Dental Benefits Program                  Suite 1300
                                                                           Phoenix, Arizona 85012
                                           RT10-022
                                                                              Page 88 of 154

primary or permanent
amalgam - two surfaces,
                                D2150       $177,877         $81,640          $259,518               2,187
primary or permanent
amalgam - three surfaces,
                                D2160       $90,239          $38,932          $129,171                923
primary or permanent
amalgam - four or more
surfaces, primary or            D2161       $19,130          $11,095          $30,225                 208
permanent
resin-based composite - one
                                D2330       $211,740         $80,269          $292,008               2,172
surface, anterior
resin-based composite - two
                                D2331       $79,000          $31,888          $110,888                855
surfaces, anterior
resin-based composite - three
                                D2332       $35,494          $11,281          $46,775                 317
surfaces, anterior
Resin-Based Composite-Four
Or More Surfaces Or Involving   D2335       $63,918          $19,742          $83,661                 426
Incisal Angle (Anterior)
resin-based composite crown,
                                D2390         $0               $0                $0                    2
anterior
resin-based composite - one
                                D2391        $127              $0               $127                   1
surface, posterior
resin-based composite - two
                                D2392        $346              $0               $346                   1
surfaces, posterior
resin-based composite - one
                                D2394        $987             $793             $1,780                  9
surface, posterior-permanent
Inlay-Metallic-One Surface      D2510         $0              $155              $155                   1
Inlay-Metallic-Two Surfaces     D2520        $556             $194              $750                   5
Inlay-Metallic-Three Surfaces   D2530        $859              $0               $859                   3
Onlay-Metallic -Two Surfaces    D2542        $2,350           $529             $2,879                  7
Onlay-Metallic-Three Surfaces   D2543        $6,331          $3,906           $10,237                 27
Onlay-Metallic-Four Or More
                                D2544       $16,980          $5,292           $22,272                 58
Surfaces
Crown-Resin-Direct              D2710         $0               $0                $0                    2
Crown-Resin With High Noble
                                D2720        $874              $0               $874                   3
Metal
Crown-Porcelain/Ceramic
                                D2740       $82,964          $28,443          $111,407                189
Substrate
Crown-Porcelain Fused To
                                D2751      $1,078,345       $362,723         $1,441,068              3,220
Predominantly Base Metal
Crown-3/4 Cast Predominantly
                                D2781        $8,028          $2,310           $10,338                 27
Base Metal
Crown-Full Cast
                                D2791       $279,898         $97,788          $377,686                892
Predominantly Base Metal
Provisional Crown               D2799         $61              $0               $61                   15
                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                            RT10-022
                                                                               Page 89 of 154

Recement Inlay                   D2910        $292             $65               $357                  17
Recement Cast or PreFab
                                 D2915         $65             $68               $133                   4
Post/Core
Recement Crown                   D2920       $11,343          $3,484           $14,827                 659
Prefabricated Stainless Steel
                                 D2930         $0              $371              $371                   5
Crown-Primary Tooth
Prefabricated Stainless Steel
                                 D2931         $0               $0                $0                    2
Crown-Permanent Tooth
Prefabricated Resin Crown        D2932         $0              $272              $272                   5
Prefabricated Stainless Steel
                                 D2933         $0              $180              $180                   1
Crown With Resin Window
Sedative Filling                 D2940         $0               $0                $0                   81
core build-up, including any
                                 D2950       $126,426         $44,646          $171,072               2,250
pins
pin retention - per tooth, in
                                 D2951        $902             $178             $1,081                 36
addition to restoration
Cast Post And Core In
                                 D2952        $5,132          $3,408            $8,540                 71
Addition To Crown
Each Additional Post And
                                 D2953        $250              $0               $250                   1
Core
Prefabricated Post And Core In
                                 D2954       $44,921          $16,793          $61,714                 565
Addition To Crown
Post Removal Not In
Conjunction With Endodontic      D2955         $0               $0                $0                   16
Therapy
Each Additional Prefabricated
                                 D2957         $0               $0                $0                    1
Post-Same Tooth
Labial Veneer (Resin
                                 D2960        $853              $0               $853                   3
Laminate)-Chairside
Labial Veneer (Porcelain
                                 D2962       $11,012          $3,523           $14,535                 28
Laminate)-Laboratory
Temporary Crown (Fractured
                                 D2970         $0               $0                $0                    7
Tooth)
Additional Crown Procedures
                                 D2971         $0               $0                $0                   14
for Partial Denture Framework
Coping                           D2975         $0              $239              $239                   1
crown repair, by report          D2980        $2,285           $429             $2,713                 36
unspecified restorative
                                 D2999         $0               $0                $0                   26
procedure, by report
Pulp Cap - Direct (Excluding
                                 D3110         $0               $0                $0                   39
Final Restoration)
Pulp Cap - Indirect (Excluding
                                 D3120         $0               $0                $0                   70
Final Restoration)
Therapeutic Pulpotomy            D3220         $0              $345              $345                  15
                                                                                           Section: Exhibit B
                                                                                         Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                            RT10-022
                                                                               Page 90 of 154

(Excluding Final Restoration)
pulpal debridement, primary
                                 D3221         $0               $0                $0                   23
and permanent teeth
pulpal therapy (resorbable
filling) - posterior, primary
                                 D3240         $0              $195              $195                   1
tooth (excluding final
restoration)
Endodontic Therapy-Anterior
Tooth (Excluding Final           D3310       $110,015         $41,802          $151,816                342
Restoration)
Endodontic Therapy-Bicuspid
Tooth (Excluding Final           D3320       $165,788         $60,747          $226,535                438
Restoration)
Endodontic Therapy-Molar
                                 D3330       $323,473        $131,164          $454,637                677
(Excluding Final Restoration)
Treatment Of Root Canal
Obstruction; Non-Surgical        D3331         $0               $0                $0                   12
Access
Incomplete Endodontic
Therapy; Inoperable Or           D3332         $0               $0                $0                   27
Fractured Tooth
Retreatment Of Previous Root
                                 D3346       $11,078          $3,157           $14,236                 24
Canal Therapy-Anterior
Retreatment Of Previous Root
                                 D3347       $18,208          $5,838           $24,046                 33
Canal Therapy-Bicuspid
Retreatment Of Previous Root
                                 D3348       $33,036          $20,469          $53,505                 79
Canal Therapy-Molar
Apexification/Recalcification-
                                 D3351        $476             $50               $526                   3
Initial Visit
Apicoectomy/Periradicular
                                 D3410        $7,219           $770             $7,989                 18
Surgery-Anterior
Apicoectomy/Periradicular
                                 D3421        $7,341          $1,966            $9,307                 18
Surgery-Bicuspid (First Root)
Apicoectomy/Periradicular
                                 D3425       $10,318          $1,312           $11,630                 20
Surgery-Molar (First Root)
Apicoectomy/Periradicular
                                 D3426        $782             $360             $1,142                  7
Surgery-Each Additional Root
Retrograde Filling-Per Root      D3430        $3,728           $679             $4,407                 38
Root Amputation-Per Root         D3450        $3,872          $1,596            $5,468                 18
Hemisection (Including Any
Root Removal) Not Including      D3920        $938              $0               $938                   5
Root Canal Therapy
Canal and/or pulp chamber
                                 D3930         $0               $0                $0                    1
enlargement

                                                                                           Section: Exhibit B
                                                                                         Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                           3300 North Central Avenue
                                   Retiree Dental Benefits Program                  Suite 1300
                                                                             Phoenix, Arizona 85012
                                             RT10-022
                                                                                Page 91 of 154

Canal Preparation And Fitting
                                  D3950         $0               $0                $0                    6
Of Preformed Dowel Or Post
Bleaching                         D3960         $0               $0                $0                    1
unspecified endodontic
                                  D3999         $0               $0                $0                    4
procedure, by report
Gingivectomy Or
Gingivoplasty-Four Or More
                                  D4210        $1,744            $0              $1,744                  8
Contiguous Teeth Per
Quadrant
Gingivectomy Or
Gingivoplasty-One To Three        D4211        $3,840          $1,534            $5,374                 89
Teeth Per Quadrant
Gingival Curettage, Per
                                  D4220         $0               $0                $0                    1
Quadrant
gingival flap procedure,
including root planing - four
or more contiguous teeth or       D4240        $6,724          $2,606            $9,330                 16
bounded teeth spaces per
quadrant
gingival flap procedure,
including root planing - one to   D4241        $2,112          $4,951            $7,063                 19
three teeth, per quadrant
Clinical Crown Lengthening-
                                  D4249       $20,788          $5,715           $26,502                 74
Hard Tissue
Osseous Surgery (Including
Flap Entry And Closure)-Four
Or More Contiguous Teeth Or       D4260       $48,881          $13,573          $62,454                 95
Bounded Teeth Spaces Per
Quadrant
osseous surgery (including
flap entry and closure)-one to    D4261       $41,858          $18,549          $60,407                 82
three teeth, per quadrant
Bone Replacement Graft-First
                                  D4263        $8,600          $4,936           $13,536                 107
Site In Quadrant
Bone Replacement Graft-Each
                                  D4264         $0               $0                $0                    1
Additional Site In Quadrant
Guided Tissue Regeneration -
                                  D4266        $6,894           $996             $7,890                 47
Resorbable
Guided Tissue Regeneration -
                                  D4267        $1,523            $0              $1,523                  9
Non-Resorbable
Pedicle Soft Tissue Graft
                                  D4270        $533              $0               $533                   2
Procedure
Free Soft Tissue Graft
Procedure (Including Donor        D4271        $3,658           $962             $4,620                  9
Site Surgery)
                                                                                            Section: Exhibit B
                                                                                          Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                            3300 North Central Avenue
                                    Retiree Dental Benefits Program                  Suite 1300
                                                                              Phoenix, Arizona 85012
                                              RT10-022
                                                                                 Page 92 of 154

Subepithelial Connective
                                   D4273       $10,580          $2,829           $13,409                 23
Tissue Graft Procedures
Distal Or Proximal Wedge
                                   D4274        $562              $0               $562                   2
Procedure
Soft Tissue Allograft              D4275        $839            $1,304            $2,143                  4
Provisional Splinting -
                                   D4320        $351              $0               $351                   7
Intracoronal
Provisional Splinting -
                                   D4321        $894            $1,840            $2,734                 10
Extracoronal
Periodontal Scaling And Root
Planing-Four Or More
                                   D4341       $165,344         $49,207          $214,551                575
Contiguous Teeth Or Bounded
Teeth Spaces Per Quadrant
periodontal scaling and root
planing, one to three teeth, per   D4342       $37,999          $13,184          $51,183                 367
quadrant
Perio Scaling/Gingival
                                   D4345         $0               $0                $0                   36
Inflammation
Full Mouth Debridement             D4355         $0               $0                $0                   202
Periodontal therapy: re-
                                   D4380         $0               $0                $0                    1
evaluation
Chemotherapeutic Agents            D4381         $0               $0                $0                   369
Periodontal Maintenance            D4910       $181,048         $52,504          $233,552               3,014
unspecified periodontal
                                   D4999         $0               $0                $0                   120
procedure, by report
Complete Denture-Maxillary         D5110       $28,608          $8,198           $36,806                 91
Complete Denture-Mandibular        D5120       $10,811          $3,930           $14,741                 38
Immediate Denture-Maxillary        D5130       $28,787          $10,545          $39,331                 75
Immediate Denture-
                                   D5140        $5,127          $7,739           $12,866                 30
Mandibular
maxillary partial denture -
resin base (including any
                                   D5211        $6,310           $968             $7,278                 22
conventional clasps, rest and
teeth)
mandibular partial denture -
resin base (including any
                                   D5212        $4,020           $732             $4,752                 10
conventional clasps, rest and
teeth)
maxillary partial denture - cast
metal framework with resin
denture bases (including any       D5213       $63,831          $20,994          $84,825                 197
conventional clasps, rest and
teeth)
mandibular partial denture -       D5214       $65,328          $16,357          $81,685                 195
                                                                                             Section: Exhibit B
                                                                                           Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL               Arizona State Retirement System
                                                                         3300 North Central Avenue
                                  Retiree Dental Benefits Program                 Suite 1300
                                                                           Phoenix, Arizona 85012
                                            RT10-022
                                                                              Page 93 of 154

cast metal framework with
resin denture bases (including
any conventional clasps, rest
and teeth)
Maxillary Denture-Flexible
                                 D5225        $3,375          $1,291           $4,666                 13
Base
Mandibular Partial Denture-
                                 D5226        $3,617          $1,957           $5,574                 13
Flexible Base
Removable Unilateral Partial
Denture-One Piece Cast Metal     D5281        $463              $0              $463                   3
(Including Clasps And Teeth)
New clasps                       D5310         $0               $0               $0                    1
Adjust Complete Denture-
                                 D5410         $98             $18              $116                  12
Maxillary
Adjust Complete Denture-
                                 D5411         $38             $54              $91                    7
Mandibular
Adjust Partial Denture-
                                 D5421        $238             $13              $251                  14
Maxillary
Adjust Partial Denture-
                                 D5422        $104             $37              $141                  20
Mandibular
Repair Broken Complete
                                 D5510        $545             $263             $807                  23
Denture Base
Replace Missing Or Broken
Teeth-Complete Denture (Each     D5520        $925             $599            $1,525                 44
Tooth)
Repair Resin Denture Base        D5610        $642             $265             $907                  33
Repair Cast Framework            D5620        $474             $43              $516                   8
Repair Or Replace Broken
                                 D5630        $2,074           $429            $2,502                 43
Clasp
Replace Broken Teeth-Per
                                 D5640        $1,918          $1,064           $2,981                 56
Tooth
Add Tooth To Existing Partial
                                 D5650       $10,536          $4,385          $14,920                 186
Denture
Replace All Teeth And Acrylic
On Cast Metal Framework          D5671        $332              $0              $332                   1
(Mandibular)
Rebase Complete Maxillary
                                 D5710        $138             $221             $359                   3
Denture
Rebase Complete Mandibular
                                 D5711         $0              $175             $175                   1
Denture
Rebase Maxillary Partial
                                 D5720        $519              $0              $519                   2
Denture
Rebase Mandibular Partial
                                 D5721        $245             $200             $445                   3
Denture

