ATTACHMENT 4 Benefits for Prepaid/Managed Dental Plan Instructions: Supplier may submit up to two (2) dental plans. Refer to Section C.1. If the Supplier submits a prepaid/managed dental plan, use the following template for each prepaid/managed plan. New and existing Suppliers must complete Plan Changes” column. “No For existing Suppliers, this column reflects the Supplier’s current plan characteristics without changes. Existing Suppliers also have the option to complete column Proposed Plan Changes”. “With Include all plan characteristics that will remain the same and any new, proposed plan changes. All proposed plan changes must be in bold. Attachment 4 must be signed by the Supplier’s President, Chief Executive Officer or authorized representative. Any exceptions must be reflected in Attachment 2. Example: No Plan Changes With Proposed Plan (Required) Changes (Optional) Annual Calendar Year No deductible or plan No deductible or plan Deductible maximum maximum $10 office copay applies $15 office copay applies [Prepaid/Managed Plan Name] PY 2019 No Plan Changes With Proposed Plan Covered Services (Required) Changes (Optional) Annual Calendar Year Deductible Diagnostic and Preventive Care Oral Exams Routine Cleanings Routine X-rays Fluoride Treatment Sealants Space Maintainers
ATTACHMENT 4 Benefits for Prepaid/Managed Dental Plan Instructions: Supplier may submit up to two (2) dental plans. Refer to Section C.1. If the Supplier submits a prepaid/managed dental plan, use the following template for each prepaid/managed plan. New and existing Suppliers must complete “No Plan Changes” column. For existing Suppliers, this column reflects the Supplier’s current plan characteristics without changes. Existing Suppliers also have the option to complete column “With Proposed Plan Changes”. Include all plan characteristics that will remain the same and any new, proposed plan changes. All proposed plan changes must be in bold. Attachment 4 must be signed by the Supplier’s President, Chief Executive Officer or authorized representative. Any exceptions must be reflected in Attachment 2. Example: No Plan Changes (Required) With Proposed Plan Changes (Optional) Annual Calendar Year Deductible No deductible or plan maximum $10 office copay applies No deductible or plan maximum $15 office copay applies [Prepaid/Managed Plan Name] PY 2019 Covered Services No Plan Changes (Required) With Proposed Plan Changes (Optional) Annual Calendar Year Deductible Diagnostic and Preventive Care Oral Exams Routine Cleanings Routine X-rays Fluoride Treatment Sealants Space Maintainers
Solicitation0900000304Attachment4.docx