Park Hill School District · Periodontal scaling and root planning, once per quadrant every 24 months Periodontal surgery, once per quadrant every 36 months Endodontics: root canal

Park Hill School District

Delta Dental PPO Plan Features1

Delta Dental PPO Dentist

Delta Dental Premier Dentist

Non-Participating Dentist

Based on a reduced fee schedule –

no balance billing

Based on a contractual agreement –

no balance billing

Based on Delta’s maximum plan

allowance; balance billing is possible

Diagnostic and Preventive Services Oral exams (all types), twice per calendar year

Periapical x-rays, as needed

Bitewing x-rays, two sets per calendar year

Full-mouth x-rays once in any 36 consecutive months

Prophylaxis (cleanings), twice per calendar year

Fluoride, twice per calendar year for dependent children under age 15

Sealants for dependent children under age 15, once per tooth every 3 years, limited to non-decayed 1

st and 2

nd

permanent molars Emergency palliative treatment

Space maintainers for dependent children under age 19

100% 80% 80%

Basic Services Restorative services using synthetic porcelain and plastic

material (white) on front teeth and amalgam (silver) on molar teeth

Periodontal maintenance, twice per calendar year (combined total of periodontal maintenance and prophylaxis cannot exceed 4 per calendar year)

Periodontal scaling and root planning, once per quadrant every 24 months

Periodontal surgery, once per quadrant every 36 months Endodontics: root canal filling and pulpal therapy

Simple and surgical extractions Oral surgery Recement crowns, inlays and bridges Denture adjustments, repairs, rebase and relines

100% 70% 70%

Major Services Prosthetics: bridges and dentures; a replacement will be

covered only once in 10 years but not during the first 12 months of coverage

2

Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes, once in 5 years

50% 40% 40%

Orthodontic Services

For dependent children to age 19 who begin treatment while covered by this plan

3 50% 40% 40%

Calendar Year Deductible $50 per person / $100 family limit

Applies to Major Services Basic & Major Services Basic & Major Services

Calendar Year Benefit Maximum $1,000 per person + MAXAdvantage

MAXAdvantage - Charges for exams, cleanings, x-rays and fluoride treatments do not apply towards your benefit maximum

Lifetime Orthodontic Maximum $1,000 per eligible dependent child up to age 19

1 This is intended to be a summary only. Please refer to your Summary Plan Description (SPD) for a more complete listing of services including plan limitations

and exclusions. Should discrepancies arise, the SPD will govern. 2 The 12 month waiting period applies to replacement bridges and dentures only. This waiting period is waived for all members who enroll on the Employer’s

original group effective date with Delta Dental of Missouri. 3 Orthodontic treatments covered by the prior carrier and in progress on the original effective date of the employer’s group contract with Delta Dental of Missouri will be covered. Benefits provided by the prior carrier will be subtracted from the lifetime maximum available from Delta Dental. Delta Dental will provide benefits until the lifetime maximum is reached or the treatment ends; whichever occurs first.

Dependent children are eligible for coverage until the end of the calendar year in which they turn age 26.

About Delta Dental… Delta Dental gives you the freedom to visit the dentist of your choice and to select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. Delta Dental also gives you access to two networks of participating dentists, Delta Dental PPO and Delta Dental Premier. If your dentist participates in both networks you will receive the best level of coverage available which is typically found in the PPO network. You can verify which network(s) your dentist participates in by visiting Delta Dental’s website at www.deltadentalmo.com and clicking on “Looking for a Dentist?” or by calling Delta’s Customer Service Team at 1-800-335-8266.

Delta Dental PPO Network

A subset of the Delta Dental Premier Network, over 159,000 dental offices participate in the Delta Dental PPO program. Delta Dental will provide the highest level of benefits (see benefit highlights) for covered services when care is received from a Delta Dental PPO dentist. These dentists agree to:

Accept payment based on a reduced fee schedule – which means fewer dollars accumulate towards your annual benefit maximum, your out-of-pocket expenses are typically less and you are protected from balance billing.

Submit dental claims for members and abide by Delta’s policies.

Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta Dental pays the dentist directly.

Your out-of-pocket expenses are typically lowest when you see a Delta Dental PPO dentist.

Delta Dental Premier Network

Comprised of over 241,000 participating dental offices, Delta Dental Premier offers you greater access to dentists while still offering the advantages of a network. These dentists have contractual agreements with Delta Dental which require them to:

Accept payment based on a contractual agreement – which means no balance billing.

Submit dental claims for members and abide by Delta’s policies.

Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta Dental pays the dentist directly.

Non-Network Dentist

If you receive services from a non-network dentist (does not participate in either Delta Dental network):

You may be responsible for filing your own claim forms.

Delta Dental’s benefit payment will be made directly to you.

Benefit payments will be based on Delta’s maximum plan allowance.

You may be balance billed if there is a difference between the dentist’s charge and Delta’ maximum plan allowance.

Your out-of-pocket expenses may be more when you use a non-network dentist.

Locating a Participating Dentist… To determine if your dentist participates with Delta Dental or to select a participating dentist in your area:

Ask your dentist if he or she participates in the Delta Dental PPO or Delta Dental Premier program, or

Search on-line at www.deltadentalmo.com, or

Call Delta Dental Customer Service at 1-800-335-8266

http://www.deltadentalmo.com/


Summary Plan Description (SPD)

Dentacare M (For Customer Service and Benefit Information)

(314) 656-3001

(800) 335-8266 www.deltadentalmo.com

Delta Dental of Missouri PO Box 8690, St. Louis, MO 63126-0690

ASPD-PPO-DMDFD4-8


A b o u t Y o u r C o v e r a g e

About Delta Dental Your dental coverage is provided by Delta Dental of Missouri (DDMO), a not-for-profit corporation. DDMO is a member of a nationwide system of dental benefit providers, known as Delta Dental Plans Association (DDPA), the largest provider of dental benefits in America.

Your Membership Card Dentists do not typically require an ID card, and your dentist can always call DDMO to verify your coverage. If you, your group or dentist prefers that you have an ID card, DDMO will provide you one. ID cards are available through your group or DDMO, by mail or on our website.

Selecting Your Dentist You may visit the dentist of your choice and select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options. 1. PPO Participating Dentist (Delta Dental PPO Network). Delta Dental’s PPO network consists of dentists who have agreed to accept payment based on the lesser of usual fees or the applicable PPO Maximum Plan Allowance and to abide by Delta Dental policies. This network offers you cost control and claim filing benefits. 2. Non-PPO Participating Dentist (Delta Dental Premier Network). Delta Dental’s Premier network consists of dentists who have agreed to accept payment based on the lesser of filed fees or the applicable Premier Maximum Plan Allowance. This network also offers you cost control and claim filing benefits. However, your out-of-pocket expenses (deductibles and coinsurance amounts) may be higher with a Premier dentist, based upon your plan design. 3. Non-Participating Dentist. If you go to a non-participating dentist (not contracted with a Delta Dental plan), DDMO will make payment directly to you based on the lesser of the dentist’s billed charge or the applicable Maximum Plan Allowance. It will be your obligation to make full payment to the dentist and file your own claim. Obtain a claim form from your Plan Administrator’s office or from DDMO.

Advantages of Selecting Participating Dentists All participating dentists (PPO and Premier) have the necessary forms needed to submit your claim. Delta Dental participating dentists will usually file your claims for you and DDMO will pay them directly for covered services. Visit our website at deltadentalmo.com to find out if your dentist participates or contact DDMO to automatically receive, at no cost, a list of PPO and Premier participating dentists in your area. You are not responsible for paying the participating dentist any amount that exceeds the PPO or Premier Maximum Plan Allowance, whichever is applicable. You are only responsible for any noncovered charges, deductible and coinsurance amounts.

Eligibility To be eligible for this coverage, you must meet the eligibility requirements set forth on the Schedule of Benefits. You become eligible for the coverage on the day specified on the Schedule of Benefits or the ERISA Information. If desired, you may obtain a copy of the qualified medical child support order and other special eligibility procedures, at no charge, upon request.

Enrolling At the time of initial enrollment, a member must select one of the membership types offered in the application. If your membership application is not received within 31 days after you first become eligible, your coverage will not become effective until your group's next renewal date. If your dependents (e.g., spouse and dependent children) are not added to your membership within 31 days after they first become eligible dependents (an additional 10 days will be allowed to enroll a newborn child), their coverage will not become effective until your group's next renewal date. During the benefit period, a member may only change his or her selected membership type because of marriage, birth, adoption (or date of placement for purposes of adoption), divorce, death, a Dependent reaching the

limiting age or another designated change in status (if any) under the Membership Certificate. Additional dues or service charges may apply to the change. If a member changes his or her membership type during the annual open enrollment, he or she must wait one-year in order to make another change in membership type (unless the member has a change in status identified above), and then only on your group’s next renewal date.

Dependent Children A dependent child (natural, stepchildren or legally adopted) is eligible for coverage until the end of the calendar year in which he or she reaches the dependent age limit (shown on your Schedule of Benefits) or is eligible to enroll or enrolled under any employer-sponsored group health plan that provides dental benefits. Unmarried dependent children who are incapable of self-support because of physical or mental impairments can continue to be protected under your membership regardless of age, if they become impaired before reaching age 19. A special application must be completed by you and your dependent child’s physician at least 31 days before your child’s 19

th birthday. DDMO may require proof of

continued disability and dependence once a year thereafter. Explanation of Benefits

In certain situations, when a claim is filed by you or your dentist, you may receive a form called an Explanation of Benefits (EOB) from us (e.g., the claim is denied or a balance due to the dentist). It tells you what services were covered and what, if any, were not. An explanation of how to appeal a claim is on the front of the EOB as well as in this Summary Plan Description (SPD).

Coordination of Benefits and Termination If you have other dental coverage, benefits under this program are coordinated with benefits under any such other program to avoid duplication of payment. The two programs together will not pay more than 100% of covered expenses. DDMO may recover benefit overpayments. An enrollee’s coverage will terminate for, among other things, the following: the enrollee no longer meets the eligibility requirements, the group’s coverage is terminated, or the member dies. Termination of coverage does not prejudice claims originating prior to termination.

Conversion and Continuation of Coverage Coverage may not be converted to an individual plan upon termination of employment. If coverage for you or an eligible dependent (qualified beneficiary) ceases because of certain “qualifying events” (e.g., termination of employment, reduction in hours, divorce, death, child’s ceasing to meet the definition of dependent) specified in a federal law called COBRA, then you or your eligible dependent may have the right to purchase continuing coverage for a limited period of time (which may be 18 or 36 months (or some other period of time) depending on the circumstances), if such coverage is timely elected during the 60 day election period, which 60 days after the date coverage would have stopped due to a qualifying event or 60 days after the date the person is sent notice of the right to continue coverage. The qualified beneficiary must timely pay the full applicable cost for this continuation coverage on a monthly basis. Enrollees that may be eligible for such continued coverage should contact their Plan Administrator’s office to advise them of the qualifying event and to receive information specific to their circumstances. For more information about COBRA rights, please contact your Plan Administrator’s office.

Claim Predetermination If the care you need costs less than $200 or is emergency care, your dentist will proceed with treatment at your option. If the cost estimate is more than $200 and is not emergency care, your dentist will determine what treatment you need and could submit a treatment plan to DDMO for predetermination of benefits. This estimate will enable you to determine in advance how much of the cost will be paid by your dental coverage and how much you will be responsible for paying.

B e n e f i t O u t l i n e

Your Schedule of Benefits included in this SPD will show which of the levels of coverage listed below are included in your dental program. It will also show the amount of your deductible and which levels of coverage the deductible applies to. After you satisfy your dental deductible (if it applies), your dental benefits will pay a specific percentage of the allowed amount of covered services, up to your benefit maximum each benefit period. You will be responsible for the remaining coinsurance amount.