                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL               Arizona State Retirement System
                                                                           3300 North Central Avenue
                                    Retiree Dental Benefits Program                 Suite 1300
                                                                             Phoenix, Arizona 85012
                                              RT10-022
                                                                                Page 94 of 154

Reline Complete Maxillary
                                   D5730        $1,461           $313            $1,774                 18
Denture (Chairside)
Reline Complete Mandibular
                                   D5731        $548             $144             $692                   8
Denture (Chairside)
Reline Maxillary Partial
                                   D5740        $313              $0              $313                   5
Denture (Chairside)
Reline Mandibular Partial
                                   D5741        $400             $150             $550                   6
Denture (Chairside)
Reline Complete Maxillary
                                   D5750        $8,469          $1,972          $10,441                 88
Denture (Laboratory)
Reline Complete Mandibular
                                   D5751        $2,750          $1,149           $3,899                 33
Denture (Laboratory)
Denture reline-upper or lower      D5755         $0               $0               $0                    1
Reline Maxillary Partial
                                   D5760        $935             $462            $1,397                 14
Denture (Laboratory)
Reline Mandibular Partial
                                   D5761        $1,193           $554            $1,747                 13
Denture (Laboratory)
Interim Complete Denture
                                   D5810         $0               $0               $0                    3
(Maxillary)
Interim Complete Denture
                                   D5811         $0               $0               $0                    1
(Mandibular)
Interim Partial Denture
                                   D5820         $0               $0               $0                   44
(Maxillary)
Interim Partial Denture
                                   D5821         $0               $0               $0                   28
(Mandibular)
tissue conditioning, maxillary     D5850        $487             $109             $596                  16
tissue conditioning,
                                   D5851        $220             $108             $327                  10
mandibular
overdenture - partial, by report   D5861         $0               $0               $0                    3
precision attachment, by report    D5862         $0               $0               $0                   15
Precision Attachment:
                                   D5867         $0               $0               $0                    4
Replacement Part
Modification Of Removable
                                   D5875         $0               $0               $0                    2
Prosthesis
Unspecified Removable
                                   D5899         $0               $0               $0                    8
Prosthodontic Procedure
Prosthesis-obturator               D5956         $0               $0               $0                    1
Surgical Stent                     D5982         $0               $0               $0                    6
Fluoride Gel Carrier               D5986         $0               $0               $0                    5
Unspecified Procedure              D5999         $0               $0               $0                    4
Surgical Placement Of Implant
                                   D6010         $0               $0               $0                   164
Body: Endosteal Implant
Abutment Placement Or
                                   D6020         $0               $0               $0                    2
Substitution: Endosteal
                                                                                            Section: Exhibit B
                                                                                          Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                           3300 North Central Avenue
                                   Retiree Dental Benefits Program                  Suite 1300
                                                                             Phoenix, Arizona 85012
                                             RT10-022
                                                                                Page 95 of 154

Implant
Implant/Abutment Supported
Removable Denture For             D6053         $0               $0                $0                    2
Completely Edentulous Arch
Implant/Abutment Supported
Removable Denture For             D6054         $0               $0                $0                    1
Partially Edentulous Arch
Prefabricated Abutment            D6056         $0               $0                $0                   62
Custom Abutment                   D6057         $0               $0                $0                   42
Abutment Supported Porcelain
Fused To Metal Crown              D6060        $879              $0               $879                  104
(Predom Inately Base Metal)
Abutment Supported Cast
Metal Crown (Predominantly        D6063         $0               $0                $0                    4
Base Metal)
abutment supported metal
crown (titanium, titanium         D6067         $0               $0                $0                   40
alloy, nigh noble metal)
Abutment Supported Retainer
For Porcelain Fused To Metal
                                  D6070         $0               $0                $0                   10
Fpd (Predominantly Base
Metal)
implant supported retainer for
porcelain fused to metal FPD
                                  D6076         $0               $0                $0                    2
(titanium, titanium alloy, nigh
noble metal)
Implant Maintenance
                                  D6080         $0               $0                $0                   12
Procedures
Recement Implant/Abutment
                                  D6092         $0               $0                $0                    3
Supported Crown
Recement Implant/Abutment
Supported Fixed Partial           D6093         $0               $0                $0                    2
Denture
repair implant abutment, by
                                  D6095         $0               $0                $0                    1
report
Abutment Supported Retainer
                                  D6190         $0               $0                $0                    5
Crown for FPD-Titanium
unspecified implant
                                  D6199         $0               $0                $0                    7
procedure, by report
Pontic-Cast Predominantly
                                  D6211        $6,330          $2,159            $8,489                 22
Base Metal
Pontic-Cast Predominantly
                                  D6241       $152,292         $55,094          $207,386                548
Base Metal
Pontic-Resin With                 D6251        $475             $212              $687                   3

                                                                                            Section: Exhibit B
                                                                                          Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                            3300 North Central Avenue
                                    Retiree Dental Benefits Program                  Suite 1300
                                                                              Phoenix, Arizona 85012
                                              RT10-022
                                                                                 Page 96 of 154

Predominantly Base Metal
Provisional Pontic                 D6253         $0               $0                $0                    2
Retainer-Cast Metal For Resin
                                   D6545        $2,395            $0              $2,395                  6
Bonded Fixed Prosthesis
onlay - cast predominantly
                                   D6612        $445              $0               $445                   1
base metal, two surfaces
onlay - cast predominantly
base metal, three or more          D6613         $0               $0                $0                    1
surfaces
Crown-Porcelain Fused To
                                   D6751       $251,993        $104,190          $356,184                591
Predominantly Base Metal
Crown-3/4 Cast Predominantly
                                   D6781        $660              $0               $660                   1
Noble Metal
Crown-Full Cast
                                   D6791        $6,842          $2,271            $9,113                 16
Predominantly Base Metal
Provisional Retainer Crown         D6793         $0               $0                $0                    1
Recement Fixed Partial
                                   D6930        $2,864           $968             $3,833                 86
Denture
Stress Breaker                     D6940         $0               $0                $0                    3
Precision Attachment               D6950         $0               $0                $0                    3
Cast Post And Core In
Addition To Fixed Partial          D6970         $0              $57               $57                    1
Denture Retainer
Prefabricated Post And Core In
Addition To Fixed Partial          D6972        $504             $158              $662                   6
Denture Retainer
core build up for retainer,
                                   D6973        $611             $44               $655                  17
including any pins
Coping - Metal                     D6975        $165              $0               $165                   1
Each Additional Prefabricated
                                   D6977         $0               $0                $0                    1
Post-Same Tooth
fixed partial denture repair, by
                                   D6980        $1,097            $0              $1,097                  9
report
unspecified, fixed
prosthodontic procedure, by        D6999         $0               $0                $0                   23
report
Extraction (Single Tooth)          D7110         $0               $0                $0                    8
Coronal Remnants-Deciduous
                                   D7111        $128             $56               $184                   2
Tooth
extraction, erupted tooth or
exposed root (elevation and/or     D7140       $115,884         $47,103          $162,987               1,106
forceps removal)
Surgical Removal Of Erupted
                                   D7210       $84,446          $24,801          $109,246                963
Tooth Requiring Elevation Of
                                                                                             Section: Exhibit B
                                                                                           Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                           3300 North Central Avenue
                                   Retiree Dental Benefits Program                  Suite 1300
                                                                             Phoenix, Arizona 85012
                                             RT10-022
                                                                                Page 97 of 154

Mucoperiosteal Flap And
Removal Of Bone And/Or
Section Of Tooth
Removal Of Impacted Tooth-
                                  D7220        $1,045          $2,068            $3,113                 21
Soft Tissue
Removal Of Impacted Tooth-
                                  D7230        $573            $4,770            $5,343                 28
Partially Bony
Removal Of Impacted Tooth-
                                  D7240        $1,259          $12,004          $13,263                 37
Completely Bony
Removal Of Impacted Tooth-
Completely Bony With
                                  D7241        $392            $1,843            $2,235                  6
Unusual Surgical
Complications
Surgical Removal Of Residual
Tooth Roots (Cutting              D7250       $13,959          $2,317           $16,276                 152
Procedure)
Oroantral Fistula Closure         D7260        $688              $0               $688                   1
Primary Closure Of A Sinus
                                  D7261         $0               $0                $0                    1
Perforation
Surgical Exposure Of Impacted
Or Unerupted Tooth To Aid In      D7281         $0              $154              $154                   1
Eruption
biopsy of oral tissue - hard
                                  D7285        $115              $0               $115                   2
(bone, tooth)
Biopsy Of Oral Tissue-Soft (All
                                  D7286        $1,534           $230             $1,764                 38
Others)
Brush Biopsy-Transepithelial
                                  D7288        $252             $148              $400                   6
Sample Collection
transseptal fiberotomy/supra
                                  D7291         $24              $0               $24                    1
crestal fiberotomy, by report
Surgical Placement:
Temporary Anchorage Device        D7294         $0              $170              $170                   1
Without Surgical Flap
Alveoloplasty In Conjunction
                                  D7310        $3,037          $1,379            $4,416                 31
With Extractions-Per Quadrant
Alveoloplasty In Conjunction
                                  D7311        $782              $0               $782                   3
with Extractions
Alveoloplasty Not In
Conjunction With Extractions-     D7320        $530              $0               $530                   4
Per Quadrant
Alveoloplasty Not In
                                  D7321         $0              $171              $171                   1
Conjunction with Extractions
Vestibuloplasty-Ridge
Extension (Secondary              D7340        $198              $0               $198                   1
Epithelialization)
                                                                                            Section: Exhibit B
                                                                                          Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL               Arizona State Retirement System
                                                                         3300 North Central Avenue
                                  Retiree Dental Benefits Program                 Suite 1300
                                                                           Phoenix, Arizona 85012
                                            RT10-022
                                                                              Page 98 of 154

Excision Of Benign Lesion Up
                                 D7410         $0               $0               $0                    5
To 1.25 Cm
Excision Of Benign Lesion
                                 D7411         $0               $0               $0                    1
Greater Than 1.25 Cm
excision of benign lesion,
                                 D7412         $0               $0               $0                    1
complicated
Removal Of Benign
Odontogenic Cyst Or Tumor-
                                 D7450         $0               $0               $0                    4
Lesion Diameter Up To 1.25
Cm
Removal Of Benign
Odontogenic Cyst Or Tumor-
                                 D7451         $0               $0               $0                    1
Lesion Diameter Greater Than
1.25 Cm
Destruction Of Lesion -
                                 D7465         $0               $0               $0                    1
Physical Or Chemical
Removal Of Lateral Exostosis-
                                 D7471        $662              $0              $662                   3
Maxilla Or Mandible
Removal Of Torus Palatinus       D7472        $1,184           $122            $1,306                  3
Removal Of Torus
                                 D7473        $1,190          $1,486           $2,676                  5
Mandibularis
Incision And Drainage Of
                                 D7510        $1,857           $345            $2,202                 17
Abscess-Intraoral Soft Tissue
Sequestrectomy For
                                 D7550         $0               $0               $0                    1
Osteomyelitis
Maxillary Sinusotomy For
                                 D7560         $0               $0               $0                    1
Removal Of Tooth Fragment
Malar And/Or Zygomatic Arch
                                 D7750         $0               $0               $0                    1
- Open Reduction
occlusal orthotic device, by
                                 D7880         $0               $0               $0                    7
report
Osteotomy - Mandibular Rami
                                 D7943         $0               $0               $0                    1
With Bone Graft
Osseoperiosteal Graft            D7950         $0               $0               $0                    7
Sinus Augmentation With
                                 D7951         $0               $0               $0                    4
Bone or Bone Substitutes
Bone Replacement Graft for
                                 D7953         $0               $0               $0                   89
Ridge Preservation-Per Site
Repair Of Maxillofacial Tissue
                                 D7955         $0               $0               $0                   11
Defect
Frenulectomy (Frenectomy Or
Frenotomy)-Separate              D7960        $395              $0              $395                   5
Procedure
Excision Of Hyperplastic
                                 D7970         $61              $0              $61                    2
Tissue-Per Arch
                                                                                          Section: Exhibit B
                                                                                        Form#RFP.02/03/10
                                   REQUEST FOR PROPOSAL               Arizona State Retirement System
                                                                        3300 North Central Avenue
                                 Retiree Dental Benefits Program                 Suite 1300
                                                                          Phoenix, Arizona 85012
                                           RT10-022
                                                                             Page 99 of 154

Excision Of Periocoronal
                                D7971         $14              $0              $14                    2
Gingiva
Synthetic Graft - Mandible      D7995         $0               $0               $0                    1
                                D7998         $0               $0               $0                    1
Unspecified Oral Surgery
                                D7999         $0               $0               $0                    4
Procedure By Report
Limited Ortho-Adolescent        D8040         $0               $0               $0                    1
Comprehensive Ortho-
                                D8070         $0               $0               $0                    1
Transitional
Comprehensive Ortho-
                                D8080         $0               $0               $0                    1
Adolescent
Comprehensive Ortho-Adult       D8090         $0               $0               $0                    4
Removable Appliance Therapy     D8210         $0               $0               $0                    3
Pre-Orthodontic Visit           D8660         $0               $0               $0                    1
Periodontic Orthodontic Visit   D8670         $0               $0               $0                    2
Orthodontic Retention           D8680         $0               $0               $0                    1
Orthodontic Treatment-2nd
                                D8690         $0               $0               $0                    1
Dentist
Repair Of Orthodontic
                                D8691         $0               $0               $0                    1
Appliances
Replacement Of Lost Or
                                D8692         $0               $0               $0                    1
Broken Retainer
Rebonding, Recementing
and/orRepair, as required, of   D8693         $0               $0               $0                    1
Fixed Retainers
unspecified orthodontic
                                D8999         $0               $0               $0                    1
procedure, by report
Palliative (Emergency)
Treatment Of Dental Pain-       D9110        $7,896          $3,006          $10,902                 248
Minor Procedure
Fixed Partial Denture
                                D9120         $55              $0              $55                   31
Sectioning
Miscellaneous Tax               D9199         $86             $96              $182                  14
Local Anesthesia                D9210         $0               $0               $0                    9
Local Anesthesia                D9215         $0               $0               $0                   20
General Anesthesia              D9220        $4,121          $4,593           $8,714                 141
Each Additional 15 Minutes      D9221        $746             $902            $1,648                 46
analgesia, anxiolysis,
                                D9230         $0               $0               $0                   165
inhalation of nitrous oxide
Intravenous Sedation            D9240         $0               $0               $0                    1
Intravenous Conscious
Sedation/Analgesia-First 30     D9241        $2,915          $2,412           $5,327                 86
Minutes

