HomeMy WebLinkAboutDental Services - California Dental Services - 1973 benntal services
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CjAj- jF'10nNIh. DR3W7I'AL SMn-TrICH;
�fl P, O BOX 7736 SAN FRANCISCO, CA 94120
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OFF ICES
101 HOWAQO T .SAN FFa NCISCO.CA (415)43°3.OiA0•S20 SO. LAFAVETI'E PARK PLACE,SAS ANGEi.ES.CA (213( 380.1251
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July 13, 1973 p
City of Cupertino
10300 Torre Avenue
Cupertino, CA 95014
Gentlemen:
Re: City of Cupertino, CDS #1949
Enclosed are copies of t11ry ful. ly executed
Agreement between the above and Cal �.fornia
Dental Service . These copies are for your
and the group ' s records .
`lany thanks for the prompt nrocessing of this
document .
Sincerely ,
CA1,1FORINTA DENFAL SI' Y1CV..
flal S-ambels
Sales Manager
`1orthern California
nsbe �
nclosures �'.�
cc: Mike Langford l `
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CALIFORNIA DENTAL SERVICE
A Nonprofit Corporation
COSGROUP 0 1949
APPLICATION FOR DENTAL CARE SERVICE AGREEMENT
CITY OF CUP cR'TINO
herein called "EMPLOYER", hereby applies for a DENTAL CARE SERVICE AGREEMENT with CALIFORNIA
DENTAL SERVICE,herein called"CDS",on the following terms:
1. Definitions:
A. Monthly Payment: The sum of $4. 8S for each eligible single employee,
the sum of $8. 70 for each eligible employee with one dependent,
the sum of $13. 9S for each eligible omployee with two or more
dependents.
B. Applicable Percentages:
L Basic Benefits(as defined in Appendix "C") so %
Prosthodontics(as defined in Appendix %11) SO %
[J Orthodontics (as defined in `,0 %
11. Benefits provided and limitations: Appendix "D")
A.Subject to the terms and conditions herein specified. CDS shall pay or otherwise discharge the applicable
percentage of the lesser of the usual, customary and reasonable fees or the fees actually charged for services rendered to
an eligible patient during the term hereof and covered by this Agreement set forth in Appendix "C"attached hereto.
B. The amounts payable by CDS for covered Basic and Prosthodontic services rendered by a participating dentist in
California who is not a rrember of COS shall not exceed the applicable percentage of the arnounts shown for correspon-
ding services in the Table of Allowances,attached hereto as Appendix "B and the amounts payable by CDS for covered
services rendered by a participating dentist outside of California shall not exceed the applicable percentage of the
customary fees in California.
C. The amounts payable to a dentist who is not a participating dentist shall not exceed the amount which CDS
would pay to such a dentist on account of such services if he were a participating dentist, but nw a member of CDS.
Such payment shall be made only upon receipt by COS of evidence which it deems satisfactory showing the rendition of
covered services during a period in which the patient was eligible for care under the provisions of this Agreement and the
amount which the patient has paid or become obligated to pay therefor. Such payment may, in the discretion of CDS, be
made to the eligible patient, to the dentist,or jointly to both of them.
FLID1. The maximum amount payable by CDS for Basic and Prosthodontic Services rendered to an eligible
patient in any calendar year or portion thereof shall be$ 1,000.00.
QDZ. The maximum amount payable by CDS for Orthodontic Benefits(as defined in Appendix "C"I rendered
to an eligible patient shall be$ 500.00.
9-71-N u-2 -1-
F�E. COS shaft not be obligated to pay for, or otherwise discharge, in whole or in part, the first
$ of fees for services rendered to each eligible patient during the tern hereof and otherwise covered by
this Agreement, which fees shall be computed on the basis of the dentist's usual,customary and reasonable fees or fees
actually charged or the Table of A"lowances,whichever is applicable under the provisions of Sections II-A and'1-B of this
Application. (Such deductible amount tall not exceed S for all eligible patients in a single family
consisting of an eligible employee and his dependents as defined in Appendix "A"attached hereto.) (Strike out words in
r panenbxses if inapplicable.)Such deductible amount shall apply:
Once each calendar year or portion thereof during which this Agreement is in effect.
Once during,he term of this Agreement.
This deductible shall not apply to the following sen ices:
The amount an eligible patient pays for the foregoing services shall not be applied towards satisfying the deductible.
17F. A patient shall be eligible for Prosthodontic Benefits only following such patient's continuous enrollment
in the dental prograrn provided hereby for a period of months.
f7G.