For your benefit maximum(s) and your covered percentage(s), refer to your Schedule of Benefits. (If you have orthodontic benefits, you will have a separate lifetime maximum for these benefits.) Your dental benefits are provided according to a benefit period as described in your Schedule of Benefits.

A: Preventive Dental Services Oral examinations (evaluations), twice in any benefit period

(includes all types) Periapical x-rays as required Bitewing x-rays two sets per benefit period Full-mouth x-rays once in any 36 month period Dental prophylaxis (cleaning, scaling, and polishing), twice in

any benefit period Topical fluoride application for dependent children under age

15, twice in any benefit period Emergency palliative treatment as needed (minor procedures to

temporarily reduce or eliminate pain) Space maintainers that replace prematurely lost teeth of eligible

dependent children under age 19 Sealants: for dependent children under age 15, limited to

caries-free occlusal surfaces of the first and second permanent molars, once in any 36 month period

B: Basic Dental Services Restorative services using amalgam, synthetic porcelain,

and plastic filling material Periodontics: treatment for diseases of the gums and bone

supporting the teeth (including periodontal maintenance visits, subject to your prophylaxis frequency limitation, 4 in any benefit period). Periodontal surgery is covered only once in a 3 year period for the same site. Coverage for scaling and root planing are limited to once per 24 months

Endodontics: root canal filling and pulpal therapy (therapy for the soft tissue of a tooth)

Simple extractions Surgical extractions General anesthesia in conjunction with covered surgical

procedures Recement crowns, inlays, onlays, and bridges Denture adjustments, repairs, rebase and relines to

complete and partial dentures Oral surgery

C: Major Dental Services Prosthetics: bridges and dentures, once in 10 years. Crowns, jackets, labial veneers, inlays, and onlays when

required for restorative purposes and when teeth cannot be restored with a filling material, once in 5 years

D: Orthodontic Dental Services Orthodontic care: treatment for correction of malposed

teeth to establish proper occlusion through movement of teeth or their maintenance in position. Applies to dependent children under age 19

C o v e r a g e L i m i t a t i o n s

A panoramic film with or without other films is considered equivalent to a full mouth series for coverage purposes. Coverage for multiple radiographs on the same date of service will not exceed the coverage level for complete mouth series.

Endodontic (root canal treatment) on the same tooth is covered only once in a 2 year period. Re-treatment of the same tooth is allowed when performed by a different dental office.

Charges for replacement of filling restorations are only covered once in a 24 month period, unless the damage to that tooth was caused by accidental injury not related to the normal function of the tooth or teeth.

If an existing bridge or denture cannot be made satisfactory, a replacement will be covered only once in 10 years, but not during the first year of Coverage C benefits.

Dental benefits for an initial or replacement crown, jacket, labial veneer, inlay or onlay on or for a particular tooth will only be provided once in 5 years, unless the damage to that tooth was caused by accidental injury not related to the normal function of the tooth or teeth.

If your membership is terminated before an orthodontic treatment plan is completed, coverage will be provided only to the end of the month of termination.

Benefits will not be paid for repair or replacement of an orthodontic appliance.

After completion of your orthodontic treatment plan or reaching your orthodontic lifetime maximum, no further orthodontic benefits will be provided.

If you receive care from more than one dentist or service provider for the same procedure, benefits will not exceed what would have been paid to one dentist for that procedure (including, but not limited to prosthetics, orthodontics, and root canal therapy). If alternative treatments are available, DDMO will be liable for the least costly professionally satisfactory treatment. This would include, but is not limited to, services such as composite resin fillings on molar teeth, in which case the benefits are based on the allowed amount for an amalgam (silver) filling; or services such as fixed bridges, in which case the benefits may be based on the allowed amount for a removable partial denture.

Refer to your Schedule of Benefits to determine the extent of your coverage.

Dental Services - Levels of Coverage

S e r v i c e s N o t C o v e r e d

Charges for the following are not covered: Services or supplies for which the enrollee, absent this coverage,

would normally incur no charge, such as care rendered by a dentist to a member of his immediate family or the immediate family of his spouse.

Services or supplies for which coverage is available under workers' compensation or employers' liability laws.

Services or supplies performed for cosmetic purposes or to correct congenital malformations, except newborns with congenital dental defects.

Services that require multiple visits, which commenced prior to the membership effective date (including prosthetics and orthodontic care).

Services or supplies related to temporomandibular joint (TMJ) dysfunction (this involves the jaw hinge joint connecting the upper and lower jaws).

Services or supplies not specifically stated as covered dental services (including hospital or prescription drug charges).

Replacement of dentures and other dental appliances which are lost or stolen.

Diseases contracted or injuries or conditions sustained as a result of any act of war.

Denture adjustments for the first six months after the dentures are initially received. Separate fees may not be charged by participating dentists.

Complete occlusal adjustments, crowns for occlusal correction, athletic mouthguards, nightguards, bruxism appliances, and bite therapy appliances.

Tooth preparation, temporary crowns, bases, impressions, and anesthesia or other services which are part of the complete dental procedure. These services are considered components of, and included in the fee for the complete procedure. Separate fees may not be charged by participating dentists.

Analgesia, including Nitrous Oxide, duplication of radiographs, temporary appliances, or implants and related procedures.

Services or supplies covered under a terminal liability, extension of benefits, or similar provision, of a program being replaced by this program.

Services or supplies rendered by a dental or medical department maintained by or on behalf of a group, a mutual benefit association, union, trustee or similar person or group.

Services or supplies provided or paid for by or under any governmental agency or program or law, except charges which the person is legally obligated to pay (this exclusion extends to any benefits provided under the U.S. Social Security Act, as amended).

Services rendered beyond the scope of a dentist’s or service provider’s license, or experimental or investigational services/supplies.

Services or supplies that a dentist determines for any reason, in his professional judgment, should not be provided.

Instructions in dental hygiene, dietary planning, or plaque control.

Missed appointments or claim form completion. Infection control, including sterilization of supplies and

equipment.

H o w T o F i l e a n d A p p e a l A C l a i m

Your claims must be filed by the end of the calendar year following the year in which services were rendered. DDMO is not obligated to pay claims submitted after this period. If a claim is denied due to a PPO or Premier participating dentist's failure to make timely submission, you will not be liable to such dentist for the amount which would have been payable by DDMO, provided you advised the dentist of your eligibility for benefits at the time of treatment.

You will be provided written notice if your claim for benefits under the Plan has been denied, setting forth the specific reasons for such denial, written in a manner to be understood by you. Additionally, if your claim for benefits has been denied, you will be afforded a reasonable opportunity for full review of the decision denying the claim, including appeals and requests for review.

DDMO has established a first-level and second-level review process for written complaints. A first-level review, whether related to an adverse benefit determination or for reasons other than an adverse benefit determination, must be submitted in writing to DDMO’s Customer Service Department. You have 180 days to submit your written complaint after receiving the denial or the notice that gave rise to the complaint. DDMO shall allow 180 days from the date allowed to file the first level complaint or 180 days from the date DDMO sent notification to the person who submitted the complaint of DDMO’s resolution of said first level complaint, whichever is later. Any complaint should be accompanied by documents or records in support of the complaint. You may review pertinent documents relating to the claim and submit issues and comments in writing for consideration.

DDMO will acknowledge receipt in writing within ten working days and will investigate the complaint within twenty working days after receipt of a complaint. If additional time is needed to complete the investigation, DDMO will notify you in writing on or before the twentieth working day with the investigation completed within thirty working days thereafter. DDMO will notify you in writing of the decision within five working days following the investigation. You have the right to request a second-level review, in which case, DDMO shall follow the same time frames as a first-level review except in the case of a request for an expedited review where life or health of an enrollee may be in jeopardy. Any first-level complaint should be sent to: Delta Dental of Missouri, Customer Service Department, 12399 Gravois Rd, St. Louis, MO 63127-1702. Second-level appeals should be sent to: Delta Dental of Missouri, Appeals Committee, 12399 Gravois Rd, St. Louis, MO 63127-1702. You have the right to file an appeal with the Director of the Missouri Department of Insurance at any time. For detailed information on filing an appeal with the Missouri Department of Insurance, (MDI), contact: Missouri Department of Insurance, ATTN: Consumer Affairs, PO Box 690, Jefferson City, MO 65102. The consumer hot line is 1-800-726-7390.

This document is a “summary plan description” (SPD) of your dental care coverage, which is more fully described in the Membership Certificate (plan document). Because this document is a summary, it does not contain a complete explanation of each and every provision or term contained within the more comprehensive Membership Certificate. Where there are conflicts or inconsistencies between the language of the SPD and the Membership Certificate, the language of the Membership Certificate governs. DDMO has the right to amend this SPD and the Membership Certificate, and has discretion and authority to interpret the provisions and terms of this SPD and the Membership Certificate. In addition, your group reserves the right to change or terminate its dental care plan at any time. This SPD is not a guarantee of employment or an employment contract.

10/12

Delta Dental of Missouri - Schedule of Benefits

PPO - Dentacare M Refer to the section, Benefit Outline, in this Summary Plan Description (SPD) for a more detailed explanation of levels of

coverage. For members of: Park Hill School District Group Number: 1942-1000 & all sublocations Coverage Levels and Percentages: PPO Dentist Premier Dentist Non-Participating Dentist

Coverage A: 100% 80% 80%

Coverage B: 100% 70% 70%

Coverage C: 50% 40% 40%

Coverage D: 50% 40% 40%

Deductible: $50 $50 $50

Applies to: C Coverage B & C Coverage B & C Coverage

Family limit: $100 $100 $100

Amounts paid by Member towards the deductible apply to all deductible categories (PPO, Premier, and Non-Participating Dentist).

Benefit Maximum:

Coverage A, B, and C (if applicable): $1,000 $1,000 $1,000

Amounts paid by Delta are applied to all benefit maximums (PPO, Premier, and Non-Participating Dentist).

Orthodontic Lifetime Maximum: $1,000 $1,000 $1,000

Amounts paid by Delta are applied to all orthodontic benefit maximums (PPO, Premier, and Non-Participating Dentist). Dependent Age Limit: 26 Effective Date of Program: 01/01/2013 Renewal Date may sometimes be referred to as Anniversary Date. Benefit Period: Dental benefits are provided according to a calendar year benefit period. The calendar year benefit period

begins on the Effective Date and ends on December 31st of the year in which the Effective Date occurs. A new calendar year

benefit period begins each year on January 1st.

Eligibility: To be eligible for this coverage, you must be an active full-time employee of the group or a designated affiliate.

"Active" means an employee regularly working at least the number of hours in the normal work week set by your group (but not

less than 20 hours). You must be actively at work, unless your group was enrolled in another DDMO program prior to changing

to this program.

If coverage is dropped at any time, members or their dependents may not reenroll until the first open enrollment following one

year.

New members and their dependents become eligible for this coverage on the first of the month following date of employment.

Coverage ends on the last day of the month of employment.

In lieu of the benefits described in this SPD, your customized program is as follows:

MAXAdvantageSM

Benefit Option is included in this program. Charges for exams, cleanings, x-rays, and fluoride

treatments do not apply towards your annual maximum.

10/12

ERISA Information The following sections contain information to meet the requirements of the Employee Retirement Income Security Act (ERISA) of 1974, as amended. It does not constitute a part of the Plan, nor of any insurance policy issued in connection with it. All inquiries relating to the following material should be referred directly to your Plan Administrator.

Name of Plan: The Park Hill School District Dental Plan referred to herein as the Plan.