                                                                                         Section: Exhibit B
                                                                                       Form#RFP.02/03/10
                                    REQUEST FOR PROPOSAL                Arizona State Retirement System
                                                                          3300 North Central Avenue
                                  Retiree Dental Benefits Program                  Suite 1300
                                                                            Phoenix, Arizona 85012
                                            RT10-022
                                                                              Page 100 of 154

Intravenous Conscious
Sedation/Analgesia-Each          D9242        $200             $47               $247                   7
Additional 15 Minutes
Non-Intravenous Conscious
                                 D9248         $0               $0                $0                   12
Sedation
Consultation (Diagnostic
Service Provided By Dentist Or
Physician Other Than             D9310         $0               $0                $0                   144
Practitioner Providing
Treatment
House/Extended Care Facility
                                 D9410         $0               $0                $0                    2
Call
Hospital Call                    D9420         $0               $0                $0                    1
Office Visit During Regularly
                                 D9430         $0               $0                $0                   56
Scheduled Hours
Office Visit-After Hours         D9440         $0               $0                $0                   11
therapeutic drug injection, by
                                 D9610        $459             $251              $710                  36
report
Therapeutic Prenteral Drugs-2
                                 D9612        $130             $112              $242                   7
Administrations/Medications
other drugs and/or
                                 D9630         $0               $0                $0                   211
medicaments, by report
Application Of Desensitizing
                                 D9910         $0               $0                $0                   78
Medicament
Application Of Desensitizing
                                 D9911         $0               $0                $0                   15
Resin
Behavior Management              D9920         $0               $0                $0                    2
Treatment Of Complications-
                                 D9930         $0               $0                $0                    1
Post Surgical
occlusal guard, by report        D9940       $41,845          $17,162          $59,007                 240
Repair and/or Reline of
                                 D9942         $0               $0                $0                    5
Occlusal Guard
Occlusion Analysis-Mounted
                                 D9950         $0               $0                $0                    1
Case
Occlusal Adjustment - Limited    D9951        $1,626           $537             $2,163                 60
Occlusal Adjustment -
                                 D9952        $221             $594              $816                   6
Complete
Odontoplasty 1 - 2 Teeth         D9971         $0               $0                $0                    3
External Bleaching - Per Arch    D9972         $0               $0                $0                    8
External Bleaching - Per Tooth   D9973         $0               $0                $0                    2
Internal Bleaching - Per Tooth   D9974         $0               $0                $0                    4
Sterilization                    D9998         $0               $0                $0                   15
Unspecified Adjunctive           D9999         $0               $0                $0                   295

                                                                                           Section: Exhibit B
                                                                                         Form#RFP.02/03/10
                REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                           3300 North Central Avenue
             Retiree Dental Benefits Program                        Suite 1300
                                                             Phoenix, Arizona 85012
                       RT10-022
                                                               Page 101 of 154

Procedure
Interest    INTRS        $1,958           $754                   $2,712             1,791
              Totals      $6,886,526        $2,556,644              $9,443,171




                                                                         Section: Exhibit B
                                                                       Form#RFP.02/03/10
                                REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                           3300 North Central Avenue
                            Retiree Dental Benefits Program                         Suite 1300
                                                                             Phoenix, Arizona 85012
                                        RT10-022
                                                                               Page 102 of 154



                                              2009
                               Arizona State Retirement System
                    Freedom Advance (high option) / Freedom Basic (low option)
                                     Indemnity Experience


           No. of           Earned               Paid             PAID
          Insureds         Premiums             Claims             L/R

Jan-09     21,120              $1,042,267         $817,162         78.40%

Feb-09     21,245              $1,048,071         $813,147         77.59%

Mar-09     21,323              $1,053,907         $900,915         85.48%       80.50%        1st Q L/R

Apr-09     21,405              $1,055,079         $898,971         85.20%

May-09     21,475              $1,061,349         $832,997         78.48%

Jun-09     21,669              $1,079,430         $820,699         76.03%       80.19%        2nd Q L/R

 Jul-09    21,942              $1,094,730         $907,756         82.92%

Aug-09     22,172              $1,108,054         $814,195         73.48%

Sep-09     22,260              $1,101,171         $834,130         75.75%       79.22%        3rd Q L/R

Oct-09     22,335              $1,101,767         $919,191         83.43%

Nov-09     22,409              $1,111,693         $812,767         73.11%

Dec-09     22,487              $1,115,389         $925,585         82.98%
                       =                    =                 =
Total                       $12,972,907         $10,297,515        79.38%                     4th Q L/R

                       Note:          The above figures are unaudited.



                                                                                         Section: Exhibit B
                                                                                       Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL               Arizona State Retirement System
                                                                               3300 North Central Avenue
                                     Retiree Dental Benefits Program                    Suite 1300
                                                                                 Phoenix, Arizona 85012
                                                 RT10-022
                                                                                    Page 103 of 154




                                          Procedure Code Breakdown

                                    ARIZONA STATE RETIREMENT SYSTEM

                                 Claims Paid between 1/1/2009 and 12/31/2009

                                Procedure    Employee       Dependent Paid                             # of
 Paid Procedure Code Desc                                                    Total Paid Claims
                                  Code      Paid Claims        Claims                               Claimants

Unspecified                       99999         $0                $0                $0                   2
Adjustments                      ADJST       -$307,023         -$145,815         -$452,838             1,566
Initial Oral Exam                D0110          $0                $0                $0                   2
Periodic Oral Exam               D0120       $517,686          $201,486          $719,173              18,253
Limited Oral Evaluation          D0140        $73,267          $28,741           $102,008              4,386
Comprehensive Oral
                                 D0150        $69,634          $31,761           $101,394              2,809
Evaluation
Detailed Oral Evaluation-
                                 D0160         $998              $303             $1,301                 46
Problem Focused
Re-Evaluation-Problem
                                 D0170         $412              $106              $518                  70
Focused
Comprehensive Periodontal
                                 D0180        $11,999           $4,320            $16,318               523
Evaluation
Intraoral-Complete Series
                                 D0210       $122,089          $48,002           $170,091              2,805
(Including Bitewings)
Intraoral-Periapical First
                                 D0220       $104,728          $37,593           $142,320              8,004
Film
Intraoral-Periapical Each
                                 D0230        $35,487          $11,898            $47,385              3,210
Additional Film
Intraoral Occlusal Film          D0240         $104              $42               $146                  7
Extraoral-First Film             D0250         $68               $39               $107                  8
Extraoral-Each Additional
                                 D0260         $14                $0               $14                   1
Film
Bitewing-Single Film             D0270        $2,280             $672             $2,952                333
Bitewings-Two Films              D0272        $27,610          $11,262            $38,872              1,625
Bitewings-Four Films             D0274       $329,723          $128,656          $458,379              12,578
Vertical Bitewings-7 To 8
                                 D0277        $4,475            $1,540            $6,015                121
Films
Post/Ant Lateral Skull/Facial
                                 D0290          $0                $0                $0                   2
Film
Sialography                      D0310         $20               $20               $40                   2
temporomandibular joint          D0320          $0                $0                $0                   1

                                                                                               Section: Exhibit B
                                                                                             Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL          Arizona State Retirement System
                                                                         3300 North Central Avenue
                                    Retiree Dental Benefits Program               Suite 1300
                                                                           Phoenix, Arizona 85012
                                                RT10-022
                                                                             Page 104 of 154

arthrogram, including
injection
Other Tmj Films                  D0321        $0              $0              $0                   1
Tomographic Survey               D0322        $0              $0              $0                   4
Panoramic Film                   D0330      $41,848         $23,660        $65,508               1,472
Cephalometric Film               D0340        $0              $0              $0                   5
Oral/Facial Images               D0350        $0              $0              $0                   41
Cone Beam CT-Craniofacial
Data Capture-Axial, Coronal,     D0360        $0              $0              $0                   15
Sagittal
Cone Beam CT-Two
                                 D0362        $0              $0              $0                   1
Dimensional Image
Cone Beam CT-Three
                                 D0363        $0              $0              $0                   19
Doimensional Image
Genetic Test for
                                 D0421        $0              $0              $0                   2
Susceptibility
Adjunctive Pre-Diagnostic
                                 D0431        $0              $0              $0                  361
Test
Pulp Vitality Tests              D0460        $37             $0             $37                  107
Diagnostic Casts                 D0470       $542            $205            $747                  67
accession of tissue, gross and
microscopic examination,
preparation and                  D0473       $790             $0             $790                  8
transmission of written
report
Microscopic Examination By
                                 D0474       $205             $0             $205                  1
Report
Decalcification Procedure        D0475       $640             $0             $640                  1
Special Stains for
                                 D0476        $80             $0             $80                   3
Microorganisms
Test/Lab Examinations            D0490        $0              $0              $0                   2
other oral pathology
                                 D0502        $0              $0              $0                   4
procedures, by report
unspecified diagnostic
                                 D0999        $0              $0              $0                   5
procedure, by report
Prophylaxis-Adult                D1110     $1,248,566       $485,659      $1,734,224             19,093
Prophylaxis-Child                D1120       $553            $8,465         $9,017                157
Topical Application of
                                 D1203        $0             $1,941         $1,941                143
Fluoride-Child
Topical Application of
                                 D1204        $0              $68            $68                  953
Fluoride-Adult
Topical Fluoride Varnish         D1206        $0             $193            $193                 381
Nutritional Counseling For       D1310        $0              $0              $0                   5

                                                                                         Section: Exhibit B
                                                                                       Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                       3300 North Central Avenue
                                   Retiree Dental Benefits Program              Suite 1300
                                                                         Phoenix, Arizona 85012
                                               RT10-022
                                                                           Page 105 of 154

Control Of Dental Disease
Tobacco Counseling For The
Control And Prevention Of       D1320        $0              $0             $0                  1
Oral Disease
Oral Hygiene Instructions       D1330        $0              $0             $0                 110
Training in Preventive
                                D1340        $0              $0             $0                  5
Dental Care
Sealant-Per Tooth               D1351        $0            $3,080         $3,080                63
Re-Cementation Of Space
                                D1550        $0              $50           $50                  1
Maintainer
Preventive procedure;
                                D1999        $0              $0             $0                  1
unspecified
amalgam - one surface,
                                D2140      $206,058        $94,851       $300,909             2,775
primary or permanent
amalgam - two surfaces,
                                D2150      $198,676        $95,965       $294,641             2,375
primary or permanent
amalgam - three surfaces,
                                D2160      $104,158        $51,519       $155,677             1,098
primary or permanent
amalgam - four or more
surfaces, primary or            D2161      $31,313         $10,190       $41,504               253
permanent
resin-based composite - one
                                D2330      $228,788        $82,962       $311,750             2,363
surface, anterior
resin-based composite - two
                                D2331      $80,440         $26,581       $107,021              820
surfaces, anterior
resin-based composite - three
                                D2332      $43,671         $15,449       $59,120               391
surfaces, anterior
Resin-Based Composite-Four
Or More Surfaces Or
                                D2335      $71,221         $23,028       $94,248               538
Involving Incisal Angle
(Anterior)
resin-based composite - one
                                D2391        $0              $0             $0                  1
surface, posterior
resin-based composite - two
                                D2392       $290             $0            $290                 2
surfaces, posterior
resin-based composite - three
                                D2393       $246            $121           $367                 3
surfaces, posterior
resin-based composite - one
                                D2394       $1,674           $0           $1,674                7
surface, posterior-permanent
Inlay-Metallic-Two Surfaces     D2520        $0             $392           $392                 2
Inlay-Metallic-Three Surfaces   D2530       $456             $26           $481                 6
Onlay-Metallic -Two
                                D2542       $950             $0            $950                 3
Surfaces
Onlay-Metallic-Three            D2543      $13,706         $2,511        $16,217                41

                                                                                      Section: Exhibit B
                                                                                    Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL          Arizona State Retirement System
                                                                        3300 North Central Avenue
                                   Retiree Dental Benefits Program               Suite 1300
                                                                          Phoenix, Arizona 85012
                                               RT10-022
                                                                            Page 106 of 154

