3.Att. B-Price Sheet (Dental)_FINAL 4.25.22-LOCKED.xlsx

General Instructions Instructions: The Respondent shall provide the information required herein and in sections 3.6, 3.8, and 4.3.2 of the RFP. The Respondent shall propose a corresponding monthly premium rate for all Plan Years (Initial and Optional Renewal Terms) for each Plan Design and Plan enrollment tier, in each highlighted cell on Forms B1 through B3 of this Price Sheet. Failure to provide premium rates (in U.S. dollars) in a highlighted cell shall result in the Respondent’s Proposal being deemed non-responsive and disqualify such Proposal from further consideration. The Procurement Officer will review and score the Attachment B: Price Sheet, submitted by each responsive Respondent, using the scoring guidelines set within section 4.3.2 of the RFP.

Respondents are required to submit this workbook (Attachment B: Price Sheet), with Forms B1 through B3 fully completed, in original file format [Excel .xls]. Please follow the general instructions on this tab, as well as instructions on each tab of this Attachment B. Respondent may not add additional tabs to the Excel workbook or delete any tabs.

Respondents must refer to part A below when rating Plans and follow the instructions in part B to ensure a responsive Proposal.

Respondents must enter premium rates in each highlighted cell specified in Attachment B, Forms B1 through B3. Any other changes made to this Attachment B workbook will result in the Respondent’s Proposal being deemed non-responsive and disqualify such Proposal from further consideration.

&"-,Bold"&K000000ATTACHMENT B: PRICE SHEET

RFP NO.: DMS-21/22-027 GROUP DENTAL INSURANCE

RFP No.: DMS-21/22-027 Group Dental Insurance Attachment B: Price Sheet Page &P of &N

B1 Indemnity with PPO Instructions: The Respondent shall propose a monthly premium rate for all of the Plan Years (Initial and Optional Renewal Terms) and Plan enrollment tiers in each highlighted cell below. Premium rates must be even numbers to the cent. For example, the premium $1.02 is acceptable while the premium $1.01 is unacceptable. Premium rates with odd cents will be rounded up to the next highest cent by the Department. The proposed Optional Renewal Term rates are maximum (not-to-exceed) amounts, subject to the rate renewal process as described in the Draft Contract (Attachment A).

Rates will be multiplied by the enrollment in each tier (item II below), summed and divided by the total enrollment, resulting in a blended monthly premium rate (item III below). Respondent shall propose rates using the definition of type 1, 2, 3, and 4 services designated Industry Standard 1 (see Allocation of Services on the General Instructions tab of this Attachment B). Failure to provide monthly premium rates (in U.S. dollars) for any Plan Year (Initial and Optional Renewal Terms) in a highlighted cell shall result in the Respondent’s Proposal being deemed non-responsive and disqualify such Proposal from further consideration.

III. Blended Monthly Rate INCOMPLETE

FORM B1: PLAN DESIGN - INDEMNITY WITH PPO

RFP NO.: DMS-21/22-027 GROUP DENTAL INSURANCE

RFP No.: DMS-21/22-027

B2 Standard PPO Instructions: The Respondent shall propose a monthly premium rate for all of the Plan Years (Initial and Optional Renewal Terms) and Plan enrollment tiers in each highlighted cell below. Premium rates must be even numbers to the cent. For example, the premium $1.02 is acceptable while the premium $1.01 is unacceptable. Premium rates with odd cents will be rounded up to the next highest cent by the Department. The proposed rates are maximum (not-to-exceed) amounts, subject to the rate renewal process as described in the Draft Contract (Attachment A).

Rates will be multiplied by the enrollment in each tier (item II below), summed and divided by the total enrollment, resulting in a blended monthly premium rate (item III below). Respondent shall propose rates using the definition of type 1, 2, 3, and 4 services designated Industry Standard 1 (see Allocation of Services on the General Instructions tab of this Attachment B). Failure to provide monthly premium rates (in U.S. dollars) for any Plan Year (Initial and Optional Renewal Terms) in a highlighted cell shall result in the Respondent’s Proposal being deemed non-responsive and disqualify such Proposal from further consideration.

III. Blended Monthly Rate INCOMPLETE

FORM B2: PLAN DESIGN - STANDARD PPO

RFP NO.: DMS-21/22-027 GROUP DENTAL INSURANCE

RFP No.: DMS-21/22-027

B3 Preventive PPO Instructions: The Respondent shall propose a monthly premium rate for all of the Plan Years (Initial and Optional Renewal Terms) and Plan enrollment tiers in each highlighted cells below. Premium rates must be even numbers to the cent. For example, the premium $1.02 is acceptable while the premium $1.01 is unacceptable. Premium rates with odd cents will be rounded up to the next highest cent by the Department. The proposed rates are maximum (not-to-exceed) amounts, subject to the rate renewal process as described in the Draft Contract (Attachment A).

Rates will be multiplied by the enrollment in each tier (item II below), summed and divided by the total enrollment, resulting in a blended monthly premium rate (item III below). Respondent shall propose rates using the definition of type 1, 2 and 3 services designated Industry Standard 1 (see Allocation of Services on the General Instructions tab of this Attachment B). Failure to provide monthly premium rates (in U.S. dollars) for any Plan Year (Initial and Optional Renewal Terms) in a highlighted cell shall result in the Respondent’s Proposal being deemed non-responsive and disqualify such Proposal from further consideration.

III. Blended Monthly Rate INCOMPLETE

FORM B3: PLAN DESIGN - PREVENTIVE PPO

RFP NO.: DMS-21/22-027 GROUP DENTAL INSURANCE

RFP No.: DMS-21/22-027

B4 Total Blended Rate Instructions: The rate on this page is automatically calculated per the calculation demonstrated in section 4.3.2 of the RFP. The calculation uses the rates provided in Attachment B: Forms B1 through B3. The formula for the blended monthly rate for any give Plan is as follows:

(((Year 1 + Year 2 + Year 3 + Year 4 + Year 5 + Year 6 ) / total enrollment) / 6)

The total blended rate = ((blended monthly rate of Attachment B: Form B1: Plan Design - Indemnity with PPO) + (blended monthly rate of Attachment B: Form B2: Plan Design - Standard PPO) + (blended monthly rate of Attachment B: Form B3: Plan Design - Preventive PPO)) / 3.

The Respondent with the lowest total blended rate will receive the full fifty (50) points and each subsequent Respondent will receive proportional points. The formula for the proportion of total points received is as follows:

(total blended rate / lowest total blended rate) x 50 = Respondent’s total points

Do not make any changes to this Attachment B workbook. Making changes to this Attachment B workbook will result in the Respondent’s Proposal being deemed non-responsive and disqualify such Proposal from further consideration.

Total Blended Rate INCOMPLETE

&"-,Bold"ATTACHMENT B: &K000000PRICE SHEET

FORM B4: TOTAL BLENDED RATE&K01+000

RFP NO.: DMS-21/22-027 GROUP DENTAL INSURANCE

RFP No.: DMS-21/22-027