Plan Number: None provided

Dental Plan for Members of: Park Hill School District

Group Address: 7703 NW Barry Road

Kansas City, MO 64153

Tax ID Number: 44-6003842

Type of Plan and Administration:

The Plan is a group dental plan. The Plan is administered by the Plan Administrator through an insured contract with

DDMO. Certain functions are performed on behalf of the Plan by DDMO. These functions include, but are not limited to,

administration and payment of claims, customer service assistance, and issuing of Summary Plan Descriptions.

Plan Administrator: Park Hill School District

Attention: Dr. Paul Kelly

7703 NW Barry Road


816-359-4020

Agent of Legal Service: Park Hill School District


7703 NW Barry Road


In addition, service of process may be made upon the Plan Administrator or Trustee.

Trustee: Park Hill School District


7703 NW Barry Road


Plan’s Fiscal Year Ends: 6/30

Funding Is: Contributory Contributions to the Plan are made by both the group and the member. The amount the group contributes to the plan will be determined at the group’s discretion from time to time. This practice can be stopped or modified at any time without prior notice to the member.

E R I S A I n f o r m a t i o n ( C o n t i n u e d ) If your Plan is subject to The Employee Retirement Income Security Act of 1974 (ERISA), the following applies. ERISA entitles you, as an enrollee in this program, to certain rights and protections. For more information, please contact your Plan Administrator’s office.

ERISA provides that all Plan enrollees shall be entitled to:

Receive Information About Your Plan And Benefits

Examine without charge, at the Plan Administrator’s office and

at other specified locations, such as worksites and union halls,

all documents governing the Plan, including insurance

contracts, collective bargaining agreements, and a copy of the

latest annual report (Form 5500 Series) filed by the Plan with

the U.S. Department of Labor and available at the Public

Disclosure Room of the Employee Benefits Security

Administration.

Obtain, upon written request to the Plan Administrator, copies

of documents governing the operation of the Plan, including

insurance contracts, collective bargaining agreements, and

copies of the latest annual report (Form 5500 Series) and an

updated Summary Plan Description. The Plan Administrator

may make a reasonable charge for the copies.

Receive a summary of the Plan’s annual financial report. The

Plan Administrator is required by law to furnish each enrollee

with a copy of this summary annual report.

Continue Group Health Plan Coverage

Continue health care coverage for yourself, spouse or

dependents if there is a loss of coverage under the Plan as a

result of a qualifying event. You or your dependents may have

to pay for such coverage. Review this Summary Plan

Description and the documents governing the Plan on the rules

governing your COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods of coverage

for pre-existing conditions under your group health plan, if you

have creditable coverage from another plan. You should be

provided with a certificate of creditable coverage, free of

charge, from your group health plan or health insurance issuer

when you lose coverage under the Plan, when you become

entitled to elect COBRA continuation coverage, when your

COBRA continuation coverage ceases, if you request it before

losing coverage, or if you request it up to 24 months after

losing coverage. Without evidence of creditable coverage, you

may be subject to a pre-existing condition exclusion for 12

months (18 months for late enrollment enrollees) after your

enrollment date in your coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan enrollees, ERISA imposes

duties upon the people who are responsible for operating the

Plan. The people who operate the Plan, called “fiduciaries” of

the Plan, have a duty to do so prudently and in the interest of

you and other Plan enrollees and beneficiaries. No one,

including your group, your union, or any other person, may fire

you or otherwise discriminate against you in any way to prevent

you from obtaining a benefit or from exercising your rights

under ERISA.

Enforce Your Rights

If your claim for a benefit is denied or ignored, in whole or in

part, you have a right to know why this was done, to obtain

copies of documents relating to the decision without charge,

and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above

rights. For instance, if you request a copy of Plan documents or

the latest annual report from the Plan and do not receive them

within 30 days, you may file suit in a Federal court. In such a

case, the court may require the Plan Administrator to provide

the materials and may pay you up to $110 a day until you

receive the materials, unless the materials were not sent because

of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits which is denied or ignored, in

whole or in part, you may file suit in a State or Federal court.

In addition, if you disagree with the Plan’s decision or lack

thereof concerning the qualified status of a domestic relations

order or a medical child support order, you may file suit in a

Federal court. If it should happen that Plan fiduciaries misuse

the Plan’s money, or if you are discriminated against for

asserting your rights, you may seek assistance from the U.S.

Department of Labor, or you may file suit in a Federal court.

The court will decide who should pay court costs and legal fees.

If you are successful, the court may order the person you have

sued to pay these costs and fees. If you lose, the court may

order you to pay these costs and fees, for example, if it finds

your claim is frivolous.

Assistance With Your Questions

If you have any questions about your Plan, you should contact

the Plan Administrator. If you have any questions about this

statement or about your rights under ERISA, or if you need

assistance in obtaining documents from the Plan Administrator,

you should contact the nearest office of the Employee Benefits

Security Administration, U.S. Department of Labor, listed in

your telephone directory or the Division of Technical

Assistance and Inquiries, Employee Benefits Security

Administration, U.S. Department of Labor, 200 Constitution

Avenue N.W., Washington, D.C. 20210. You may also obtain

certain publications about your rights and responsibilities under

ERISA by calling the publications hotline of the Employee

Benefits Security Administration.

Month Regular Claims Orthodontic Claims Paid Claims Number of

Services EE EE+1 FAMTotal

Primary Subscribers

Premium

Mar-2015 $60,248 $2,331 $62,579 1,003 1,132 255 275 1,662 $83,871Apr-2015 $88,154 $4,921 $93,075 1,344 1,130 257 275 1,662 $83,699May-2015 $44,945 $5,112 $50,057 809 1,130 257 275 1,662 $84,008Jun-2015 $53,775 $2,319 $56,094 1,053 1,127 258 275 1,660 $83,700Jul-2015 $94,492 $5,116 $99,609 1,657 1,127 257 274 1,658 $83,097Aug-2015 $63,181 $3,358 $66,539 1,052 1,122 257 274 1,653 $83,611Sep-2015 $44,872 $4,237 $49,108 781 1,152 262 279 1,693 $79,592Oct-2015 $69,317 $2,452 $71,769 1,122 1,159 262 280 1,701 $89,949Nov-2015 $47,372 $2,263 $49,635 792 1,155 259 281 1,695 $86,190Dec-2015 $58,321 $2,347 $60,668 1,082 1,156 257 282 1,695 $85,574Jan-2016 $81,735 $1,608 $83,343 1,342 1,150 269 272 1,691 $78,990Feb-2016 $64,327 $4,047 $68,374 1,151 1,154 269 272 1,695 $78,127Mar-2016 $70,421 $899 $71,320 1,220 1,157 268 271 1,696 $91,162Apr-2016 $64,690 $2,982 $67,672 975 1,163 273 272 1,708 $83,335May-2016 $56,374 $2,872 $59,246 880 1,163 274 273 1,710 $92,704Jun-2016 $75,245 $4,768 $80,013 1,345 1,158 274 273 1,705 $86,355Jul-2016 $79,441 $3,781 $83,222 1,361 1,160 274 274 1,708 $86,215Aug-2016 $75,061 $3,783 $78,844 1,278 1,162 279 274 1,715 $85,793Sep-2016 $62,498 $3,253 $65,750 970 1,197 282 277 1,756 $85,062Oct-2016 $49,301 $1,141 $50,443 849 1,198 283 277 1,758 $90,385Nov-2016 $50,726 $3,143 $53,869 866 1,201 279 280 1,760 $86,469Dec-2016 $74,043 $2,065 $76,108 1,231 1,200 277 280 1,757 $89,039Jan-2017 $73,293 $4,012 $77,305 1,372 1,173 278 296 1,747 $86,638Feb-2017 $74,610 $1,292 $75,902 1,173 1,179 277 296 1,752 $86,793Mar-2017 $92,157 $2,059 $94,216 1,449 1,178 277 298 1,753 $86,535Apr-2017 $60,103 $1,371 $61,475 1,014 1,179 278 295 1,752 $87,689May-2017 $53,227 $2,377 $55,604 869 1,173 279 295 1,747 $86,826Jun-2017 $89,779 $1,618 $91,397 1,488 1,169 278 296 1,743 $86,745Jul-2017 $77,260 $2,216 $79,476 1,369 1,163 277 293 1,733 $86,624Aug-2017 $90,236 $3,611 $93,847 1,586 1,168 276 297 1,741 $85,764

Park Hill School DistrictMarch 1, 2015 through February 28, 2018Claims, Enrollment and Premium Report

Sep-2017 $45,494 $2,259 $47,752 815 1,206 271 305 1,782 $85,543Oct-2017 $61,641 $2,328 $63,969 977 1,212 270 306 1,788 $91,756Nov-2017 $65,511 $1,765 $67,276 1,078 1,207 269 308 1,784 $89,002Dec-2017 $65,099 $3,634 $68,733 1,134 1,203 269 307 1,779 $87,997Jan-2018 $76,428 $2,930 $79,358 1,233 1,202 275 312 1,789 $89,392Feb-2018 $71,616 $1,547 $73,163 1,190 1,201 275 314 1,790 $89,546Total $2,424,992 $101,819 $2,526,811 40,910 42,066 9,731 10,283 62,080 $3,103,777

NPI License ID TIN Specialty First Name MI Last Name Address1 Address2 City State Zip # of Members # of Claims # of Services Paid Claims Claim Network Status

1578524534 15677 431712321 General Dentist KIRBY L KAVANAUGH 7200 NW 86TH ST STE F KANSAS CITY MO 64153 172 376 922 $48,294.90 PPO

1184796336 15736 431854543 NO SPECIALTYCODE

ERICA L FISHER 6300 N REVERE STE 210 KANSAS CITY MO 64151 116 231 546 $30,231.00 PPO

1164451712 14634 010552063 General Dentist DAVID R BURNS 8600 NW 64TH ST STE 201 KANSAS CITY MO 64152 66 185 399 $23,955.01 Premier


KRISTY K FISHER 6300 N REVERE STE 210 KANSAS CITY MO 64151 86 163 377 $19,472.50 PPO

1164412128 15875 870699001 Pediatric Dentist MICHAEL P BERRY 6004 NW 9 HWY PARKVILLE MO 64152 60 110 377 $16,826.00 PPO

1801951660 15161 431661946 General Dentist WILLIAM C BUSCH 2000 SWIFT STREET N KANSAS CITY MO 64116 34 87 270 $15,043.80 PPO


SCOTT M NGUYEN 8355 N CONGRESS AVE STE A KANSAS CITY MO 64152 39 97 241 $10,853.50 PPO


STEPHEN K RUSSELL 9501 NORTH OAK STE 205 KANSAS CITY MO 64155 41 90 232 $15,779.20 PPO


BERNARD G BRUNS 5501 NW 62ND TERRACE STE 101 KANSAS CITY MO 64151 32 69 220 $10,552.00 PPO


STACI R BLAHA 2204 KENTUCKY AVE Platte City MO 64079 32 63 220 $10,527.50 PPO

1497864417 15723 431726963 General Dentist DEAUN S REGAN 407 N MAIN ST PARKVILLE MO 64152 39 87 198 $11,675.40 PPO


DOUGLAS M TRIPLETT 1129 W KANSAS ST STE C LIBERTY MO 64068 41 84 189 $9,998.50 PPO


ARSEN ADJEMIAN 5713 NW 64TH TERRACE KANSAS CITY MO 64151 31 78 188 $12,047.00 PPO


JOY M MILLER 4268 N OAK TRAFFICWAY KANSAS CITY MO 64116 38 79 183 $9,526.40 Premier


MICHAEL D ARNETT 1805 NW PLATTE RD STE 140 KANSAS CITY MO 64150 32 73 183 $11,427.50 PPO

1316014780 13641 431398699 General Dentist CHARLES W BISHOP 7211 NW 83RD ST STE 120 KANSAS CITY MO 64152 32 77 180 $9,413.70 PPO