Surfaces
Onlay-Metallic-Four Or
                                D2544      $14,500          $4,898        $19,398                 51
More Surfaces
Onlay-Porcelain/Ceramic-
                                D2644        $0              $0              $0                   1
Four Or More Surfaces
Crown-Resin With High
                                D2720        $5             $525            $530                  2
Noble Metal
Crown-Porcelain/Ceramic
                                D2740      $85,760         $46,046        $131,806               212
Substrate
Crown-Porcelain Fused To
                                D2750       $170             $0             $170                  1
High Noble Metal
Crown-Porcelain Fused To
                                D2751     $1,129,192       $434,941      $1,564,133             3,420
Predominantly Base Metal
Crown-3/4 Cast
                                D2781      $13,039          $1,614        $14,653                 35
Predominantly Base Metal
Crown-Full Cast High Noble
                                D2790        $0              $31            $31                   1
Metal
Crown-Full Cast
                                D2791      $337,198        $116,480       $453,679              1,050
Predominantly Base Metal
Provisional Crown               D2799        $0              $61            $61                   9
Recement Inlay                  D2910       $317            $198            $515                  21
Recement Cast or PreFab
                                D2915        $59            $166            $225                  9
Post/Core
Recement Crown                  D2920      $12,687          $4,768        $17,455                737
Prefabricated Stainless Steel
                                D2930        $0             $849            $849                  4
Crown-Primary Tooth
Prefabricated Stainless Steel
                                D2931        $0              $0              $0                   6
Crown-Permanent Tooth
Prefabricated Resin Crown       D2932        $0              $0              $0                   5
Sedative Filling                D2940        $0              $0              $0                   92
core build-up, including any
                                D2950      $150,023        $56,532        $206,555              2,568
pins
pin retention - per tooth, in
                                D2951       $754            $396           $1,150                 36
addition to restoration
Cast Post And Core In
                                D2952       $8,256          $3,474        $11,730                 81
Addition To Crown
Each Additional Post And
                                D2953        $93            $101            $194                  2
Core
Prefabricated Post And Core
                                D2954      $46,977         $17,180        $64,157                575
In Addition To Crown
Post Removal Not In
Conjunction With                D2955        $0              $0              $0                   12
Endodontic Therapy
Each Additional                 D2957        $0              $0              $0                   2
                                                                                        Section: Exhibit B
                                                                                      Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL          Arizona State Retirement System
                                                                        3300 North Central Avenue
                                   Retiree Dental Benefits Program               Suite 1300
                                                                          Phoenix, Arizona 85012
                                               RT10-022
                                                                            Page 107 of 154

Prefabricated Post-Same
Tooth
Labial Veneer (Resin
                                D2960       $263             $0             $263                 3
Laminate)-Chairside
Labial Veneer (Resin
                                D2961        $0              $0              $0                  1
Laminate)-Laboratory
Labial Veneer (Porcelain
                                D2962      $11,923          $338          $12,261                30
Laminate)-Laboratory
Temporary Crown
                                D2970        $0              $0              $0                  18
(Fractured Tooth)
Additional Crown
Procedures for Partial          D2971        $0              $0              $0                  9
Denture Framework
crown repair, by report         D2980       $2,657          $778           $3,435                47
unspecified restorative
                                D2999        $0              $0              $0                  33
procedure, by report
Pulp Cap - Direct (Excluding
                                D3110        $0              $0              $0                  33
Final Restoration)
Pulp Cap - Indirect
                                D3120        $0              $0              $0                  86
(Excluding Final Restoration)
Therapeutic Pulpotomy
                                D3220        $0             $894            $894                 13
(Excluding Final Restoration)
pulpal debridement, primary
                                D3221        $0              $0              $0                  28
and permanent teeth
Endodontic Therapy-
Anterior Tooth (Excluding       D3310      $114,527        $37,884        $152,411              331
Final Restoration)
Endodontic Therapy-
Bicuspid Tooth (Excluding       D3320      $169,303        $62,441        $231,743              457
Final Restoration)
Endodontic Therapy-Molar
                                D3330      $371,081        $126,955       $498,036              739
(Excluding Final Restoration)
Treatment Of Root Canal
Obstruction; Non-Surgical       D3331        $0              $0              $0                  23
Access
Incomplete Endodontic
Therapy; Inoperable Or          D3332       $181             $0             $181                 29
Fractured Tooth
Retreatment Of Previous
                                D3346      $10,794          $8,640        $19,434                34
Root Canal Therapy-Anterior
Retreatment Of Previous
Root Canal Therapy-             D3347      $11,635          $9,764        $21,399                37
Bicuspid
Retreatment Of Previous
                                D3348      $45,554         $17,698        $63,253                88
Root Canal Therapy-Molar
                                                                                       Section: Exhibit B
                                                                                     Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                        3300 North Central Avenue
                                    Retiree Dental Benefits Program              Suite 1300
                                                                          Phoenix, Arizona 85012
                                               RT10-022
                                                                            Page 108 of 154

Apexification/Recalcification-
                                 D3351       $509             $0            $509                3
Initial Visit
Apexification/Recalcification-
Interim Medication               D3352        $0              $50           $50                 1
Replacement
Apicoectomy/Periradicular
                                 D3410      $7,296          $4,740        $12,036               23
Surgery-Anterior
Apicoectomy/Periradicular
                                 D3421      $8,869           $651          $9,519               17
Surgery-Bicuspid (First Root)
Apicoectomy/Periradicular
                                 D3425      $13,136         $5,133        $18,269               25
Surgery-Molar (First Root)
Apicoectomy/Periradicular
Surgery-Each Additional          D3426      $1,262           $719          $1,981               13
Root
Retrograde Filling-Per Root      D3430      $5,842          $2,785         $8,627               52
Root Amputation-Per Root         D3450      $4,088          $1,178         $5,266               15
Hemisection (Including Any
Root Removal) Not
                                 D3920      $1,143           $614          $1,757               9
Including Root Canal
Therapy
Canal Preparation And
Fitting Of Preformed Dowel       D3950        $0              $0             $0                 2
Or Post
Bleaching                        D3960        $0              $0             $0                 1
unspecified endodontic
                                 D3999        $0              $0             $0                 9
procedure, by report
Gingivectomy Or
Gingivoplasty-Four Or More
                                 D4210       $553             $0            $553                5
Contiguous Teeth Per
Quadrant
Gingivectomy Or
Gingivoplasty-One To Three       D4211      $3,722          $2,246         $5,969               76
Teeth Per Quadrant
Crown Exposure-4+
                                 D4230        $0              $0             $0                 1
Contiguous Teeth/Quadrant
gingival flap procedure,
including root planing - four
or more contiguous teeth or      D4240      $3,386            $0           $3,386               11
bounded teeth spaces per
quadrant
gingival flap procedure,
including root planing - one     D4241      $5,505          $2,094         $7,598               29
to three teeth, per quadrant
Apically Positioned Flap         D4245       $492             $0            $492                2

                                                                                      Section: Exhibit B
                                                                                    Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                      3300 North Central Avenue
                                  Retiree Dental Benefits Program              Suite 1300
                                                                        Phoenix, Arizona 85012
                                              RT10-022
                                                                          Page 109 of 154

Clinical Crown Lengthening-
                               D4249      $17,717         $5,406        $23,123                58
Hard Tissue
Osseous Surgery (Including
Flap Entry And Closure)-
Four Or More Contiguous        D4260      $38,955         $17,692       $56,646                97
Teeth Or Bounded Teeth
Spaces Per Quadrant
osseous surgery (including
flap entry and closure)-one    D4261      $52,563         $18,816       $71,379               114
to three teeth, per quadrant
Bone Replacement Graft-
                               D4263       $9,294         $2,759        $12,054                97
First Site In Quadrant
Bone Replacement Graft-
Each Additional Site In        D4264        $0              $0             $0                  1
Quadrant
Guided Tissue Regeneration
                               D4266       $5,825         $2,192         $8,017                49
- Resorbable
Guided Tissue Regeneration
                               D4267       $1,894         $1,018         $2,912                18
- Non-Resorbable
Surgical Revision Procedure    D4268        $0              $0             $0                  1
Pedicle Soft Tissue Graft
                               D4270        $0              $0             $0                  1
Procedure
Free Soft Tissue Graft
Procedure (Including Donor     D4271       $5,695         $3,806         $9,502                12
Site Surgery)
Subepithelial Connective
                               D4273      $15,491         $7,566        $23,057                27
Tissue Graft Procedures
Distal Or Proximal Wedge
                               D4274       $2,209           $0           $2,209                6
Procedure
Soft Tissue Allograft          D4275        $0              $0             $0                  1
Provisional Splinting -
                               D4320       $1,118         $1,051         $2,170                12
Intracoronal
Provisional Splinting -
                               D4321       $2,558          $326          $2,884                15
Extracoronal
Periodontal Scaling And
Root Planing-Four Or More
Contiguous Teeth Or            D4341      $174,746        $63,345       $238,091              628
Bounded Teeth Spaces Per
Quadrant
periodontal scaling and root
planing, one to three teeth,   D4342      $46,809         $16,746       $63,555               436
per quadrant
Perio Scaling/Gingival
                               D4345        $0              $0             $0                  34
Inflammation

                                                                                     Section: Exhibit B
                                                                                   Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                       3300 North Central Avenue
                                   Retiree Dental Benefits Program              Suite 1300
                                                                         Phoenix, Arizona 85012
                                               RT10-022
                                                                           Page 110 of 154

Full Mouth Debridement          D4355        $0              $0             $0                 193
Chemotherapeutic Agents         D4381        $0              $0             $0                 484
Periodontal Maintenance         D4910      $209,612        $63,141       $272,753             3,405
Unscheduled Dressing
Change (By Someone Other        D4920        $0              $0             $0                  1
Than Treating Dentist)
unspecified periodontal
                                D4999       $128             $0            $128                154
procedure, by report
Complete Denture-Maxillary      D5110      $28,094         $12,339       $40,433                91
Complete Denture-
                                D5120      $13,572         $7,265        $20,836                49
Mandibular
Immediate Denture-
                                D5130      $29,658         $10,336       $39,994                76
Maxillary
Immediate Denture-
                                D5140      $14,716         $3,410        $18,126                37
Mandibular
maxillary partial denture -
resin base (including any
                                D5211       $5,723         $2,024         $7,747                24
conventional clasps, rest and
teeth)
mandibular partial denture -
resin base (including any
                                D5212       $3,855          $648          $4,502                13
conventional clasps, rest and
teeth)
maxillary partial denture -
cast metal framework with
resin denture bases             D5213      $58,499         $19,398       $77,897               177
(including any conventional
clasps, rest and teeth)
mandibular partial denture -
cast metal framework with
resin denture bases             D5214      $55,695         $20,185       $75,880               183
(including any conventional
clasps, rest and teeth)
Maxillary Denture-Flexible
                                D5225       $2,831         $1,248         $4,079                17
Base
Mandibular Partial Denture-
                                D5226       $3,373         $1,114         $4,486                14
Flexible Base
Removable Unilateral Partial
Denture-One Piece Cast
                                D5281       $1,716          $179          $1,895                9
Metal (Including Clasps And
Teeth)
Adjust Complete Denture-
                                D5410        $87             $70           $157                 12
Maxillary
Adjust Complete Denture-        D5411       $142             $10           $152                 13

                                                                                      Section: Exhibit B
                                                                                    Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                    3300 North Central Avenue
                                Retiree Dental Benefits Program              Suite 1300
                                                                      Phoenix, Arizona 85012
                                           RT10-022
                                                                        Page 111 of 154

Mandibular
Adjust Partial Denture-
                             D5421       $136             $38           $174                13
Maxillary
Adjust Partial Denture-
                             D5422       $153            $141           $294                27
Mandibular
Repair Broken Complete
                             D5510      $1,324           $697          $2,021               34
Denture Base
Replace Missing Or Broken
Teeth-Complete Denture       D5520      $1,458           $932          $2,390               36
(Each Tooth)
Repair Resin Denture Base    D5610      $1,682           $301          $1,983               35
Repair Cast Framework        D5620       $499            $113           $612                9
Repair Or Replace Broken
                             D5630      $2,890           $811          $3,700               47
Clasp
Replace Broken Teeth-Per
                             D5640      $2,709           $606          $3,315               61
Tooth
Add Tooth To Existing
                             D5650      $12,384         $4,289        $16,673              201
Partial Denture
Rebase Complete Maxillary
                             D5710       $102             $0            $102                2
Denture
Rebase Complete
                             D5711        $0             $110           $110                1
Mandibular Denture
Rebase Maxillary Partial
                             D5720       $50              $0            $50                 1
Denture
Rebase Mandibular Partial
                             D5721       $310            $261           $571                3
Denture
Reline Complete Maxillary
                             D5730      $1,216           $329          $1,545               22
Denture (Chairside)
Reline Complete Mandibular
                             D5731       $334             $70           $404                10
Denture (Chairside)
Reline Maxillary Partial
                             D5740       $489             $48           $537                7
Denture (Chairside)
Reline Mandibular Partial
                             D5741       $266             $58           $323                8
Denture (Chairside)
Reline Complete Maxillary
                             D5750      $6,865          $2,910         $9,775               83
Denture (Laboratory)
Reline Complete Mandibular
                             D5751      $3,376           $739          $4,115               37
Denture (Laboratory)
Denture reline-upper or
                             D5755        $0              $0             $0                 1
lower
Reline Maxillary Partial
                             D5760      $1,484           $426          $1,910               12
Denture (Laboratory)
Reline Mandibular Partial
                             D5761      $2,312          $1,150         $3,462               22
Denture (Laboratory)

                                                                                  Section: Exhibit B
                                                                                Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                     3300 North Central Avenue
                                 Retiree Dental Benefits Program              Suite 1300
                                                                       Phoenix, Arizona 85012
                                            RT10-022
                                                                         Page 112 of 154

Interim Complete Denture
                              D5810        $0              $0             $0                 3
(Maxillary)
Interim Complete Denture
                              D5811        $0              $0             $0                 2
(Mandibular)
Interim Partial Denture
                              D5820        $0              $0             $0                 71
(Maxillary)
Interim Partial Denture
                              D5821        $0              $0             $0                 16
(Mandibular)
tissue conditioning,
                              D5850       $589            $195           $783                15
maxillary
tissue conditioning,
                              D5851       $454             $24           $478                9
mandibular
overdenture - complete, by
                              D5860        $0              $0             $0                 4
report
overdenture - partial, by
                              D5861        $0              $0             $0                 1
report
precision attachment, by
                              D5862        $0              $0             $0                 14
report
Precision Attachment:
                              D5867        $0              $0             $0                 6
Replacement Part
Modification Of Removable
                              D5875        $0              $0             $0                 4
Prosthesis
Unspecified Removable
                              D5899        $0              $0             $0                 3
Prosthodontic Procedure
obturator prosthesis.
                              D5933        $0              $0             $0                 1
modification
Surgical Stent                D5982        $0              $0             $0                 11
Fluoride Gel Carrier          D5986        $0              $0             $0                 5
Unspecified Procedure         D5999        $0              $0             $0                 7
Surgical Placement Of
Implant Body: Endosteal       D6010        $0              $0             $0                215
Implant
Surgical Placement of
Interim Implant Body-
                              D6012        $0              $0             $0                 1
Transitional Prosthesis;
Endosteal Implant
Surgical Placement-Eposteal
                              D6040        $0              $0             $0                 2
Implant
Surgical Placement:
                              D6050        $0              $0             $0                 1
Transosteal Implant
Implant/Abutment
Supported Removable
                              D6053        $0              $0             $0                 2
Denture For Completely
Edentulous Arch

                                                                                   Section: Exhibit B
                                                                                 Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                      3300 North Central Avenue
                                  Retiree Dental Benefits Program              Suite 1300
                                                                        Phoenix, Arizona 85012
                                            RT10-022
                                                                          Page 113 of 154

Prefabricated Abutment         D6056       $0               $0             $0                 75
Custom Abutment                D6057       $0               $0             $0                 61
Abutment Supported
Porcelain Fused To Metal
                               D6060       $0               $0             $0                128
Crown (Predom Inately Base
Metal)
Abutment Supported Cast
Metal Crown                    D6063       $0               $0             $0                 6
(Predominantly Base Metal)
abutment supported metal
crown (titanium, titanium      D6067       $0               $0             $0                 42
alloy, nigh noble metal)
Abutment Supported
Retainer For Porcelain Fused
                               D6070       $0               $0             $0                 6
To Metal Fpd
(Predominantly Base Metal)
Abutment Supported
Retainer For Cast Metal Fpd    D6073       $0               $0             $0                 2
(Predominantly Base Metal)
implant supported retainer
for porcelain fused to metal
                               D6076       $0               $0             $0                 1
FPD (titanium, titanium
alloy, nigh noble metal)
Implant/Abutment
Supported Fixed Denture For    D6078       $0               $0             $0                 2
Completely Edentulous Arch
Implant Maintenance
                               D6080       $0               $0             $0                 10
Procedures
Replacement of Semi-
Precision or Precision
Attachment of
                               D6091       $0               $0             $0                 3
Implant/Abutment
Supported Prosthesis, per
Attachement
Recement Implant/Abutment
                               D6092       $0               $0             $0                 1
Supported Crown
Recement Implant/Abutment
Supported Fixed Partial        D6093       $0               $0             $0                 1
Denture
repair implant abutment, by
                               D6095       $0               $0             $0                 2
report
implant removal, by report     D6100       $0               $0             $0                 7
Abutment Supported
Retainer Crown for FPD-        D6190       $0               $0             $0                 4
Titanium
                                                                                    Section: Exhibit B
                                                                                  Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                       3300 North Central Avenue
                                   Retiree Dental Benefits Program              Suite 1300
                                                                         Phoenix, Arizona 85012
                                               RT10-022
                                                                           Page 114 of 154

unspecified implant
                                D6199        $0              $0             $0                  9
procedure, by report
Pontic-Cast Predominantly
                                D6211       $2,394         $1,551         $3,945                19
Base Metal
Pontic-Porcelain Fused To
                                D6240        $0              $0             $0                  1
High Noble Metal
Pontic-Cast Predominantly
                                D6241      $139,932        $45,525       $185,456              530
Base Metal
Pontic-Resin With
                                D6251        $0            $1,130         $1,130                3
Predominantly Base Metal
Provisional Pontic              D6253        $0              $0             $0                  2
Retainer-Cast Metal For
Resin Bonded Fixed              D6545       $2,330           $0           $2,330                8
Prosthesis
inlay - cast predominantly
                                D6604       $106            $187           $293                 3
base metal, two surfaces
onlay - cast predominantly
base metal, three or more       D6613        $0              $0             $0                  2
surfaces
Crown-Indirect Resin Based
                                D6710        $0              $0             $0                  1
Composite
Crown-Porcelain Fused To
                                D6751      $266,122        $93,046       $359,167              580
Predominantly Base Metal
Crown-Full Cast
                                D6791       $2,040         $2,315         $4,355                9
Predominantly Base Metal
Provisional Retainer Crown      D6793        $0              $0             $0                  3
Recement Fixed Partial
                                D6930       $3,095          $814          $3,908               102
Denture
Stress Breaker                  D6940        $0              $0             $0                  2
Precision Attachment            D6950        $0              $0             $0                  7
Prefabricated Post And Core
In Addition To Fixed Partial    D6972       $450            $270           $720                 10
Denture Retainer
core build up for retainer,
                                D6973       $411            $240           $651                 9
including any pins
Coping - Metal                  D6975        $0              $0             $0                  1
fixed partial denture repair,
                                D6980       $418            $332           $749                 10
by report
unspecified, fixed
prosthodontic procedure, by     D6999        $0              $0             $0                  18
report
Extraction (Single Tooth)       D7110        $0              $0             $0                  10
Coronal Remnants-
                                D7111       $305            $338           $643                 9
Deciduous Tooth

                                                                                      Section: Exhibit B
                                                                                    Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                      3300 North Central Avenue
                                  Retiree Dental Benefits Program              Suite 1300
                                                                        Phoenix, Arizona 85012
                                              RT10-022
                                                                          Page 115 of 154

extraction, erupted tooth or
exposed root (elevation        D7140      $121,701        $47,338       $169,039             1,127
and/or forceps removal)
Surgical Removal Of Erupted
Tooth Requiring Elevation
Of Mucoperiosteal Flap And     D7210      $104,946        $36,253       $141,199             1,179
Removal Of Bone And/Or
Section Of Tooth
Removal Of Impacted Tooth-
                               D7220       $653           $1,736         $2,388                27
Soft Tissue
Removal Of Impacted Tooth-
                               D7230       $833           $6,377         $7,210                42
Partially Bony
Removal Of Impacted Tooth-
                               D7240       $1,749         $12,135       $13,884                51
Completely Bony
Removal Of Impacted Tooth-
Completely Bony With
                               D7241       $762            $249          $1,011                6
Unusual Surgical
Complications
Surgical Removal Of
Residual Tooth Roots           D7250      $15,491         $2,900        $18,391               161
(Cutting Procedure)
Primary Closure Of A Sinus
                               D7261        $0              $0             $0                  1
Perforation
Surgical Access Of An
                               D7280        $0             $200           $200                 1
Unerupted Tooth
Placement of Device to
Facilitate Eruption of         D7283        $0              $0             $0                  1
Impacted Tooth
biopsy of oral tissue - hard
                               D7285       $326             $0            $326                 5
(bone, tooth)
Biopsy Of Oral Tissue-Soft
                               D7286       $2,196          $196          $2,391                26
(All Others)
Brush Biopsy-Transepithelial
                               D7288       $297            $111           $408                 10
Sample Collection
Surgical Placement:
Temporary Anchorage            D7294        $0              $0             $0                  1
Device Without Surgical Flap
Alveoloplasty In Conjunction
With Extractions-Per           D7310       $2,088          $818          $2,907                25
Quadrant
Alveoloplasty In Conjunction
                               D7311       $183            $255           $437                 5
with Extractions
Alveoloplasty Not In
Conjunction With               D7320       $826            $184          $1,009                9
Extractions-Per Quadrant
                                                                                     Section: Exhibit B
                                                                                   Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                        3300 North Central Avenue
                                    Retiree Dental Benefits Program              Suite 1300
                                                                          Phoenix, Arizona 85012
                                               RT10-022
                                                                            Page 116 of 154

Alveoloplasty Not In
                                 D7321        $8              $0             $8                 1
Conjunction with Extractions
Vestibuloplasty-Ridge
Extension (Secondary             D7340       $815            $390          $1,205               3
Epithelialization)
vestibuloplasty - ridge
extension (including soft
tissue grafts, muscle
reattachment, revision of soft
                                 D7350       $283             $0            $283                2
tissue attachment and
management of
hypertrophied and
hyperplastic tissue)
Excision Of Benign Lesion
                                 D7410        $0              $0             $0                 6
Up To 1.25 Cm
Removal Of Benign
Odontogenic Cyst Or
                                 D7450        $0              $0             $0                 1
Tumor-Lesion Diameter Up
To 1.25 Cm
Removal Of Benign
Odontogenic Cyst Or
                                 D7451        $0              $0             $0                 1
Tumor-Lesion Diameter
Greater Than 1.25 Cm
Removal Of Benign
Nonodontogenic Cyst Or
                                 D7460        $0              $0             $0                 1
Tumor-Lesion Diameter Up
To 1.25 Cm
Removal Of Benign
Nonodontogenic Cyst Or
                                 D7461        $0              $0             $0                 2
Tumor-Lesion Diameter
Greater Than 1.25 Cm
Destruction Of Lesion -
                                 D7465        $0              $0             $0                 1
Physical Or Chemical
Removal Of Lateral
Exostosis-Maxilla Or             D7471      $1,290           $151          $1,441               7
Mandible
Removal Of Torus Palatinus       D7472       $615             $0            $615                1
Removal Of Torus
                                 D7473      $1,350            $0           $1,350               4
Mandibularis
Surgical Reduction Of
                                 D7485       $175             $0            $175                1
Osseous Tuberosity
Incision And Drainage Of
                                 D7510      $1,432           $288          $1,720               13
Abscess-Intraoral Soft Tissue
Incision and Drainage of
                                 D7511       $35              $0            $35                 1
Abscess-Intraoral Soft
                                                                                      Section: Exhibit B
                                                                                    Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                      3300 North Central Avenue
                                  Retiree Dental Benefits Program              Suite 1300
                                                                        Phoenix, Arizona 85012
                                             RT10-022
                                                                          Page 117 of 154

Tissue-Complicated
Removal Of Reaction
                               D7540       $113             $0            $113                1
Producing Foreign Body
Sequestrectomy For
                               D7550        $0              $0             $0                 1
Osteomyelitis
occlusal orthotic device, by
                               D7880        $0              $0             $0                 10
report
Unspecified Tmj Therapy By
                               D7899        $0              $0             $0                 1
Report
Suture Of Recent Small
                               D7910        $0              $0             $0                 2
Wound Up To 5 Cm
Osseoperiosteal Graft          D7950        $0              $0             $0                 8
Sinus Augmentation With
                               D7951        $0              $0             $0                 10
Bone or Bone Substitutes
Bone Replacement Graft for
                               D7953        $0              $0             $0                137
Ridge Preservation-Per Site
Repair Of Maxillofacial
                               D7955        $0              $0             $0                 7
Tissue Defect
Frenulectomy (Frenectomy
Or Frenotomy)-Separate         D7960       $292            $106           $398                4
Procedure
Excision Of Hyperplastic
                               D7970        $0             $100           $100                2
Tissue-Per Arch
Excision Of Periocoronal
                               D7971       $97              $22           $118                4
Gingiva
Surgical Reduction Of
                               D7972        $5              $0             $5                 1
Fibrous Tuberosity
Synthetic Graft - Mandible     D7995        $0              $0             $0                 4
Unspecified Oral Surgery
                               D7999        $0              $0             $0                 11
Procedure By Report
Limited Ortho-Adolescent       D8040        $0              $0             $0                 3
Interceptive Ortho-Primary     D8050        $0              $0             $0                 1
Comprehensive Ortho-
                               D8070        $0              $0             $0                 2
Transitional
Comprehensive Ortho-
                               D8080        $0              $0             $0                 6
Adolescent
Comprehensive Ortho-Adult      D8090        $0              $0             $0                 16
Removable Appliance
                               D8210        $0              $0             $0                 1
Therapy
Fixed Appliance Therapy        D8220        $0              $0             $0                 2
Orthodontic Treatment          D8570        $0              $0             $0                 1
Atypical/extended skull        D8650        $0              $0             $0                 1
Pre-Orthodontic Visit          D8660        $0              $0             $0                 1

                                                                                    Section: Exhibit B
                                                                                  Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL         Arizona State Retirement System
                                                                       3300 North Central Avenue
                                   Retiree Dental Benefits Program              Suite 1300
                                                                         Phoenix, Arizona 85012
                                              RT10-022
                                                                           Page 118 of 154

Periodontic Orthodontic
                                D8670        $0              $0             $0                 2
Visit
Orthodontic Retention           D8680        $0              $0             $0                 6
Rebonding, Recementing
and/orRepair, as required, of   D8693        $0              $0             $0                 1
Fixed Retainers
unspecified orthodontic
                                D8999        $0              $0             $0                 2
procedure, by report
Palliative (Emergency)
Treatment Of Dental Pain-       D9110      $8,700          $3,078        $11,778              265
Minor Procedure
Fixed Partial Denture
                                D9120       $55              $0            $55                 38
Sectioning
Miscellaneous Tax               D9199       $359             $39           $398                15
Local Anesthesia                D9210        $0              $0             $0                 8
Regional Block Anesthesia       D9211        $0              $0             $0                 2
Local Anesthesia                D9215        $0              $0             $0                 22
General Anesthesia              D9220      $5,570          $6,024        $11,594              188
Each Additional 15 Minutes      D9221       $752            $865          $1,617               53
analgesia, anxiolysis,
                                D9230        $0              $0             $0                174
inhalation of nitrous oxide
Intravenous Conscious
Sedation/Analgesia-First 30     D9241      $2,073           $547          $2,619               92
Minutes
Intravenous Conscious
Sedation/Analgesia-Each         D9242       $133            $231           $364                27
Additional 15 Minutes
Non-Intravenous Conscious
                                D9248        $0              $0             $0                 16
Sedation
Consultation (Diagnostic
Service Provided By Dentist
Or Physician Other Than         D9310        $0              $0             $0                167
Practitioner Providing
Treatment
House/Extended Care
                                D9410        $0              $0             $0                 5
Facility Call
Office Visit During Regularly
                                D9430        $5              $0             $5                 53
Scheduled Hours
Office Visit-After Hours        D9440        $0              $0             $0                 12
Case Presentation               D9450        $0              $0             $0                 3
therapeutic drug injection,
                                D9610       $877            $402          $1,278               40
by report
Irrigation                      D9611        $0              $0             $0                 1