D GRANT SMITH 9501 NORTH OAK STE 205 Kansas City MO 64155 30 61 178 $10,367.00 PPO

1780759829 14778 479700306 General Dentist LESLIE P MCCLAFLIN 6336 NORTH LUCERNE KANSAS CITY MO 64151 36 74 175 $8,995.70 Premier


STEPHANIE M ALTENBURG 5571 NW BARRY ROAD KANSAS CITY MO 64154 23 57 173 $8,538.50 PPO


MATTHEW H YIP 6340 NORTH CHATHAM AVE KANSAS CITY MO 64151 40 61 167 $12,339.20 PPO

1275667370 14201 363331540 General Dentist CRAIG B MARSHALL 6112 N STATE ROUTE 9 KANSAS CITY MO 64152 24 67 164 $9,766.50 PPO

1427045582 15071 431870570 General Dentist BETTY HORSTMANN 10560 NW AMBASSADOR DR STE 200 KANSAS CITY MO 64153 33 67 160 $9,020.10 Premier


JOHN T HUKE III 6320 LAKECREST LN PARKVILLE MO 64152 25 66 151 $8,849.40 Premier


WENDY J WEIMER 4151 N MULBERRY DR STE 210 KANSAS CITY MO 64116 23 63 141 $7,978.43 PPO


GEOFFREY C RILEY 6412 N COSBY AVE KANSAS CITY MO 64151 20 52 140 $7,361.50 PPO


DAVID TAYLOR BURNS 10915 N W HIGHWAY 45 KANSAS CITY MO 64152 32 55 134 $7,286.30 PPO


KRISTEN R ERSKIN 8530 N GREENHILLS RD KANSAS CITY MO 64154 23 51 131 $5,575.00 PPO


DAVID S THOMAS 9051 NE 81ST TERRACE STE 220 Kansas City MO 64158 18 42 130 $6,392.00 PPO


MARK E KING 2431 BURLINGTON AVE North Kansas City MO 64116 16 30 130 $4,051.50 PPO

1457435547 15043 364348281 General Dentist THOMAS J KOZICKI 5400 N OAK TRAFFICWAY STE 205 KANSAS CITY MO 64118 25 53 129 $6,361.43 PPO


GUY S DEYTON 6416 N COSBY KANSAS CITY MO 64151 24 53 119 $7,697.20 Premier


THOMAS G LAKEBRINK 105 N STEWART CT STE 140 LIBERTY MO 64068 20 45 116 $7,154.80 Premier


HOWARD M SHAPIRO 8603 NORTH OAK TRAFFICWAY KANSAS CITY MO 64155 31 48 114 $5,649.00 PPO

1881812600 15288 431853174 General Dentist LANCE M MILLER 5400 N OAK TRAFFICWAY STE 107 GLADSTONE MO 64118 16 47 110 $11,460.60 Premier

1386747624 15825 431801362 General Dentist MATTHEW GARRISON 14790 N 169 HIGHWAY SMITHVILLE MO 64089 18 43 98 $5,484.60 Premier

1851507727 12679 431375087 Orthodontist STEVEN P BILLINGS 8600 TOM WATSON PKWY STE 101 KANSAS CITY MO 64152 18 35 98 $10,522.35 Premier


G BRENT EVERS 5815 NW BARRY RD Kansas City MO 64154 20 38 97 $5,842.90 Premier

1659485027 15897 431936413 General Dentist CHRISTOPHER H SHULTZ 2 WESTWOODS DR LIBERTY MO 64068 23 36 94 $5,098.00 PPO


MICHAEL A KEMMLING 6004 NW 9 HWY PARKVILLE MO 64152 25 41 93 $5,265.84 PPO


PHILIP J GORDON 5901 NW 63RD TERRACE STE 150 KANSAS CITY MO 64151 16 30 89 $5,886.00 Premier


HELEN E GARRISON 8603 NORTH OAK TRAFFICWAY KANSAS CITY MO 64155 18 28 89 $4,298.00 PPO


ERIC J VANBOENING 10201 N OAK TRAFFICWAY STE 300 KANSAS CITY MO 64155 13 27 89 $4,747.60 PPO


BENJAMIN L WESTMAN 2109 NE 72ND ST STE 105 KANSAS CITY MO 64118 16 43 87 $4,690.70 PPO


KATHERINE L RAMSEY 9018 NORTH SKYVIEW AVE KANSAS CITY MO 64154 15 36 87 $5,273.00 PPO


TIMOTHY J ALTENBURG 5571 NW BARRY ROAD KANSAS CITY MO 64154 14 29 86 $4,311.50 PPO

1427162965 14869 431936413 General Dentist WILLIAM S TINSLEY 2 WESTWOODS DR LIBERTY MO 64068 20 39 82 $5,116.50 PPO


SCOTT T MELTON 6000 N OAK TRAFFICWAY STE 304 GLADSTONE MO 64118 13 38 82 $5,146.00 PPO


BRANDI K ROEBER 113 BLUE JAY DR STE 201 LIBERTY MO 64068 12 21 82 $4,165.25 PPO

1740326966 15300 431581799 General Dentist ROBERT W RECHTIEN JR 231 NW 72ND ST KANSAS CITY MO 64118 17 38 80 $4,769.00 Premier

Report Name: Provider Utilization Report

Group Name: Park Hill School District

Start Paid Date: 01/01/2017

End Paid Date: 12/31/2017

Group List: mo19421000,mo19422000,mo19423000

Show Results: By Provider

Date: 3/20/2018 1:16:24 PM

Duration: 1 minute(s), 3 second(s)

Report Parameters

DELTA DENTAL TOTAL PREMIUM EMPLOYER COST EMPLOYEE COSTJanuary 1, 2018 through December 31, 2018

Employee $31.46 $31.46 $0.00Employee + One $67.18 $31.46 $35.72Employee + Family $105.74 $31.46 $74.28

January 1, 2017 through December 31, 2017






No change in benefits.




Zip Code Gender Date of Birth Date of Hire Dental Option Dental Tier64151 F 9/23/1957 8/9/2013 PPO Dental Plan Employee Only64157 M 3/19/1964 11/1/1999 PPO Dental Plan Employee Only64152 M 12/25/1975 2/3/2014 PPO Dental Plan Employee Only64118 F 8/3/1966 8/18/2008 PPO Dental Plan Employee Only64108 F 8/10/1988 8/3/2011 PPO Dental Plan Employee Only64118 M 8/6/1979 8/3/2005 PPO Dental Plan Employee Only64118 F 4/9/1983 7/2/2002 PPO Dental Plan Employee Only64152 F 9/12/1972 8/20/1997 PPO Dental Plan Employee Only64153 M 11/21/1959 4/22/2003 PPO Dental Plan Employee Only64155 F 9/6/1989 8/2/2012 PPO Dental Plan Employee Only64119 F 4/29/1962 10/17/2016 PPO Dental Plan Employee Only64154 F 12/29/1960 3/1/2005 PPO Dental Plan Employee Only64155 M 5/26/1977 8/8/2017 PPO Dental Plan Employee Only64154 F 7/23/1972 8/16/2006 PPO Dental Plan Employee Only64117 M 6/5/1974 8/1/2016 PPO Dental Plan Employee Only64109 F 12/2/1992 2/3/2014 PPO Dental Plan Employee Only64116 M 5/19/1990 7/31/2014 PPO Dental Plan Employee Only64151 F 4/3/1981 8/2/2007 PPO Dental Plan Employee Only64153 F 10/7/1960 5/5/1997 PPO Dental Plan Employee Only64151 F 5/11/1962 7/27/2015 PPO Dental Plan Employee Only64152 F 8/2/1988 8/3/2017 PPO Dental Plan Employee Only64150 F 5/27/1970 9/18/2017 PPO Dental Plan Employee Only64156 F 1/24/1990 8/1/2016 PPO Dental Plan Employee Only64151 F 8/29/1961 9/24/2012 PPO Dental Plan Employee Only66207 F 11/4/1970 7/31/2008 PPO Dental Plan Employee Only64151 F 10/18/1962 10/4/2010 PPO Dental Plan Employee Only64152 F 2/21/1979 8/7/2002 PPO Dental Plan Employee Only64151 M 2/12/1984 8/2/2012 PPO Dental Plan Employee Only66205 F 6/20/1985 8/3/2015 PPO Dental Plan Employee Only64152 F 4/21/1965 8/21/1992 PPO Dental Plan Employee Only64089 F 5/3/1958 7/28/2014 PPO Dental Plan Employee Only64153 F 11/14/1954 1/18/1994 PPO Dental Plan Employee Only64089 F 9/2/1974 3/31/2005 PPO Dental Plan Employee Only64151 F 1/17/1979 8/11/2014 PPO Dental Plan Employee Only64024 M 5/13/1969 9/10/2002 PPO Dental Plan Employee Only64153 F 4/1/1979 1/2/2002 PPO Dental Plan Employee Only64151 F 10/7/1960 8/2/2012 PPO Dental Plan Employee Only64106 F 8/14/1990 8/1/2013 PPO Dental Plan Employee Only64118 F 9/20/1992 11/28/2016 PPO Dental Plan Employee Only64154 M 9/21/1973 10/10/2017 PPO Dental Plan Employee Only64123 M 9/28/1990 8/11/2014 PPO Dental Plan Employee Only64153 F 10/19/1963 8/19/1999 PPO Dental Plan Employee Only64117 F 9/7/1994 1/5/2017 PPO Dental Plan Employee Only64155 F 8/20/1966 8/19/1999 PPO Dental Plan Employee Only

64106 F 4/9/1982 8/1/2013 PPO Dental Plan Employee Only64114 F 1/18/1974 7/16/2012 PPO Dental Plan Employee Only64154 F 12/18/1967 2/1/2017 PPO Dental Plan Employee Only64152 F 4/29/1957 8/21/1992 PPO Dental Plan Employee Only64114 F 8/6/1990 8/2/2012 PPO Dental Plan Employee Only64155 F 3/3/1985 8/3/2015 PPO Dental Plan Employee Only64110 F 9/27/1989 1/3/2014 PPO Dental Plan Employee Only64151 F 2/26/1966 8/2/2007 PPO Dental Plan Employee Only64151 F 10/25/1973 12/1/2016 PPO Dental Plan Employee Only64116 F 1/19/1963 7/17/2017 PPO Dental Plan Employee Only64118 F 7/25/1986 7/31/2008 PPO Dental Plan Employee Only64105 F 9/7/1992 1/14/2016 PPO Dental Plan Employee Only64151 F 7/15/1977 9/1/2001 PPO Dental Plan Employee Only64157 F 6/30/1979 8/3/2015 PPO Dental Plan Employee Only64119 F 2/16/1993 8/3/2015 PPO Dental Plan Employee Only64111 F 8/13/1967 8/1/2016 PPO Dental Plan Employee Only64079 F 11/8/1973 8/9/2001 PPO Dental Plan Employee Only64151 M 10/15/1959 7/28/2017 PPO Dental Plan Employee Only64477 F 3/21/1961 11/1/2013 PPO Dental Plan Employee Only64151 M 2/23/1952 8/13/2008 PPO Dental Plan Employee Only64150 F 6/18/1984 8/3/2015 PPO Dental Plan Employee Only64068 F 4/11/1990 8/7/2015 PPO Dental Plan Employee Only64151 F 1/31/1961 8/26/2005 PPO Dental Plan Employee Only66202 F 4/12/1982 8/16/2012 PPO Dental Plan Employee Only64068 M 1/10/1986 10/29/2012 PPO Dental Plan Employee Only64152 F 4/1/1987 3/9/2007 PPO Dental Plan Employee Only64151 M 8/24/1990 3/13/2014 PPO Dental Plan Employee Only64068 M 11/22/1974 8/16/2000 PPO Dental Plan Employee Only64068 F 9/23/1954 6/8/1998 PPO Dental Plan Employee Only64155 F 9/17/1966 1/12/2009 PPO Dental Plan Employee Only64152 F 7/16/1973 9/22/2014 PPO Dental Plan Employee Only64157 M 7/28/1987 8/3/2015 PPO Dental Plan Employee Only64151 F 7/28/1964 1/10/2005 PPO Dental Plan Employee Only64154 F 10/14/1981 8/3/2006 PPO Dental Plan Employee Only64154 M 9/22/1981 8/6/2004 PPO Dental Plan Employee Only64152 M 3/19/1945 6/16/2008 PPO Dental Plan Employee Only64111 M 8/22/1994 8/3/2017 PPO Dental Plan Employee Only64152 F 9/8/1989 8/1/2016 PPO Dental Plan Employee Only64152 F 4/23/1983 8/3/2005 PPO Dental Plan Employee Only64152 F 9/7/1974 8/12/2011 PPO Dental Plan Employee Only64079 M 10/20/1956 7/11/2011 PPO Dental Plan Employee Only64151 F 9/30/1982 8/3/2006 PPO Dental Plan Employee Only64119 M 2/9/1968 3/28/2016 PPO Dental Plan Employee Only64155 F 7/26/1966 9/13/1989 PPO Dental Plan Employee Only64152 F 1/16/1984 7/20/2015 PPO Dental Plan Employee Only