                                                                                     Section: Exhibit B
                                                                                   Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL           Arizona State Retirement System
                                                                          3300 North Central Avenue
                                    Retiree Dental Benefits Program                Suite 1300
                                                                            Phoenix, Arizona 85012
                                                RT10-022
                                                                              Page 119 of 154

Therapeutic Prenteral Drugs-
2                               D9612        $176            $332             $508                   8
Administrations/Medications
other drugs and/or
                                D9630         $0              $0               $0                   236
medicaments, by report
Application Of Desensitizing
                                D9910         $0              $0               $0                    84
Medicament
Application Of Desensitizing
                                D9911         $0              $0               $0                    17
Resin
Behavior Management             D9920         $0              $0               $0                    4
Treatment Of Complications-
                                D9930         $0              $0               $0                    2
Post Surgical
occlusal guard, by report       D9940       $50,068         $16,416         $66,484                 265
Fabrication Of Athletic
                                D9941         $0              $0               $0                    2
Mouthguard
Repair and/or Reline of
                                D9942         $0              $0               $0                    4
Occlusal Guard
Occlusion Analysis-Mounted
                                D9950         $0              $0               $0                    4
Case
Occlusal Adjustment -
                                D9951       $1,640           $603            $2,243                  94
Limited
Occlusal Adjustment -
                                D9952       $2,047            $0             $2,047                  6
Complete
Enamel Microabrasion            D9970         $0              $0               $0                    2
Odontoplasty 1 - 2 Teeth        D9971         $0              $0               $0                    6
External Bleaching - Per Arch   D9972         $0              $0               $0                    10
External Bleaching - Per
                                D9973         $0              $0               $0                    2
Tooth
Internal Bleaching - Per
                                D9974         $0              $0               $0                    1
Tooth
Sterilization                   D9998         $0              $0               $0                    8
Unspecified Adjunctive
                                D9999         $0              $15             $15                   230
Procedure
Interest                        INTRS        $1,602           $628           $2,230                1,636
                                Totals     $7,455,088      $2,842,470      $10,297,558




                                                                                           Section: Exhibit B
                                                                                         Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                 3300 North Central Avenue
                                   Retiree Dental Benefits Program                        Suite 1300
                                                                                   Phoenix, Arizona 85012
                                               RT10-022
                                                                                      Page 120 of 154




                                  Exhibit C
            PLANS’ SCHEDULES OF
                 BENEFITS
Exhibit C includes the following PDF documents, which are either following below, or are attached separately.

      Advance Plan

      Basic Plan




                                                                                               Section: Exhibit C
                                                                                             Form#RFP.02/03/10
  REQUEST FOR PROPOSAL            Arizona State Retirement System
                                    3300 North Central Avenue
Retiree Dental Benefits Program              Suite 1300
                                      Phoenix, Arizona 85012
          RT10-022
                                        Page 121 of 154




Exhibit C
Continued




                                                  Section: Exhibit C
                                                Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                    Arizona State Retirement System
                                                                                3300 North Central Avenue
                                    Retiree Dental Benefits Program                      Suite 1300
                                                                                  Phoenix, Arizona 85012
                                               RT10-022
                                                                                     Page 122 of 154




                    ARIZONA
                  PRE-PAY PLAN
Pre-Paid Dental Plans are also available in CA, CO, Fl, GA, KS, MO, NE, NV, NM, OH, OK, OR, TX,
UT.

The benefits and co-payment schedules for these pre-paid dental plans are not materially different from
the pre-paid dental plan offered to Arizona residents. For a copy of the Schedule of Benefits in these
states, please call or email the solicitation contact person listed in this RFP.




Exhibit 4 Continued - includes the following PDF documents, which are either following below, or are attached
separately.


      Pre-Paid plan

      2010 Open enrollment guide




                                                                                              Section: Exhibit C
                                                                                            Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL                               Arizona State Retirement System
                                                                                                    3300 North Central Avenue
                                            Retiree Dental Benefits Program                                  Suite 1300
                                                                                                      Phoenix, Arizona 85012
                                                           RT10-022
                                                                                                          Page 123 of 154




                                         ATTACHMENT A: Exceptions

                                                   *NOTE TO OFFEROR*
                             If there are no exceptions to this offer, leave this Attachment blank.

Offeror to indicate below any exceptions taken to the terms contained in this solicitation by clearly identifying the section within this
solicitation that offeror proposes to be replaced, and include the proposed replacement language. The Offeror’s preprinted or standard
terms will not be considered by the State as a part of any resulting Contract, as indicated in the Uniform Instructions to Offerors,
Request for Proposals.: “An Offer that takes exception to a material requirement of any part of the Solicitation, may be rejected.”

[List exceptions here]




                                                                                                    Section: Attachment A - Exceptions
                                                                                                                     Form#RFP.11/09
                                          REQUEST FOR PROPOSAL                             Arizona State Retirement System
                                                                                             3300 North Central Avenue
                                       Retiree Dental Benefits Program                                Suite 1300
                                                                                               Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                      Page 124 of 154



                           ATTACHMENT B1: References for Offeror

                                        INFORMATION TO BE PROVIDED
                                           REFERENCES FOR OFFER




1.   Contract Title (if applicable):    [Title]

2.   Contract Period:                   From       [Date]           To       [Date]

3.   Geographic Area Served:            [Describe Area]

4.   Scope of Work:                     [Describe Scope of Work]

5.   Reference:                         Company:            [Company Name]

                                        Individual:         [Contact Name]                   Title:     [Contact's Title]

                                        City:               [Company's City]                 State:     [Company's State]

                                        Telephone:          [Contact's Phone]                Email: [Contact's Email]

                                        Website:            [Company's Website Address]

                                        Certifications:     [List Certifications Here]




                                                                                   Section: Attachment B1 References for Offeror
                                                                                                           Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                             Arizona State Retirement System
                                                                                             3300 North Central Avenue
                                       Retiree Dental Benefits Program                                Suite 1300
                                                                                               Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                      Page 125 of 154



                           ATTACHMENT B2: References for Offeror

                                        INFORMATION TO BE PROVIDED
                                           REFERENCES FOR OFFER




1.   Contract Title (if applicable):    [Title]

2.   Contract Period:                   From       [Date]           To       [Date]

3.   Geographic Area Served:            [Describe Area]

4.   Scope of Work:                     [Describe Scope of Work]

5.   Reference:                         Company:            [Company Name]

                                        Individual:         [Contact Name]                   Title:     [Contact's Title]

                                        City:               [Company's City]                 State:     [Company's State]

                                        Telephone:          [Contact's Phone]                Email: [Contact's Email]

                                        Website:            [Company's Website Address]

                                        Certifications:     [List Certifications Here]




                                                                                   Section: Attachment B2 References for Offeror
                                                                                                           Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                             Arizona State Retirement System
                                                                                             3300 North Central Avenue
                                       Retiree Dental Benefits Program                                Suite 1300
                                                                                               Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                      Page 126 of 154



                           ATTACHMENT B3: References for Offeror

                                        INFORMATION TO BE PROVIDED
                                           REFERENCES FOR OFFER

                                                *NOTE TO OFFEROR*
                    If a third reference is not required for this offer, leave this Attachment blank.


1.   Contract Title (if applicable):    [Title]

2.   Contract Period:                   From       [Date]           To       [Date]

3.   Geographic Area Served:            [Describe Area]

4.   Scope of Work:                     [Describe Scope of Work]

5.   Reference:                         Company:            [Company Name]

                                        Individual:         [Contact Name]                   Title:     [Contact's Title]

                                        City:               [Company's City]                 State:     [Company's State]

                                        Telephone:          [Contact's Phone]                Email: [Contact's Email]

                                        Website:            [Company's Website Address]

                                        Certifications:     [List Certifications Here]




                                                                                   Section: Attachment B3 References for Offeror
                                                                                                           Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                              3300 North Central Avenue
                                       Retiree Dental Benefits Program                                 Suite 1300
                                                                                                Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                       Page 127 of 154



                    ATTACHMENT C1: References for Subcontractor

                                         INFORMATION TO BE PROVIDED
                                       REFERENCES FOR SUBCONTRACTOR

                                               *NOTE TO OFFEROR*
                  If a subcontractor will not be proposed for this offer, leave this Attachment blank.


1.   Contract Title (if applicable):    [Title]

2.   Contract Period:                   From       [Date]           To       [Date]

3.   Geographic Area Served:            [Describe Area]

4.   Scope of Work:                     [Describe Scope of Work]

5.   Reference:                         Company:            [Company Name]

                                        Individual:         [Contact Name]                    Title:     [Contact's Title]

                                        City:               [Company's City]                  State:     [Company's State]

                                        Telephone:          [Contact's Phone]                 Email: [Contact's Email]

                                        Website:            [Company's Website Address]

                                        Certifications:     [List Certifications Here]




                                                                             Section: Attachment C1 References for Subcontractor
                                                                                                            Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                              3300 North Central Avenue
                                       Retiree Dental Benefits Program                                 Suite 1300
                                                                                                Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                       Page 128 of 154



                    ATTACHMENT C2: References for Subcontractor

                                     INFORMATION TO BE PROVIDED
                               REFERENCES FOR PROPOSED SUBCONTRACTOR

                                               *NOTE TO OFFEROR*
                  If a subcontractor will not be proposed for this offer, leave this Attachment blank.



1.   Contract Title (if applicable):    [Title]

2.   Contract Period:                   From       [Date]           To       [Date]

3.   Geographic Area Served:            [Describe Area]

4.   Scope of Work:                     [Describe Scope of Work]

5.   Reference:                         Company:            [Company Name]

                                        Individual:         [Contact Name]                    Title:     [Contact's Title]

                                        City:               [Company's City]                  State:     [Company's State]

                                        Telephone:          [Contact's Phone]                 Email: [Contact's Email]

                                        Website:            [Company's Website Address]

                                        Certifications:     [List Certifications Here]




                                                                             Section: Attachment C2 References for Subcontractor
                                                                                                            Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                              Arizona State Retirement System
                                                                                              3300 North Central Avenue
                                       Retiree Dental Benefits Program                                 Suite 1300
                                                                                                Phoenix, Arizona 85012
                                                      RT10-022
                                                                                                       Page 129 of 154



                    ATTACHMENT C3: References for Subcontractor

                                     INFORMATION TO BE PROVIDED
                               REFERENCES FOR PROPOSED SUBCONTRACTOR

                                               *NOTE TO OFFEROR*
                  If a subcontractor will not be proposed for this offer, leave this Attachment blank.



1.   Contract Title (if applicable):    [Title]

2.   Contract Period:                   From       [Date]           To       [Date]

3.   Geographic Area Served:            [Describe Area]

4.   Scope of Work:                     [Describe Scope of Work]

5.   Reference:                         Company:            [Company Name]

                                        Individual:         [Contact Name]                    Title:     [Contact's Title]

                                        City:               [Company's City]                  State:     [Company's State]

                                        Telephone:          [Contact's Phone]                 Email: [Contact's Email]

                                        Website:            [Company's Website Address]

                                        Certifications:     [List Certifications Here]




                                                                             Section: Attachment C3 References for Subcontractor
                                                                                                            Form#RFP.02/03/10
                                           REQUEST FOR PROPOSAL                         Arizona State Retirement System
                                                                                          3300 North Central Avenue
                                       Retiree Dental Benefits Program                             Suite 1300
                                                                                            Phoenix, Arizona 85012
                                                     RT10-022
                                                                                                Page 130 of 154



                                             Attachment D
The offeror must address the Scope of Work as specified herein.

Instructions for Completion of the Minimum Requirements

        Indicate “yes” or “no” of your organization's ability to meet the minimum requirements.

        Contractor will be held accountable for the accuracy/validity of all answers.

                                   Minimum Requirements                                                 Yes        No

 1.    . Properly licensed in Arizona.

 2.      Compliance with performance guarantees in the Scope of Work.

 3.      Agree to comply with audits as specified in performance guarantees.

         Toll-free, dedicated line in member services with minimum access from 8:00
 4.      a.m. to 5:00 p.m. (MST) in Arizona, exclusive of State holidays.

 5.      Dedicated member services staff for the ASRS.

 6.      At least one full time onsite Contractor staff located at the ASRS.

         Attend scheduled meetings as needed to discuss reports, problems, etc.
 7.

 8.      Customize enrollment materials.

         Cost must include: Satisfaction survey, directory reprints, dental wellness
 9.      promotion assistance, ID cards, etc.

         Personnel staffing grids, resumes, and organization chart submitted.
 10.
           a. Agree to waive all pre-existing condition provisions or give credit for partial
              completion of the waiver period for retirees and dependents covered under
              the group insurance program?
 11.
           b. Permit annual open enrollment periods at which time evidence of
              insurability will not be required and no pre-existing condition limitations
              will apply to participants transferring between plans?

                                                                        Section: Attachment D Minimum Requirement Checklist
                                                                                                       Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                 3300 North Central Avenue
                                   Retiree Dental Benefits Program                        Suite 1300
                                                                                   Phoenix, Arizona 85012
                                              RT10-022
                                                                                       Page 131 of 154


                              Minimum Requirements                                             Yes        No

      No retiree will suffer a loss of coverage by virtue of a change in Contractor
12.   other than by plan design.

      Waive the actively-at-work restrictions or deferred effective date for retirees and
      dependents eligible on the effective date contained within the contract. This
13.   provision, however, does not remove the liability of the prior Contractor for
      expenses incurred with respect to the extension of benefits provisions of their
      contract.

      Draft of the following communications material.

        a.   Claim forms and instructions

        b.   ID Cards

14.     c.   Provider directories

        d.   Master policy

        e.   Certificate booklet

        f.   Summary plan description

        a.    Maintain a formal grievance and appeals process as stipulated by the
              ASRS Scope of Work.
15.
        b.    Provide a copy of the formal grievance procedure available to
              member.

        Produce required reports as specified in the Scope of Work.
16.
        Properly administer claims for the ASRS adhering to the claims performance
17.     standards.

18.     Establish a dedicated claims unit to service the ASRS account.

        Assist ASRS staff by responding to their inquiries in one business day or
19.     less. Response means return phone call as well as an update on the status of
        the issue (e.g., when the claim will be paid and why it was pended).




                                                               Section: Attachment D Minimum Requirement Checklist
                                                                                              Form#RFP.02/03/10
                                  REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                3300 North Central Avenue
                               Retiree Dental Benefits Program                           Suite 1300
                                                                                  Phoenix, Arizona 85012
                                            RT10-022
                                                                                       Page 132 of 154


                            Minimum Requirements                                             Yes         No

      Maintain systems capabilities to accommodate timely and accurate
      sharing/transmission of data between eligibility, claims, billing and
20.
      reporting.

      Perform member satisfaction survey at least annually, using a tool and
21.   methodology acceptable by the ASRS.

      Provide to ASRS enrollees network directories at open enrollment and
      directory updates. Directory shall provide the phone number to call to verify
22.   if a provider is on the network. Directories shall be user friendly to identify
      the customer service number as well as the doctor's office.

      Identify other means that the ASRS may access the provider network
23.   directory. (e.g., electronically through the internet).

      For an experience-rated/retention-accounting contract, the annual experience
      accounting must be submitted to the ASRS within 120 days of the
24.
      completion of the policy year.

      Rates are guaranteed for a minimum of at least 12 months (initial contract
25.   period).

26.   Proposal is submitted net of commissions.

      Flexible communication material within reason (e.g., Braille/cassette).
27.   Complies with ADA.

      Provide a complete description of benefits and limitations and/or exclusions
      relative to benefits requested in the Scope of Work and submit a Summary
28.
      Plan Description.

      Provide a complete description of the method for determining the premium,
      as well as how it is administered. Describe the renewal calculation
29.   procedure in detail, including determination of retention, reserves, trend and
      margins as appropriate.

      Provide a complete description of the claims administration process.
30.

31.   Provide a sample Explanation of Benefits (EOB) and all possible codes with

                                                             Section: Attachment D Minimum Requirement Checklist
                                                                                            Form#RFP.02/03/10
                                  REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                               3300 North Central Avenue
                               Retiree Dental Benefits Program                          Suite 1300
                                                                                 Phoenix, Arizona 85012
                                            RT10-022
                                                                                       Page 133 of 154


                            Minimum Requirements                                             Yes         No

      definitions.

      Provide details on any plans for revisions in Contractor’s claims system.
32.
      Coverage is provided locally, statewide, nationally and internationally.
33.
      Include your proposed implementation plan or schedule of events assuming
      a
34.
      January 1, 2011 effective date.

      Your proposal provides the ASRS with information relating to its contracts,
35.   such as terms of the physician contracts as well as discounts and information
      on reimbursement methodology.

      Can you provide the ASRS with geographic network capabilities by retiree
36.   and zip code?

      Proposal provides copies of all directories relating to the requested networks
37.   proposed, which will include all ancillary providers in the State of Arizona
      and outlying areas outside of Arizona.

      Sample reports that the ASRS would receive as standard reports.
38.

39.   Ability to provide the requested deliverables in the Scope of Work.


40.   Respond accurately and completely to all the required exhibits and forms.

      Provide insurance certificate(s) as requested in Special Terms and
41.   Conditions.




                                                             Section: Attachment D Minimum Requirement Checklist
                                                                                            Form#RFP.02/03/10
                                           REQUEST FOR PROPOSAL                   Arizona State Retirement System
                                                                                    3300 North Central Avenue
                                      Retiree Dental Benefits Program                        Suite 1300
                                                                                      Phoenix, Arizona 85012
                                                 RT10-022
                                                                                          Page 134 of 154




                            Attachment E
                                    Questionnaire
  General Questions Applicable to All DENTAL Proposals
        * Offeror must respond to all the following questions that apply to the programs offered. Provide a
        separate response to each question for each type of plan which your organization is offering
        (Indemnity, Prepaid Plan or Both). Reference should not be made to a prior response nor should an
        overall response be used to answer more than one question. Each question has been written to
        address a specific area of concern and not general concepts of dental care delivery systems and
        their operation. A full answer to each question is required even when such answers may appear
        repetitious. The ASRS recognizes some of the information may be proprietary; therefore, the
        offeror should clearly identify the responses.



        GENERAL REQUIREMENTS

1.   Company name.


2.   Street address of principal office.


3.   Contact Information
     3.1 Telephone number
     3.2 Fax number
     3.3 Email address
     3.4 Contact Name
     3.5 Contact Title
     3.6 Give the total number of personnel employed in Maricopa County and the rate of turnover
          during the last 12 months.


4.   It is the intent of ASRS to determine the method by which your renewal rates will be calculated
     prior to entering into a contract. Describe your renewal calculation and dividend calculation
     procedures in detail including determination of administration, network access and risk charges,
     reserves, projected claims, pooling points/charges, and any margin included in the calculations. Are
     the retention estimate, margin, and the renewal procedures guaranteed with respect to ASRS
                                                                                  Section: Attachment E: Questionnaire
                                                                                                  Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                     Retiree Dental Benefits Program                           Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                  RT10-022
                                                                                           Page 135 of 154

     contract? For how long? How, if at all, will the initial renewal methodology differ from subsequent
     renewals? Create a sample dividend calculation using appropriate percentages.


5.   Describe in detail the funding arrangement you are proposing.


6.   What is the full legal name of your company?


7.   Considering all of the information contained in this RFP and your knowledge about the Arizona State
     Retirement System (ASRS) and the senior population, describe your strategic vision for meeting the
     dental care needs of ASRS retirees and family members. Comment on why your organization is best
     suited to bring that vision to reality and the product portfolio offerings that you believe would service the
     retirees in the future.


8.   If you plan to subcontract any part of your proposed products or services, please explain.


9.   Do you provide worldwide emergency services coverage, If yes, please explain.


10. List all sanctions, fines and their associated reasons brought by CMS against your current plan or
    any affiliated plan in the past five years.


11. List all lawsuits in the past 5 years for which your organization is a party involving this product or
    similar products.


12. List all past or pending investigations during the past 5 years by the Federal or State governments
    for the plan you are submitting for this proposal.


13. Does your plan have any pending corrective action plans with CMS or any state department of
    insurance?


14. Please include a sample administrative manual with your response to this questionnaire.


15. Explain your grievance procedure.


16. Describe in detail the deficit carry-forward provisions of your contract, if any.
                                                                                   Section: Attachment E: Questionnaire
                                                                                                   Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                   3300 North Central Avenue
                                    Retiree Dental Benefits Program                         Suite 1300
                                                                                     Phoenix, Arizona 85012
                                                RT10-022
                                                                                        Page 136 of 154




17. Are network access fees charged as part of retention or as a claim? How much are the fees? Please
    list all fees.


18. Describe the financial obligations of ASRS in the event of contract termination for incurred but
    unpaid claims.


19. Check all of the following which apply to your organization in the past two (2) years.
                      Have been acquired by another organization

                      Expanded into one or more new states

                      Have merged with another plan

                      Implemented a new computer system

                      Purchased another organization

                      Changed from non-profit to for-profit

                      Changed from for-profit to non-profit

                      Had a name change, from and to

                      Moved your corporate headquarters

                      Implemented a new telephone system

                      Implemented a new billing system

                      Implemented a new claim system

                      National affiliation

                      Changed claim office location

                      Expanded into 1 or more new states

                      Expanded staff by more than 15%

                      Contracted staff by more than 15%

                      Other (specify or elaborate)
                                                                                Section: Attachment E: Questionnaire
                                                                                                Form#RFP.02/03/10
                                          REQUEST FOR PROPOSAL                         Arizona State Retirement System
                                                                                         3300 North Central Avenue
                                      Retiree Dental Benefits Program                             Suite 1300
                                                                                           Phoenix, Arizona 85012
                                                   RT10-022
                                                                                               Page 137 of 154




         b.     Is your organization for profit or not for profit?



20. Indicate the most recent ratings for your organization. Please explain, any notes identify rating
    change:

Organization                 Rating            Last Date Rated           Notes

Standard and Poors

Duff and Phelps

A.M. Best

Moody's

21. a.        Indicate the number of clients you have in Arizona by employee group sizes below:

                <1,000                1,000 - 5,000           5,001 - 10,000                  >10,000




         b. Complete the following grid for clients over 1000 employees in Arizona who have terminated your
            services within the last two years:


     Company Name               Contact       Phone #         Benefit            Reason for       Term.        # of
                                Person                        Offering             Term.          Date       Employees




                                                                                      Section: Attachment E: Questionnaire
                                                                                                      Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                      3300 North Central Avenue
                                    Retiree Dental Benefits Program                            Suite 1300
                                                                                        Phoenix, Arizona 85012
                                                 RT10-022
                                                                                          Page 138 of 154




22. Complete the following grid of the largest current Arizona client references.




Company Name           Contact Person           Phone #           Coverage(s)             Initial         # of
                                                                   Provided              Effective      Employees
                                                                                           Date




23. Have you ever had a financial penalty applied as a result of not meeting a certain performance
    guarantee?


                              No

                              Yes (provide an explanation)



24. Will you agree to the performance guarantees in the Scope of Work, Item 13?


25. Will you guarantee your schedule of benefits for the life of the contract?


26. What data, information and resources do you provide for enrollees on your web-site?


    OPEN ENROLLMENT AND COMMUNICATIONS

27. Will you send a welcome packet to all enrollees following enrollment? Please attach a sample of
    your welcome kit.
                                                                                 Section: Attachment E: Questionnaire
                                                                                                 Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                       Arizona State Retirement System
                                                                                   3300 North Central Avenue
                                   Retiree Dental Benefits Program                          Suite 1300
                                                                                     Phoenix, Arizona 85012
                                               RT10-022
                                                                                         Page 139 of 154




28. How do you monitor member satisfaction? Attach a copy of any survey utilized and summarize the
    outcome of any such surveys taken in the last 6 months.


29. How many days in advance of open enrollment will transition of care be available for members to
    call in and ask questions?


30. Explain how members can check a dentist’s participation status.


31.   What standards or guidelines does your company follow before printing your provider directory?
      How often is your directory updated?


32. Complete the following grid regarding your customer services department.


         a) Average number of calls completed per hour per member service rep in an
             average week.
         b) Goal number of calls completed per hour per member service rep.

         c) Average time on hold before speaking to a member service rep.

         d) Realistic goal for time on hold before speaking to a member service rep.

         e) What is the “busy” rate experienced by callers in an average week?

         f) Targeted Goal of “busy” rate

         g) What is the abandonment rate of callers in an average week?



      32.1   Describe the method and frequency for tracking/updating the following:
             a) Benefit Changes


             b)   Enrollee Age


             c)   Student Status

                                                                                 Section: Attachment E: Questionnaire
                                                                                                 Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                 3300 North Central Avenue
                                   Retiree Dental Benefits Program                        Suite 1300
                                                                                   Phoenix, Arizona 85012
                                               RT10-022
                                                                                       Page 140 of 154



            d)   Eligibility


            e)   Claims History


            f)   Family Deductibles


            g)   Individual Deductible




    CLAIMS ADMINISTRATION SYSTEM

33. Provide the performance standards and performance results for the last twelve months as requested
    below for the claims processing unit(s) that will be assigned to ASRS for dental claims processing:


    33.1 Turnaround time


    33.2 Payment Error Rates


    33.3 Coding Accuracy Rates


    33.4 Percent of Claims without Dollar Error


34. Do members have access to the claims / customer service group via e-mail (internet) or fax?


35. Can the CSR access claims status on-line real time?


36. What was the average number of customer calls received monthly during 2009?


37. Will customer service representatives answer the phone when ASRS members call or will they
    listen to a prerecorded voice?


                                                                               Section: Attachment E: Questionnaire
                                                                                               Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                         Arizona State Retirement System
                                                                                     3300 North Central Avenue
                                   Retiree Dental Benefits Program                            Suite 1300
                                                                                       Phoenix, Arizona 85012
                                                RT10-022
                                                                                           Page 141 of 154

38. Do you have a member services department dedicated to retiree groups? Will you dedicate a
    member services unit to ASRS?


39. Will you provide a toll-free number for ASRS participants? Will the phone number be dedicated
    exclusively for the use of ASRS participants?


40. ADMINISTRATIVE SERVICES
     40.1 Are customer service inquiries and their resolution tracked on the system (e.g. comment
          screens)?


     40.2   Do you have translators available for non-English speaking participants? If yes, please list
            the languages.


     40.3   Describe how you manage hearing impaired calls.


     40.4   Are you able to accommodate requests for ad hoc or customized reporting (including
            utilization information)?


     40.5   Do you use standard formatted answers to respond to certain inquiries? If so, please
            describe.


41. ELECTRONIC ELIGIBILITY PROCESSING
     41.1 Please confirm that you can do electronic eligibility processing?


     41.2   How will eligibility data be transferred from the employer to your organization?


     41.3   How is eligibility input verified in the system?


     41.4   Can you accept eligibility via paper, as well as by electronic feed?


     41.5   Is eligibility updated on a monthly basis?




                                                                                   Section: Attachment E: Questionnaire
                                                                                                   Form#RFP.02/03/10
                                      REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                  3300 North Central Avenue
                                   Retiree Dental Benefits Program                         Suite 1300
                                                                                    Phoenix, Arizona 85012
                                                 RT10-022
                                                                                        Page 142 of 154

42. DESCRIBE YOUR ADMINISTRATION OF REASONABLE AND CUSTOMARY (R&C)
    CHARGES, INCLUDING:
     42.1 How do you define "usual, reasonable and customary" charges? If your reimbursement
          methodology differs from usual, reasonable and customary, please fully describe your
          methodology and answer all remaining questions appropriately.