64109 M 2/5/1980 7/31/2008 PPO Dental Plan Employee Only64157 M 2/15/1978 8/1/2016 PPO Dental Plan Employee Only64154 F 4/29/1980 8/4/2003 PPO Dental Plan Employee Only66062 F 1/4/1981 7/1/2017 PPO Dental Plan Employee Only64152 M 12/14/1964 8/29/1989 PPO Dental Plan Employee Only64106 M 5/22/1967 8/3/2005 PPO Dental Plan Employee Only64068 M 5/3/1990 3/27/2017 PPO Dental Plan Employee Only64152 F 6/14/1965 8/3/2005 PPO Dental Plan Employee Only64154 F 2/26/1967 11/5/2012 PPO Dental Plan Employee Only66208 F 3/23/1988 8/2/2012 PPO Dental Plan Employee Only64079 M 2/17/1984 1/4/2016 PPO Dental Plan Employee Only64109 F 3/25/1994 8/10/2017 PPO Dental Plan Employee Only64119 F 4/13/1990 8/8/2016 PPO Dental Plan Employee Only64111 F 6/1/1991 10/5/2015 PPO Dental Plan Employee Only64152 F 3/18/1959 8/13/2012 PPO Dental Plan Employee Only64151 M 1/20/1962 1/2/2008 PPO Dental Plan Employee Only64110 M 1/1/1988 11/12/2012 PPO Dental Plan Employee Only64118 M 8/25/1957 1/6/2004 PPO Dental Plan Employee Only64154 F 11/30/1990 8/11/2016 PPO Dental Plan Employee Only64119 F 5/5/1964 9/24/2007 PPO Dental Plan Employee Only64118 F 2/11/1991 12/4/2017 PPO Dental Plan Employee Only66109 F 6/23/1962 7/25/2016 PPO Dental Plan Employee Only64068 M 6/10/1991 12/4/2017 PPO Dental Plan Employee Only64113 F 3/10/1975 7/6/1999 PPO Dental Plan Employee Only64152 F 8/20/1981 8/12/2013 PPO Dental Plan Employee Only66046 F 1/14/1966 1/21/2014 PPO Dental Plan Employee Only64154 M 10/25/1990 8/8/2016 PPO Dental Plan Employee Only64155 F 2/27/1996 1/2/2018 PPO Dental Plan Employee Only64057 M 3/24/1990 1/4/2016 PPO Dental Plan Employee Only64152 M 11/22/1982 2/23/2015 PPO Dental Plan Employee Only64152 F 1/27/1980 9/12/2016 PPO Dental Plan Employee Only64068 F 9/7/1978 8/4/2003 PPO Dental Plan Employee Only64068 M 6/24/1986 8/3/2015 PPO Dental Plan Employee Only64116 M 4/25/1962 6/30/2000 PPO Dental Plan Employee Only64157 F 8/21/1959 8/15/1995 PPO Dental Plan Employee Only64152 F 8/8/1982 2/22/2016 PPO Dental Plan Employee Only64155 F 8/19/1991 8/3/2017 PPO Dental Plan Employee Only64151 F 8/25/1989 8/3/2015 PPO Dental Plan Employee Only64155 F 11/12/1987 9/5/2017 PPO Dental Plan Employee Only64111 F 7/7/1983 8/3/2015 PPO Dental Plan Employee Only64114 F 10/10/1983 7/31/2008 PPO Dental Plan Employee Only64155 F 8/1/1954 8/2/2007 PPO Dental Plan Employee Only64119 M 2/9/1982 8/3/2011 PPO Dental Plan Employee Only64119 M 4/29/1987 2/1/2018 PPO Dental Plan Employee Only64155 F 12/9/1987 8/2/2012 PPO Dental Plan Employee Only

64118 F 4/16/1971 8/3/2015 PPO Dental Plan Employee Only64157 F 10/7/1977 1/9/2001 PPO Dental Plan Employee Only64157 F 11/15/1972 8/21/1996 PPO Dental Plan Employee Only64118 F 1/21/1984 8/2/2007 PPO Dental Plan Employee Only64152 F 11/10/1964 7/20/2009 PPO Dental Plan Employee Only64024 M 6/6/1954 8/2/2005 PPO Dental Plan Employee Only64151 F 4/7/1969 8/15/2007 PPO Dental Plan Employee Only64153 M 9/11/1975 8/3/2005 PPO Dental Plan Employee Only64153 F 2/21/1985 8/9/2007 PPO Dental Plan Employee Only64152 F 1/5/1980 8/15/2012 PPO Dental Plan Employee Only64151 F 12/14/1957 8/6/2004 PPO Dental Plan Employee Only64151 F 9/30/1986 5/12/2016 PPO Dental Plan Employee Only64155 F 7/31/1984 8/3/2006 PPO Dental Plan Employee Only64155 F 10/12/1963 9/2/2008 PPO Dental Plan Employee Only66061 F 10/20/1978 8/6/2004 PPO Dental Plan Employee Only64151 F 12/10/1969 8/7/2002 PPO Dental Plan Employee Only64119 F 8/27/1992 8/3/2015 PPO Dental Plan Employee Only64152 F 4/12/1986 8/4/2009 PPO Dental Plan Employee Only64477 M 2/16/1961 8/26/2002 PPO Dental Plan Employee Only64154 F 4/23/1964 8/2/2007 PPO Dental Plan Employee Only64154 F 5/23/1961 8/20/1997 PPO Dental Plan Employee Only64154 F 8/16/1965 8/9/2001 PPO Dental Plan Employee Only64153 M 6/21/1965 3/23/2015 PPO Dental Plan Employee Only64157 F 11/6/1976 8/16/2000 PPO Dental Plan Employee Only64152 F 9/19/1980 8/2/2007 PPO Dental Plan Employee Only64156 F 4/21/1972 8/20/1997 PPO Dental Plan Employee Only64057 M 9/11/1971 7/31/2014 PPO Dental Plan Employee Only64157 M 4/12/1988 8/9/2013 PPO Dental Plan Employee Only64154 F 7/25/1970 8/1/2016 PPO Dental Plan Employee Only64114 M 5/2/1965 6/21/1990 PPO Dental Plan Employee Only64152 F 9/2/1987 8/1/2013 PPO Dental Plan Employee Only64155 F 5/26/1988 8/16/2011 PPO Dental Plan Employee Only64157 F 10/26/1990 8/1/2013 PPO Dental Plan Employee Only64151 F 12/6/1948 8/15/2007 PPO Dental Plan Employee Only64155 M 10/6/1960 10/6/2003 PPO Dental Plan Employee Only64151 F 2/6/1975 7/28/2016 PPO Dental Plan Employee Only64155 M 4/8/1981 9/19/2005 PPO Dental Plan Employee Only64152 F 10/26/1989 8/1/2016 PPO Dental Plan Employee Only64157 F 3/24/1973 8/7/2002 PPO Dental Plan Employee Only64156 F 10/7/1976 8/16/2000 PPO Dental Plan Employee Only66061 F 6/30/1969 7/31/2008 PPO Dental Plan Employee Only64079 F 7/26/1982 10/19/2010 PPO Dental Plan Employee Only64068 F 2/21/1959 9/15/2008 PPO Dental Plan Employee Only64114 F 3/27/1968 8/17/1994 PPO Dental Plan Employee Only64151 F 6/8/1955 8/9/2001 PPO Dental Plan Employee Only

64151 F 3/18/1959 8/19/2002 PPO Dental Plan Employee Only64154 F 12/24/1960 8/6/2004 PPO Dental Plan Employee Only64153 F 11/29/1965 8/10/2005 PPO Dental Plan Employee Only64156 M 9/20/1967 7/1/2010 PPO Dental Plan Employee Only64152 M 11/21/1972 8/21/1996 PPO Dental Plan Employee Only64152 M 6/20/1981 1/25/2006 PPO Dental Plan Employee Only64156 F 1/31/1986 8/2/2012 PPO Dental Plan Employee Only64151 F 4/28/1955 8/10/2009 PPO Dental Plan Employee Only64152 F 12/4/1958 4/9/1990 PPO Dental Plan Employee Only66223 M 8/22/1973 8/3/2006 PPO Dental Plan Employee Only66211 F 10/13/1978 7/20/2017 PPO Dental Plan Employee Only64018 F 7/26/1979 8/3/2005 PPO Dental Plan Employee Only64155 F 5/23/1981 8/3/2017 PPO Dental Plan Employee Only66109 F 4/3/1990 8/2/2012 PPO Dental Plan Employee Only64111 F 3/22/1989 8/2/2012 PPO Dental Plan Employee Only64118 F 12/15/1988 8/21/2017 PPO Dental Plan Employee Only64153 F 1/21/1987 8/1/2013 PPO Dental Plan Employee Only64155 F 6/9/1986 8/3/2015 PPO Dental Plan Employee Only64152 F 11/23/1987 8/3/2011 PPO Dental Plan Employee Only64118 F 5/10/1991 8/11/2014 PPO Dental Plan Employee Only64154 M 4/11/1991 7/31/2014 PPO Dental Plan Employee Only64151 F 4/29/1991 8/1/2013 PPO Dental Plan Employee Only64155 M 7/13/1985 6/1/2016 PPO Dental Plan Employee Only64152 F 11/21/1992 8/1/2016 PPO Dental Plan Employee Only64030 F 9/1/1988 3/28/2016 PPO Dental Plan Employee Only64119 F 8/9/1994 8/3/2017 PPO Dental Plan Employee Only64068 M 7/8/1945 1/16/2013 PPO Dental Plan Employee Only64111 M 3/24/1963 7/31/2008 PPO Dental Plan Employee Only64151 M 8/28/1954 3/16/2016 PPO Dental Plan Employee Only64151 F 9/24/1963 3/19/2001 PPO Dental Plan Employee Only64152 F 11/24/1962 5/28/1987 PPO Dental Plan Employee Only64152 F 12/4/1959 8/16/2000 PPO Dental Plan Employee Only64152 M 2/21/1966 7/22/1985 PPO Dental Plan Employee Only64152 F 2/22/1956 2/28/2000 PPO Dental Plan Employee Only64151 F 2/8/1962 8/6/2004 PPO Dental Plan Employee Only64151 M 6/27/1968 8/26/1992 PPO Dental Plan Employee Only64118 M 6/23/1968 8/1/1993 PPO Dental Plan Employee Only64151 F 4/14/1963 8/2/2007 PPO Dental Plan Employee Only64118 F 1/6/1974 7/13/2015 PPO Dental Plan Employee Only64153 F 8/6/1964 8/17/2010 PPO Dental Plan Employee Only64485 F 1/26/1969 8/3/2015 PPO Dental Plan Employee Only64151 F 11/6/1970 7/25/2005 PPO Dental Plan Employee Only64152 F 6/8/1976 1/2/2015 PPO Dental Plan Employee Only64117 F 11/6/1975 1/2/2003 PPO Dental Plan Employee Only64152 F 9/9/1979 8/3/2005 PPO Dental Plan Employee Only