     42.2   Describe the data base used to develop reasonable and customary screens.             At what
            percentile does your plan(s) consider charges reasonable and customary?


     42.3   How frequently are R&C screens/tables updated?


     42.4   How Frequently do you review UCR changes?


     42.5   Do R&C allowances differ between in-network (or in service area) and out of network (or
            out of service area)?


43. AUDIT AND ACCOUNTING
     43.1 The use and role of dental consultants in reviewing questionable claims.


     43.2   Measures taken to prevent fraud by your own employees related to claims processing and
            claim/draft control.


     43.3   Your guidelines with respect to detection of and action on overcharges, unnecessary dental
            procedures, multiple procedures to the same tooth and other cost control programs you may
            utilize.


     43.4   What is the standard turnaround time for a dental pre-certification request?


     43.5   Are audits performed on a pre- or post-disbursement basis?


     43.6   How are claims selected for audit?


     43.7   On average, what percentages of all claims are audited?


                                                                                Section: Attachment E: Questionnaire
                                                                                                Form#RFP.02/03/10
                                         REQUEST FOR PROPOSAL                   Arizona State Retirement System
                                                                                  3300 North Central Avenue
                                   Retiree Dental Benefits Program                         Suite 1300
                                                                                    Phoenix, Arizona 85012
                                               RT10-022
                                                                                       Page 143 of 154

     43.8   Do you have a dedicated claims staff that provides regular audits? Briefly describe.


     43.9   Do you review claims for billing irregularities by a provider (such as regular overcharging,
            unbundling of procedures, upcoding or billing for inappropriate care for stated diagnosis,
            etc.)?


     43.10 The plan will timely update and correct the data when updated data is received. Do you
           agree or disagree?




44. CLAIMS PAYMENT
     44.1 For each of the following claim processes, provide your response as to whether your claim
          system handles the task in an AUTOMATED (A) manner, uses MANUAL REVIEW (MR)
          or if it is NOT CHECKED (NC).


                                                    A                   MR                      NC

        a) Total charges against total
           allowable payment
        b) Checks for duplicate
           charges
        c) Assures services
           provided are or are not,
           within the scope of a
           work-related
           injury/illness
        d) Identifies that a provider
           is licensed to perform the
           type of services billed
        e) Identifies that the
           provider is a
           participating dentist
           especially one who has
           multiple locations or tax
           identification numbers
        f) Overpayment/Underpay
           ment

        g) Pending claims
                                                                               Section: Attachment E: Questionnaire
                                                                                               Form#RFP.02/03/10
                                              REQUEST FOR PROPOSAL                        Arizona State Retirement System
                                                                                            3300 North Central Avenue
                                          Retiree Dental Benefits Program                            Suite 1300
                                                                                              Phoenix, Arizona 85012
                                                        RT10-022
                                                                                                      Page 144 of 154


            h) Upcoding



      44.2        What percentage of claims auto-adjudicate?




45. NETWORK / PROVIDERS
     45.1 Give the total number of dental professionals currently contracted in Arizona in the following
     categories and the rate of turnover during the last twelve months.
                                                                                                                     Turn-over

      County/          General     Ortho-      Endodontists   Periodontists   Oral        Dental           Grand        Rate
                       Dentists                                               Surgeons
                                   dontists
           City                                                                          Hygienists        Total    (last 12 mo.)



    Apache



    Cochise



    Coconino



    Gila



    Graham



    Greenlee



    La Paz



    Maricopa




                                                                                          Section: Attachment E: Questionnaire
                                                                                                          Form#RFP.02/03/10
                                       REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                   3300 North Central Avenue
                                    Retiree Dental Benefits Program                         Suite 1300
                                                                                     Phoenix, Arizona 85012
                                                RT10-022
                                                                                         Page 145 of 154

    Mohave



    Navajo



    Pima



    Pinal



    Santa Cruz



    Yavapai



    Yuma




    Total




46. Describe your continuing education philosophy.        Indicate any special training dentists receive
    relative to the needs of elderly?


47. At what level will you provide (or recommend providing) predetermination services? Are they
    voluntary or mandatory (describe)?


48. If you will be changing you provider base in the next 18 months, please explain any deletions or
    additions and their projected effective dates.


49. How do you notify participants of additions and terminations to your provider network?


50. Are there any restrictions on provider access (e.g. limitation on new patients for certain providers)?
    If so, note each individual provider currently under such restrictions.
                                                                                 Section: Attachment E: Questionnaire
                                                                                                 Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL                     Arizona State Retirement System
                                                                                   3300 North Central Avenue
                                     Retiree Dental Benefits Program                        Suite 1300
                                                                                     Phoenix, Arizona 85012
                                                  RT10-022
                                                                                         Page 146 of 154




51. How many dentist contracts have been terminated by the dentist, per year, during the past three
    years? How many contracts have been terminated by the dental plan? How accurate is your current
    provider directory with respect to dentists under contract, dentists accepting new patients, etc.? Are
    provider directories available on the Internet?


52. What is your capacity to enroll new members with the current provider base?


53. What is your current ratio of members to general dentists? What is your maximum target ratio for
    member to general dentists?


54. What percentage of general dentists offer extended hours (before or after normal business hours) or
    Saturday hours for non-emergency care? Provide information on the hours such care is available.


55. What provisions have you made for urgent or emergency care in and out of service area?


56. What is the average waiting period (measured in days) to schedule a routine appointment?
    Urgent/emergency care (measured in hours)?


57. What criteria do you use for the selection of providers if any?


58. Please describe any special training dentists receive from you.


59. Please describe the procedure for referring a patient to a specialist.


60. Indicate the frequency with which you survey your Arizona pre-paid providers on their satisfaction.
    Provide a sample of your most recent provider satisfaction survey.


61. Describe your action plan devised to resolve any unfavorable survey results for the pre-paid
    provider network.


62. Discuss the impact of any anticipated Arizona pre-paid network changes.


                                                                                 Section: Attachment E: Questionnaire
                                                                                                 Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL                      Arizona State Retirement System
                                                                                    3300 North Central Avenue
                                      Retiree Dental Benefits Program                        Suite 1300
                                                                                      Phoenix, Arizona 85012
                                                RT10-022
                                                                                         Page 147 of 154

63. Describe your Quality Assurance measures (e.g. outcome analysis, peer review, medical/dental
    education, patient exit surveys, etc.). Are all dentists subject to Q.A. reviews? Describe the items
    reviewed. Do the Q.A. measures change over time or are they constant? How are providers who
    fail to perform at an acceptable level removed from the network?


64. What are the restrictions and/or limitations with respect to any benefit available under your dental
    plan?


65. Describe your Coordination of Benefits administration procedures in full.


66. Verify whether you have a hold harmless agreement that prohibits providers for billing or collecting
    from patients more than the plan’s designated coinsurance and/or co-payment.


67. Can family members choose different dentists? How often can members change their dentist? Is
    there a limit on the number of changes allowed per year?


68. Explain in detail how your contract addresses benefits for: a) procedures that begin before the
    effective date of coverage and continue after the effective date and; b) procedures that begin before
    the termination date of coverage and continue after the termination date (e.g. orthodontics, crowns,
    bridges, endodontics/periodontics).


69. Component 1 (Scope of Work, Section 3.1) – Current Plan Designs


    In the table that follows, indicate where your proposed plan designs differ from the current plans.
    Do not merely refer to a section of your proposal. Current plans provide two indemnity plans
    and one pre-paid plan design.



                        Current Plan        Variance   to   Current   Current Plan        Variance to
                                            Plan
                                                                                          Current Plan

                          Indemnity                                       Prepaid

     SERVICE

    Type I                                                             See Prepaid Co-
                          Deductible
  Diagnostic                                                            Pay Schedule
                                                                                 Section: Attachment E: Questionnaire
                                                                                                 Form#RFP.02/03/10
                                     REQUEST FOR PROPOSAL                    Arizona State Retirement System
                                                                               3300 North Central Avenue
                                  Retiree Dental Benefits Program                       Suite 1300
                                                                                 Phoenix, Arizona 85012
                                            RT10-022
                                                                                     Page 148 of 154

 Preventive            $50/$150                                     (Exhibit C)



                  Deductible Waived



                   20% member co-
                        pay

 Type II          Deductible Applies
 Restorative                                                   See Prepaid Co-
 Oral Surgery                                                   Pay Schedule
Endodontics        20% member co-                                (Exhibit C)
 Periodontics           pay
 Emergency
                  Deductible Applies


 Type III
 Prosthodontics    50% member co-
 Bridge &               pay                                    See Prepaid Co-
                                                                Pay Schedule
 DentureRepair                                                   (Exhibit C)

 Major             New enrollees are
 Restorative       at the 25% co-pay
                       level for 12
                   continuous months

                      $2,500.00
                     Advance Plan
 Annual Benefit
 Maximum                                                               N/A

                   $1,000.00 Basic Plan
                  (no Type III Services)




                                                                             Section: Attachment E: Questionnaire
                                                                                             Form#RFP.02/03/10
                                        REQUEST FOR PROPOSAL                    Arizona State Retirement System
                                                                                  3300 North Central Avenue
                                    Retiree Dental Benefits Program                        Suite 1300
                                                                                    Phoenix, Arizona 85012
                                                RT10-022
                                                                                       Page 149 of 154




70. Component 2 (Scope of Work, Section 4.1) – Alternative Plan Designs


    In the table that follows, indicate where your proposed plan designs differ from the current plans.
    Do not merely refer to a section of your proposal.



                                              Current Plan           Variance to Current Plan

                                                Indemnity

             SERVICE

  Type I                                   Deductible $50/$150
  (Deductible does not apply to Class
  I Services)
  Diagnostic
                                            Deductible Waived
  Preventive


                                           20% member co-pay

  Type II
  Restorative                               Deductible Applies
  Oral Surgery
  Endodontics
  Periodontics
  Emergency                                20% member co-pay



  Type III                                  Deductible Applies
  Prosthodontics
  Bridge & Denture Repair

  Major Restorative                        50% member co-pay



                                          New enrollees are at the
                                          25% co-pay level for 12
                                            continuous months



                                                                               Section: Attachment E: Questionnaire
                                                                                               Form#RFP.02/03/10
                           REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                             3300 North Central Avenue
                         Retiree Dental Benefits Program              Suite 1300
                                                               Phoenix, Arizona 85012
                                    RT10-022
                                                                   Page 150 of 154

                              $2,500.00 Advance Plan

Annual Benefit Maximum

                              $1,000.00 Basic Plan (no
                                 Type III Services)




                                                           Section: Attachment E: Questionnaire
                                                                           Form#RFP.02/03/10
                                                   REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                                     3300 North Central Avenue
                                                 Retiree Dental Benefits Program              Suite 1300
                                                                                       Phoenix, Arizona 85012
                                                           RT10-022
                                                                                           Page 151 of 154



71.If you are proposing an indemnity plan                   ADA Code                   UCR Allowance
  with or without a fee schedule, please
  provide your UCR allowance for the
  ADA code shown.
  Initial Oral Exam                                         110

Periodic Oral Exam                                          120

  Bitewings – Two Films                                     272

Bitewings – Four Films                                      274

  Prophylaxis – Adult                                       1110

Prophylaxis – Child                                         1120

Amalgam – One surface, permanent                            2140

Amalgam – Two surfaces, permanent                           2150

Amalgam – Three surfaces, permanent                         2160

Composite Acrylic Resin - One surface                       2330

Crown – porcelain with Gold Crown                           2750

Crown – porcelain with Base Metal                           2751

Crown – porcelain with Noble Metal                          2752

Gold Crown – Full Cast                                      2790

Root Canal – three canals (including treatment              3330

 plan, clinical procedures and follow-up care;

 Excludes final restoration)

Osseous Surgery - Quad                                      4260

Root Planning – Quad                                        4341

Dentures – complete upper                                   5110

Fixed Bridge                                                6240

Crown with High Noble Metal                                 6750



                                                                                   Section: Attachment E: Questionnaire
                                                                                                   Form#RFP.02/03/10
                                               REQUEST FOR PROPOSAL            Arizona State Retirement System
                                                                                 3300 North Central Avenue
                                             Retiree Dental Benefits Program              Suite 1300
                                                                                   Phoenix, Arizona 85012
                                                       RT10-022
                                                                                       Page 152 of 154

Crown with Base Metal                                   6751

Crown with Noble Metal                                  6752

Extraction – Single tooth (includes local               7110

 Anesthesia and routine post-op care)

Comprehensive Orthodontic Treatment

 Children (Under Age 19)                                8080

 Adults (Age 19+)                                       8090

Other Orthodontic Services

 Initial Diagnostic Workup and Radiographs              8027

  Without Orthodontic Treatment

 Pre-Orthodontic Treatment Service                      8660

 Periodic Orthodontic Treatment Service                 8670

R&C Percentile Used

Data Base Source:




                                                                               Section: Attachment E: Questionnaire
                                                                                               Form#RFP.02/03/10
  REQUEST FOR PROPOSAL            Arizona State Retirement System
                                    3300 North Central Avenue
Retiree Dental Benefits Program              Suite 1300
                                      Phoenix, Arizona 85012
          RT10-022
                                         Page 153 of 154

           NARRATIVE




                                      Section: Attachment F:Narrative
                                                  Form#RFP.02/03/10
  REQUEST FOR PROPOSAL            Arizona State Retirement System
                                    3300 North Central Avenue
Retiree Dental Benefits Program              Suite 1300
                                      Phoenix, Arizona 85012
          RT10-022
                                        Page 154 of 154



   END OF DOCUMENT

        No. RT10-022-




                                           Section: End Of Document
                                                 Form#RFP.02/03/10

				
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