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64151 F 5/11/1976 3/9/2015 PPO Dental Plan Employee Plus One64152 F 7/30/1980 8/3/2006 PPO Dental Plan Employee Plus One64098 M 3/27/1990 12/7/2015 PPO Dental Plan Employee Plus One64152 F 2/2/1957 3/11/1999 PPO Dental Plan Employee Plus One66085 M 12/3/1953 8/3/2017 PPO Dental Plan Employee Plus One66202 F 5/19/1987 3/14/2016 PPO Dental Plan Employee Plus One64157 F 8/16/1958 9/8/2009 PPO Dental Plan Employee Plus One64089 F 8/1/1961 8/25/1997 PPO Dental Plan Employee Plus One64068 F 6/27/1978 1/2/2001 PPO Dental Plan Employee Plus One64118 M 6/6/1953 8/13/2012 PPO Dental Plan Employee Plus One64151 M 12/27/1965 10/15/2014 PPO Dental Plan Employee Plus One64151 F 1/26/1976 7/31/2008 PPO Dental Plan Employee Plus One64155 F 8/3/1983 8/2/2007 PPO Dental Plan Employee Plus One66106 M 12/12/1990 1/3/2017 PPO Dental Plan Employee Plus One64079 F 3/21/1954 12/1/1992 PPO Dental Plan Employee Plus One64151 M 1/13/1957 1/19/2017 PPO Dental Plan Employee Plus One64118 M 5/22/1990 8/3/2015 PPO Dental Plan Employee Plus One64079 F 8/5/1980 1/20/2009 PPO Dental Plan Employee Plus One64151 M 5/12/1953 9/9/2013 PPO Dental Plan Employee Plus One64151 F 3/27/1985 8/1/2014 PPO Dental Plan Employee Plus One64156 F 8/25/1983 9/8/2015 PPO Dental Plan Employee Plus One64151 M 4/26/1987 7/5/2017 PPO Dental Plan Employee Plus One64118 F 8/4/1987 8/12/2011 PPO Dental Plan Employee Plus One64079 M 5/2/1982 6/20/2016 PPO Dental Plan Employee Plus One64152 M 8/28/1976 7/16/2012 PPO Dental Plan Family64152 M 1/9/1986 8/4/2009 PPO Dental Plan Family64152 F 9/30/1970 2/12/2013 PPO Dental Plan Family64153 M 11/18/1965 10/21/2013 PPO Dental Plan Family66202 F 1/8/1978 8/9/2001 PPO Dental Plan Family64152 F 6/9/1961 9/6/2011 PPO Dental Plan Family64154 F 7/23/1963 7/20/2009 PPO Dental Plan Family66207 F 9/13/1970 8/3/2015 PPO Dental Plan Family64089 F 1/9/1975 7/31/2014 PPO Dental Plan Family64151 M 3/2/1966 8/20/1997 PPO Dental Plan Family64152 F 4/13/1970 8/15/2012 PPO Dental Plan Family64156 F 9/29/1972 8/4/2010 PPO Dental Plan Family64151 F 4/9/1979 8/11/2017 PPO Dental Plan Family64154 F 11/8/1979 8/3/2006 PPO Dental Plan Family64152 F 5/13/1968 7/31/2014 PPO Dental Plan Family64068 F 4/8/1977 10/23/2014 PPO Dental Plan Family64151 F 10/14/1961 8/1/2011 PPO Dental Plan Family64152 F 3/31/1970 8/3/2016 PPO Dental Plan Family64030 M 7/11/1972 8/26/1996 PPO Dental Plan Family64152 F 3/13/1981 9/17/2014 PPO Dental Plan Family64152 F 11/15/1966 2/2/2015 PPO Dental Plan Family

64151 F 8/15/1965 10/15/2003 PPO Dental Plan Family64158 F 4/22/1969 8/17/1998 PPO Dental Plan Family64153 F 9/9/1985 8/1/2013 PPO Dental Plan Family64152 F 9/14/1970 10/13/2004 PPO Dental Plan Family64153 F 6/12/1977 9/8/2014 PPO Dental Plan Family64151 F 6/13/1959 8/13/2001 PPO Dental Plan Family64089 F 6/15/1972 8/9/2001 PPO Dental Plan Family64156 F 6/22/1979 8/3/2006 PPO Dental Plan Family64152 M 3/30/1976 8/9/2001 PPO Dental Plan Family64089 M 5/5/1971 5/3/2001 PPO Dental Plan Family64118 F 3/7/1985 7/31/2014 PPO Dental Plan Family64151 F 10/20/1980 8/1/2013 PPO Dental Plan Family64152 F 5/23/1963 6/21/1990 PPO Dental Plan Family64157 F 4/24/1970 8/22/1995 PPO Dental Plan Family64154 F 3/24/1981 8/3/2015 PPO Dental Plan Family64152 F 7/28/1974 8/9/2017 PPO Dental Plan Family64152 F 5/9/1973 8/12/2013 PPO Dental Plan Family64153 F 11/15/1976 8/16/2006 PPO Dental Plan Family64152 F 2/11/1975 8/3/2005 PPO Dental Plan Family64119 M 7/31/1972 8/17/2010 PPO Dental Plan Family64152 F 10/14/1976 8/4/2003 PPO Dental Plan Family64152 F 4/18/1981 8/6/2004 PPO Dental Plan Family64151 F 8/18/1977 8/7/2017 PPO Dental Plan Family64154 F 3/26/1976 8/16/2011 PPO Dental Plan Family66212 F 4/27/1975 8/9/2001 PPO Dental Plan Family64154 F 7/25/1967 6/8/1989 PPO Dental Plan Family64153 F 7/18/1967 9/6/2005 PPO Dental Plan Family64118 F 2/21/1976 8/17/2010 PPO Dental Plan Family64153 F 3/9/1970 8/19/1999 PPO Dental Plan Family64079 F 7/30/1972 8/3/2006 PPO Dental Plan Family64154 F 7/14/1977 10/24/2002 PPO Dental Plan Family64157 F 8/13/1966 3/14/2016 PPO Dental Plan Family64154 M 7/26/1973 8/7/2002 PPO Dental Plan Family64151 F 9/2/1975 8/11/2008 PPO Dental Plan Family64151 F 4/3/1987 8/4/2010 PPO Dental Plan Family64153 F 4/27/1989 10/9/2012 PPO Dental Plan Family64151 F 2/11/1976 1/24/2013 PPO Dental Plan Family64153 M 6/10/1962 2/28/2000 PPO Dental Plan Family64151 F 4/16/1966 8/3/2005 PPO Dental Plan Family64152 M 4/29/1967 12/3/2003 PPO Dental Plan Family64118 M 11/20/1976 8/4/2009 PPO Dental Plan Family64153 F 2/2/1984 7/31/2008 PPO Dental Plan Family64060 F 4/23/1973 7/31/2012 PPO Dental Plan Family64119 M 12/31/1962 8/25/2003 PPO Dental Plan Family64152 F 7/29/1981 7/17/2017 PPO Dental Plan Family

64151 F 6/7/1982 8/8/2016 PPO Dental Plan Family64152 F 10/17/1969 8/21/1992 PPO Dental Plan Family64151 F 5/25/1972 9/1/2006 PPO Dental Plan Family64068 F 5/26/1977 8/3/2017 PPO Dental Plan Family64152 F 1/3/1960 7/23/2002 PPO Dental Plan Family64152 F 2/8/1974 11/5/2014 PPO Dental Plan Family64154 F 11/27/1971 8/9/2001 PPO Dental Plan Family64152 F 4/30/1963 8/16/2005 PPO Dental Plan Family64152 F 12/1/1970 7/30/2015 PPO Dental Plan Family64157 F 7/5/1980 7/31/2008 PPO Dental Plan Family64154 F 5/27/1966 8/26/1994 PPO Dental Plan Family64152 F 1/12/1974 8/3/2006 PPO Dental Plan Family64151 M 3/11/1969 7/1/2012 PPO Dental Plan Family64152 M 8/21/1980 8/3/2006 PPO Dental Plan Family64157 M 1/12/1977 8/16/2000 PPO Dental Plan Family64151 F 4/12/1979 8/1/2016 PPO Dental Plan Family64152 F 6/2/1986 8/4/2009 PPO Dental Plan Family64152 F 9/29/1970 7/31/2017 PPO Dental Plan Family64152 F 7/26/1959 8/24/1999 PPO Dental Plan Family64152 F 10/19/1973 8/6/2004 PPO Dental Plan Family64119 M 4/14/1979 3/6/2013 PPO Dental Plan Family64079 F 10/12/1969 8/4/2015 PPO Dental Plan Family64157 F 10/13/1977 8/16/2000 PPO Dental Plan Family64157 F 7/30/1981 8/1/2016 PPO Dental Plan Family64152 F 12/6/1976 8/1/2016 PPO Dental Plan Family64016 F 3/31/1970 8/3/2006 PPO Dental Plan Family64151 F 12/18/1971 8/17/1998 PPO Dental Plan Family64155 F 9/23/1982 11/4/2002 PPO Dental Plan Family64152 M 7/2/1968 8/1/2016 PPO Dental Plan Family64152 F 12/21/1976 7/31/2014 PPO Dental Plan Family64079 F 4/2/1971 1/9/1995 PPO Dental Plan Family64151 F 7/1/1965 6/25/1987 PPO Dental Plan Family64157 F 4/29/1976 8/3/2009 PPO Dental Plan Family64152 M 6/27/1983 10/11/2001 PPO Dental Plan Family64151 M 5/8/1982 4/20/2015 PPO Dental Plan Family64079 F 6/15/1970 8/11/2014 PPO Dental Plan Family64058 M 11/1/1982 1/9/2012 PPO Dental Plan Family64151 F 8/20/1971 8/14/2017 PPO Dental Plan Family64152 F 9/10/1972 8/20/1997 PPO Dental Plan Family64158 F 5/30/1978 7/31/2008 PPO Dental Plan Family64075 M 10/19/1965 8/7/2002 PPO Dental Plan Family64152 M 8/14/1974 8/1/2013 PPO Dental Plan Family65321 F 3/17/1981 8/3/2006 PPO Dental Plan Family64158 F 8/30/1975 10/10/2016 PPO Dental Plan Family64108 F 12/24/1974 8/6/2004 PPO Dental Plan Family

64151 F 5/10/1973 7/19/2016 PPO Dental Plan Family64152 F 1/22/1972 8/13/2010 PPO Dental Plan Family64429 M 9/15/1966 8/16/2000 PPO Dental Plan Family64151 M 9/30/1962 8/31/2010 PPO Dental Plan Family64151 F 6/29/1971 8/1/2002 PPO Dental Plan Family64056 M 2/25/1987 9/5/2017 PPO Dental Plan Family64116 F 5/19/1973 7/1/2014 PPO Dental Plan Family64152 F 12/9/1960 8/4/2009 PPO Dental Plan Family64152 F 5/19/1959 11/8/2010 PPO Dental Plan Family64151 F 4/6/1967 8/19/1993 PPO Dental Plan Family64152 F 5/31/1973 8/16/2000 PPO Dental Plan Family64152 F 2/11/1975 7/17/2012 PPO Dental Plan Family64152 M 7/20/1968 8/21/1996 PPO Dental Plan Family64153 F 3/5/1968 8/30/1994 PPO Dental Plan Family64152 F 8/14/1979 8/7/2002 PPO Dental Plan Family64153 F 5/29/1977 8/3/2006 PPO Dental Plan Family64152 F 7/31/1976 1/28/2013 PPO Dental Plan Family64151 F 1/31/1979 8/9/2001 PPO Dental Plan Family64154 F 11/3/1961 8/14/2017 PPO Dental Plan Family64152 F 2/19/1976 2/1/2010 PPO Dental Plan Family64154 M 1/17/1970 8/19/1999 PPO Dental Plan Family64152 F 7/28/1969 10/23/2017 PPO Dental Plan Family64079 F 11/26/1968 8/21/1996 PPO Dental Plan Family64158 F 12/19/1968 12/7/2017 PPO Dental Plan Family64155 F 8/3/1972 10/25/2004 PPO Dental Plan Family64152 M 4/27/1982 8/3/2015 PPO Dental Plan Family64157 F 10/22/1979 8/15/2012 PPO Dental Plan Family64151 F 3/9/1971 9/5/2017 PPO Dental Plan Family64133 M 8/15/1979 10/13/2014 PPO Dental Plan Family64151 M 7/15/1977 8/1/2016 PPO Dental Plan Family64151 F 12/11/1980 8/1/2016 PPO Dental Plan Family64152 M 7/28/1976 10/19/2007 PPO Dental Plan Family64151 F 1/8/1966 8/14/2013 PPO Dental Plan Family64152 M 5/1/1963 9/8/2015 PPO Dental Plan Family64157 M 1/19/1976 8/2/2007 PPO Dental Plan Family64151 F 6/23/1965 9/9/2013 PPO Dental Plan Family64152 F 3/30/1970 7/1/2005 PPO Dental Plan Family64057 F 4/8/1967 8/26/1992 PPO Dental Plan Family64156 F 10/30/1971 8/8/2002 PPO Dental Plan Family64153 F 10/15/1983 8/2/2007 PPO Dental Plan Family64157 M 6/17/1982 8/3/2017 PPO Dental Plan Family64153 F 8/25/1979 8/3/2017 PPO Dental Plan Family64118 F 12/7/1990 8/1/2014 PPO Dental Plan Family64151 F 5/20/1958 8/19/2002 PPO Dental Plan Family64152 F 10/7/1964 8/21/1991 PPO Dental Plan Family

64151 M 6/1/1979 8/3/2005 PPO Dental Plan Family64118 F 3/12/1978 8/2/2012 PPO Dental Plan Family64151 F 10/19/1972 8/17/1999 PPO Dental Plan Family64157 F 4/3/1967 8/3/2005 PPO Dental Plan Family64151 F 4/8/1968 7/24/1990 PPO Dental Plan Family64152 F 8/16/1979 8/7/2002 PPO Dental Plan Family64152 M 4/22/1974 8/26/1996 PPO Dental Plan Family64156 F 7/31/1972 8/20/1997 PPO Dental Plan Family64152 F 11/27/1980 7/28/2016 PPO Dental Plan Family64155 F 8/29/1973 8/16/2006 PPO Dental Plan Family64151 F 4/28/1967 9/1/2001 PPO Dental Plan Family64151 F 7/16/1973 8/14/2002 PPO Dental Plan Family64151 F 1/6/1972 1/19/2010 PPO Dental Plan Family64154 F 7/27/1983 8/4/2009 PPO Dental Plan Family64089 F 6/6/1968 8/3/2005 PPO Dental Plan Family64029 F 7/24/1980 8/2/2012 PPO Dental Plan Family64153 F 10/12/1977 3/12/2015 PPO Dental Plan Family64151 F 8/22/1982 1/13/2006 PPO Dental Plan Family64068 F 10/28/1973 8/3/2015 PPO Dental Plan Family64157 F 1/28/1991 7/31/2014 PPO Dental Plan Family64154 M 6/7/1958 2/1/2015 PPO Dental Plan Family64485 F 2/26/1973 8/1/2013 PPO Dental Plan Family64154 M 6/30/1967 8/19/1999 PPO Dental Plan Family64454 F 10/11/1976 9/21/2009 PPO Dental Plan Family64152 F 10/8/1970 9/1/1993 PPO Dental Plan Family64152 M 5/29/1976 8/12/2014 PPO Dental Plan Family64119 M 9/6/1972 8/26/1996 PPO Dental Plan Family64153 F 2/12/1989 8/14/2017 PPO Dental Plan Family64152 F 7/24/1963 7/24/1990 PPO Dental Plan Family64151 M 1/29/1959 2/1/2010 PPO Dental Plan Family64089 F 3/26/1972 8/20/2004 PPO Dental Plan Family64152 F 3/9/1959 2/17/1998 PPO Dental Plan Family64079 F 10/17/1978 2/2/1998 PPO Dental Plan Family64157 F 11/23/1971 8/16/2000 PPO Dental Plan Family64112 M 4/27/1966 1/2/2003 PPO Dental Plan Family64113 F 3/30/1979 8/3/2006 PPO Dental Plan Family64154 F 8/14/1980 7/14/2014 PPO Dental Plan Family64156 F 1/30/1978 8/3/2006 PPO Dental Plan Family64152 F 1/21/1969 8/21/1992 PPO Dental Plan Family64089 F 9/14/1962 10/1/2012 PPO Dental Plan Family64151 F 9/30/1965 8/21/1992 PPO Dental Plan Family64154 F 12/14/1966 8/3/2015 PPO Dental Plan Family64157 F 8/9/1969 8/27/2012 PPO Dental Plan Family64152 F 3/21/1971 4/13/2016 PPO Dental Plan Family64151 F 5/17/1983 7/31/2014 PPO Dental Plan Family

64155 F 9/18/1983 8/3/2017 PPO Dental Plan Family64156 F 1/7/1987 8/4/2009 PPO Dental Plan Family64157 F 4/10/1990 8/2/2012 PPO Dental Plan Family64152 F 12/19/1970 8/13/2014 PPO Dental Plan Family64118 F 9/15/1980 8/6/2004 PPO Dental Plan Family64152 M 9/5/1973 8/21/1996 PPO Dental Plan Family64079 M 9/8/1974 8/24/1998 PPO Dental Plan Family66218 M 6/22/1955 8/2/2016 PPO Dental Plan Family64152 F 12/10/1971 8/3/2015 PPO Dental Plan Family64119 F 8/19/1976 10/3/2013 PPO Dental Plan Family64151 F 8/30/1963 2/12/1988 PPO Dental Plan Family64154 F 11/7/1977 8/9/2001 PPO Dental Plan Family64153 F 9/20/1974 8/6/2004 PPO Dental Plan Family64157 M 11/20/1966 8/16/2000 PPO Dental Plan Family64079 F 5/10/1982 8/2/2012 PPO Dental Plan Family64079 F 11/8/1970 4/1/2006 PPO Dental Plan Family64116 F 2/24/1981 8/3/2015 PPO Dental Plan Family64152 F 6/22/1966 11/14/2011 PPO Dental Plan Family64079 M 12/24/1974 8/6/2004 PPO Dental Plan Family64111 M 7/6/1982 8/15/2016 PPO Dental Plan Family64151 M 12/26/1981 8/2/2007 PPO Dental Plan Family64151 F 12/13/1973 8/1/2013 PPO Dental Plan Family64152 F 1/17/1958 3/7/2007 PPO Dental Plan Family64118 M 5/8/1974 8/20/1997 PPO Dental Plan Family64152 M 6/6/1968 5/25/1990 PPO Dental Plan Family64152 M 7/5/1972 8/16/1995 PPO Dental Plan Family64152 F 9/13/1971 8/7/2002 PPO Dental Plan Family66104 M 6/21/1979 7/1/2017 PPO Dental Plan Family64152 M 6/13/1977 8/4/2009 PPO Dental Plan Family64156 F 2/14/1974 8/1/2016 PPO Dental Plan Family64152 F 1/22/1964 8/21/1996 PPO Dental Plan Family64014 M 9/26/1974 7/1/2013 PPO Dental Plan Family64089 M 2/1/1969 8/16/2000 PPO Dental Plan Family64152 F 12/8/1969 8/12/2010 PPO Dental Plan Family64152 M 11/2/1957 10/28/1992 PPO Dental Plan Family64119 F 1/16/1982 8/4/2009 PPO Dental Plan Family64118 F 1/3/1966 8/24/1989 PPO Dental Plan Family64151 M 6/10/1967 7/1/2008 PPO Dental Plan Family64152 F 7/25/1970 8/9/2001 PPO Dental Plan Family64152 F 8/2/1981 1/10/2018 PPO Dental Plan Family64151 M 8/7/1986 7/23/2012 PPO Dental Plan Family64152 F 4/14/1968 11/16/2006 PPO Dental Plan Family66217 F 6/22/1974 8/3/2005 PPO Dental Plan Family64155 F 2/27/1971 8/9/2001 PPO Dental Plan Family64155 F 7/24/1980 8/1/2016 PPO Dental Plan Family

64152 M 12/27/1956 12/1/2008 PPO Dental Plan Family64151 F 8/30/1966 8/17/2009 PPO Dental Plan Family64154 F 11/28/1967 12/2/2013 PPO Dental Plan Family64152 F 12/15/1978 8/1/2013 PPO Dental Plan Family64151 F 8/16/1965 8/2/2007 PPO Dental Plan Family64151 F 2/19/1965 5/28/1987 PPO Dental Plan Family64079 M 7/4/1974 7/1/2002 PPO Dental Plan Family64152 F 2/11/1989 8/9/2017 PPO Dental Plan Family64154 F 8/27/1977 9/9/2013 PPO Dental Plan Family64152 F 4/15/1970 7/17/2012 PPO Dental Plan Family64060 M 8/29/1968 8/3/2006 PPO Dental Plan Family64152 F 3/17/1983 7/31/2014 PPO Dental Plan Family64152 F 12/2/1982 8/3/2006 PPO Dental Plan Family64152 F 4/25/1990 7/31/2014 PPO Dental Plan Family64116 F 10/1/1985 8/1/2016 PPO Dental Plan Family64157 F 2/14/1976 8/4/2010 PPO Dental Plan Family64151 M 11/8/1977 7/10/2002 PPO Dental Plan Family64151 F 10/21/1974 8/20/1997 PPO Dental Plan Family66018 M 2/3/1958 8/1/2013 PPO Dental Plan Family64151 M 5/15/1977 7/31/2014 PPO Dental Plan Family64154 F 12/22/1977 8/9/2001 PPO Dental Plan Family64154 M 11/21/1967 8/31/1992 PPO Dental Plan Family64155 F 7/5/1979 9/27/2002 PPO Dental Plan Family64153 M 2/22/1977 8/3/2011 PPO Dental Plan Family64152 M 10/31/1967 8/7/2002 PPO Dental Plan Family64152 F 8/13/1966 9/5/2001 PPO Dental Plan Family64153 F 6/5/1979 8/4/2003 PPO Dental Plan Family64151 F 8/5/1977 8/4/2003 PPO Dental Plan Family64152 F 6/8/1970 8/19/1993 PPO Dental Plan Family64151 F 12/20/1981 8/4/2010 PPO Dental Plan Family64153 F 4/16/1970 8/31/1992 PPO Dental Plan Family64151 M 12/2/1979 8/6/2004 PPO Dental Plan Family64154 M 9/29/1977 8/1/2016 PPO Dental Plan Family64154 M 6/28/1982 8/2/2012 PPO Dental Plan Family64118 M 9/15/1983 8/10/2015 PPO Dental Plan Family64154 F 6/7/1971 8/4/2003 PPO Dental Plan Family64151 F 1/29/1969 1/26/2009 PPO Dental Plan Family64154 F 6/7/1974 8/29/1996 PPO Dental Plan Family64153 F 9/10/1982 8/3/2005 PPO Dental Plan Family64153 F 4/29/1970 8/17/1998 PPO Dental Plan Family64155 F 8/20/1979 8/1/2016 PPO Dental Plan Family64118 F 5/5/1977 7/31/2008 PPO Dental Plan Family64151 M 10/25/1963 8/20/1997 PPO Dental Plan Family64151 M 2/26/1973 8/20/1997 PPO Dental Plan Family64155 M 4/9/1974 8/1/2013 PPO Dental Plan Family

64155 F 11/14/1974 8/19/1999 PPO Dental Plan Family64155 F 7/7/1978 8/4/2003 PPO Dental Plan Family64068 M 10/4/1985 7/31/2008 PPO Dental Plan Family64152 M 2/26/1975 7/1/2010 PPO Dental Plan Family64089 F 7/20/1979 8/3/2006 PPO Dental Plan Family64151 F 2/18/1967 8/17/1998 PPO Dental Plan Family64119 F 7/14/1979 8/7/2015 Waive Coverage Waive Coverage64154 F 7/11/1982 8/28/2017 Waive Coverage Waive Coverage64154 F 6/26/1991 8/3/2017 Waive Coverage Waive Coverage64068 F 2/10/1991 12/7/2015 Waive Coverage Waive Coverage64155 M 12/2/1981 12/16/2002 Waive Coverage Waive Coverage64116 M 8/4/1993 8/15/2017 Waive Coverage Waive Coverage64151 F 12/20/1994 8/3/2017 Waive Coverage Waive Coverage64152 F 1/14/1965 8/11/2014 Waive Coverage Waive Coverage64151 F 8/19/1958 9/19/1996 Waive Coverage Waive Coverage64153 M 6/15/1969 8/17/1998 Waive Coverage Waive Coverage64152 F 3/25/1970 8/1/2016 Waive Coverage Waive Coverage64151 F 4/18/1982 8/13/2014 Waive Coverage Waive Coverage64154 F 3/31/1993 8/3/2015 Waive Coverage Waive Coverage64151 F 6/21/1967 9/13/2010 Waive Coverage Waive Coverage64154 F 8/27/1971 8/3/2015 Waive Coverage Waive Coverage64151 M 3/1/1979 8/7/2002 Waive Coverage Waive Coverage64118 M 11/30/1974 8/4/2009 Waive Coverage Waive Coverage64151 M 1/11/1977 8/1/2013 Waive Coverage Waive Coverage64152 F 1/18/1961 8/2/2007 Waive Coverage Waive Coverage64154 F 7/19/1967 8/9/2001 Waive Coverage Waive Coverage64152 M 9/5/1994 1/8/2018 Waive Coverage Waive Coverage64152 F 7/22/1994 8/3/2017 Waive Coverage Waive Coverage64152 F 9/27/1959 8/5/2013 Waive Coverage Waive Coverage64154 F 5/20/1985 8/2/2012 Waive Coverage Waive Coverage64153 F 1/13/1984 7/28/2016 Waive Coverage Waive Coverage64154 M 11/19/1970 1/5/1998 Waive Coverage Waive Coverage74434 F 9/25/1984 8/3/2017 Waive Coverage Waive Coverage64089 M 7/12/1977 8/3/2006 Waive Coverage Waive Coverage64158 F 4/26/1989 8/3/2016 Waive Coverage Waive Coverage64056 M 2/10/1962 2/2/2015 Waive Coverage Waive Coverage64152 F 9/13/1960 4/10/2007 Waive Coverage Waive Coverage64152 F 9/23/1978 8/3/2015 Waive Coverage Waive Coverage64152 F 4/23/1993 1/5/2016 Waive Coverage Waive Coverage64154 M 7/6/1973 1/21/1997 Waive Coverage Waive Coverage64151 F 9/10/1983 12/11/2017 Waive Coverage Waive Coverage64154 M 9/8/1976 8/9/2001 Waive Coverage Waive Coverage64152 F 12/2/1970 3/2/2015 Waive Coverage Waive Coverage64153 F 12/9/1982 2/10/2014 Waive Coverage Waive Coverage64151 M 5/17/1993 8/8/2016 Waive Coverage Waive Coverage

64113 F 6/28/1982 8/4/2010 Waive Coverage Waive Coverage64157 F 3/23/1976 10/16/2003 Waive Coverage Waive Coverage64155 F 8/19/1980 8/14/2017 Waive Coverage Waive Coverage64152 F 4/1/1995 8/3/2017 Waive Coverage Waive Coverage64152 F 6/11/1980 8/3/2006 Waive Coverage Waive Coverage64118 F 3/26/1982 8/18/2005 Waive Coverage Waive Coverage64116 F 7/16/1993 8/3/2017 Waive Coverage Waive Coverage66018 F 2/7/1959 7/31/2014 Waive Coverage Waive Coverage64068 F 7/8/1981 8/2/2007 Waive Coverage Waive Coverage64152 M 11/11/1968 8/23/1991 Waive Coverage Waive Coverage64152 F 4/25/1968 8/7/2002 Waive Coverage Waive Coverage64151 F 1/29/1987 10/4/2010 Waive Coverage Waive Coverage64151 F 7/8/1967 8/20/1997 Waive Coverage Waive Coverage64151 F 4/23/1982 8/2/2012 Waive Coverage Waive Coverage64151 F 11/2/1974 8/17/1998 Waive Coverage Waive Coverage64506 F 11/10/1975 8/1/2016 Waive Coverage Waive Coverage64057 F 10/20/1993 8/1/2016 Waive Coverage Waive Coverage64152 M 10/21/1963 3/16/2009 Waive Coverage Waive Coverage64152 M 5/31/1974 8/29/2016 Waive Coverage Waive Coverage64089 F 1/5/1966 8/13/2008 Waive Coverage Waive Coverage64153 M 8/22/1983 6/1/2001 Waive Coverage Waive Coverage64118 F 4/1/1985 7/1/2016 Waive Coverage Waive Coverage64152 F 7/12/1965 11/6/2017 Waive Coverage Waive Coverage64131 F 7/19/1982 8/3/2017 Waive Coverage Waive Coverage64157 F 12/31/1981 8/4/2009 Waive Coverage Waive Coverage66086 F 9/26/1976 7/30/2009 Waive Coverage Waive Coverage64152 F 3/29/1981 12/9/2003 Waive Coverage Waive Coverage64151 M 1/29/1974 8/4/2003 Waive Coverage Waive Coverage64152 F 5/29/1982 8/3/2017 Waive Coverage Waive Coverage64153 M 2/14/1968 8/22/1995 Waive Coverage Waive Coverage64154 F 1/22/1979 8/1/2016 Waive Coverage Waive Coverage64152 F 5/5/1994 9/4/2012 Waive Coverage Waive Coverage64152 F 6/15/1994 8/1/2016 Waive Coverage Waive Coverage64151 F 1/7/1959 5/8/2017 Waive Coverage Waive Coverage64155 M 12/4/1974 8/3/2015 Waive Coverage Waive Coverage66085 M 5/10/1980 7/22/2004 Waive Coverage Waive Coverage64152 F 3/9/1986 8/1/2013 Waive Coverage Waive Coverage64155 F 2/18/1990 8/1/2017 Waive Coverage Waive Coverage64153 F 10/6/1977 8/1/2013 Waive Coverage Waive Coverage64155 M 6/16/1977 8/4/2003 Waive Coverage Waive Coverage64153 M 10/12/1975 8/4/2010 Waive Coverage Waive Coverage64153 M 7/6/1983 8/2/2007 Waive Coverage Waive Coverage64151 F 8/11/1976 8/16/2000 Waive Coverage Waive Coverage64152 F 12/25/1970 8/10/2006 Waive Coverage Waive Coverage64152 F 9/25/1975 10/2/2017 Waive Coverage Waive Coverage

66109 F 8/24/1979 8/3/2017 Waive Coverage Waive Coverage64152 F 10/16/1985 8/15/2012 Waive Coverage Waive Coverage64068 F 8/30/1980 8/7/2002 Waive Coverage Waive Coverage66109 M 3/2/1976 5/26/2015 Waive Coverage Waive Coverage64151 F 10/23/1980 8/3/2005 Waive Coverage Waive Coverage64152 F 3/28/1981 8/3/2017 Waive Coverage Waive Coverage64079 M 11/21/1996 3/7/2016 Waive Coverage Waive Coverage64151 M 3/9/1965 8/17/1998 Waive Coverage Waive Coverage64157 F 8/6/1974 12/2/2015 Waive Coverage Waive Coverage64492 F 12/23/1960 9/5/1995 Waive Coverage Waive Coverage64152 F 2/9/1963 2/16/2016 Waive Coverage Waive Coverage64152 M 6/9/1977 6/9/2014 Waive Coverage Waive Coverage64155 M 11/11/1980 8/3/2017 Waive Coverage Waive Coverage64155 F 1/21/1983 8/26/2009 Waive Coverage Waive Coverage64158 F 4/13/1988 8/2/2012 Waive Coverage Waive Coverage64151 F 1/11/1968 1/9/2008 Waive Coverage Waive Coverage64119 F 6/14/1971 8/3/2017 Waive Coverage Waive Coverage64152 F 11/18/1992 8/21/2015 Waive Coverage Waive Coverage64154 F 2/24/1981 8/9/2013 Waive Coverage Waive Coverage78249 F 8/25/1988 8/3/2017 Waive Coverage Waive Coverage

Birth Date Gender Zip Health Health Tier Plan Dental Dental Tier Vision Vision Tier Total Premium: Cobra Began Cobra Ends

11/24/1979 Female 64118 543.00$ Employee Only BSP Buy Up ‐$ ‐$ 543.00$ 3/1/2018 8/31/2019

9/27/1959 Male 66212 ‐$ 31.46$ Employee Only ‐$ 31.46$ 11/1/2016 4/30/2018

3/22/1992 Male 64151 ‐$ ‐$ 7.23$ Employee Only 7.23$ 9/1/2017 2/28/2019

10/8/1973 Male 64118 465.00$ Employee Only BSP Base 31.46$ Employee Only 7.23$ Employee Only 503.69$ 3/1/2017 8/31/2018

5/15/1990 Male 64152 ‐$ 31.46$ Employee Only ‐$ 31.46$ 1/1/2017 6/30/2018

10/29/1952 Female 64152 ‐$ 31.46$ Employee Only 7.23$ Employee Only 38.69$ 9/1/2017 2/28/2019

11/21/1966 Female 64152 ‐$ 105.74$ Family 19.68$ Family 125.42$ 10/1/2016 3/31/2018

11/30/1975 Female 64152 465.00$ Employee Only BSP Base 67.18$ Employee Plus One 19.68$ Family 551.86$ 9/1/2017 2/28/2019

5/2/1955 Male 64152 894.00$ Employee Plus One BSP Base 31.46$ Employee Only ‐$ 925.46$ 11/1/2017 4/28/2019

10/20/1966 Female 64102 543.00$ Employee Only BSP Buy Up 105.74$ Family 19.68$ Family 668.42$ 11/1/2017 4/28/2019

2,910.00$ 435.96$ 80.73$ 3,426.69$

T:\Benefits\2019 RFP\PHSD RFPs and Components\PHSD RFPs and Components\PHSD 2019 Dental RFP\COBRA and Retiree Census.xlsx

Documents

Park Hill School District · Periodontal scaling and root planning, once per quadrant every 24 months Periodontal surgery, once per quadrant every 36 months Endodontics: root canal