THE FOREGOING PROVISIONS DESIGNATED D, THROUGH G ARE APPLICABLE ONLY WHERE A
CHECK MARK HAS BEEN PLACED IN THE BOX PRECEDING SUCH PROVISION.
Ill. In the event that the number of eligible employees reported by EMPLOYER to COS pursuant to paragraph 1la)of
General.Agreements shall be less than so in each of any three consecutive months. COS shall,at its option,
terminate this Agreement upon written notice w EMPLOYE given not more than fifteen 05)days after receipt of the
List of Eligible Employees which indicates that such ground for termination exists. Such termination shalt be effective as
of the last day of the month in which notice of termination is given,and COS shall make payment to dentists for dental
services authorized ririor to termination and dental services which were rendered without prior authorization by the
dentist prior to receipt by him of notice of such termination of benefits.
IV. Any notice which is required or permitted to be given under the terms of this Agreement may be given by registered
or certified mail ad+iressed to the parties at the addresses which are indicated below and shall be deemed to have been
given 48 hours after deposit in the mail with postage fully prepaid at any post office located in the continental United
States. The addresses of the parties are as follows subject to change by written request:
la)EMPLOYER
CITY OF CUPER71NO
10300 Torre ,Avenue
Cupertino, Cal`.foruia 95014
MCALIFURNIA DENTAL SERVICE
Director of Marketing
101 Howard Street
San Francisco,California 94105
9-71-NU-2,aT-2 -2-
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V. The term of this Agreement shall be July A, 1973. fth
June 30, 197S s and shall continua Omweafter from year to year until terminated as herein provided.
This Agreement may be terminated on any anniversary data by at lest sixty (60) days' written notice of termination
given by the party desiring to terminate to the other party. In the event that COS shaft desire to change
ter.ns and conditions of this Agreement effective on an 8tn N rates other
Ag ivttsary date.advice of such proposed b may e given
with a notice of termination, and such notice of termination shall be effective; only in the event that as►eement is not
reached as to such changes. In the event that this Agreement is terminated pursuant to this paragraph, COS is hereby
empowered not to authorize treatment plans beyond such termination. An anniversary date shall mean
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July 1, 19 7 S, and July 1 of each subsequent year.
The attached Definitions, Recitals, General Agreements and Appendices A, B. C. (and "D" I are each a skirt of
this Application and, upon arxptance hereof by CDS, this Application and the aforesaid documents shah constitute the
entire Agreement between EMPLOYER and COS.All prior negotiations,representations and understandings are intended
to be merged herein. No modification of this Agreement shall be effective for any purpose unless in writing and signed by
both parties or their duly outhorized representatives.
ACCEPTED: DATED: July 1, 1973
CALIFORNIA DENTAL SERVICE: CITY OF CUPERTINO*
tt �t �d MM✓1. AA,
PRESIDENT `-" (Tale) CITY MANAGER
By �lR ll�'rl�fE" By
ASSIST VICE F DEET;CONTROLLER DI CTOR, TNZSTRATIvE SERVICES
(Title)
tf•��-rou-a.Mr••a
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RECITALS
COS is a nonprofit corporation, organized and existing under Section 9201 of the Corporations Code of the State of
California, composed of members licensed to practice dentistry under the provisions of the Dental Practice Act. It is the
purpose of COS to provide dental care under programs writh responsible entities so as to maintain the prime requisites of
an independent and responsible profession,i.e.,fee for services,free choice of dentists and preservation of dentist-patient
ndationship without lay control, interference.promotion or commercialization.
GENERAL AGREEMENTS
1. EMPLOYER agrees:
(a)To compile, certify and furnish to COS on or prior to the first of ever month commencing on the commence-
ment date of the term of this Agreement, a LIST OF ALL ELIGIBLE EMPLOYEES AND THEIR SOCIA..SECURITY
NUMBERS entitled to receive dental benefiis hereunder. Eligible employees shall be determined according to the
Eligibility Rules. Appendix "A",attached hereto.
(b)To pay COS monthly, commencing on the commencement date of the term of this Agreement,and or or before
the first day of each succeeding month, the monthly payment specified in Section i-A of the Application for Dental Care
Service Agreement.
(c)To provide information to all eligible employees as to the existence and terms of this Agreement and the right
of eligible patients to receive care as provided herein from a dentist of each natient's choice, as such choice may be
exercised from time to time by a patient during the continued eligibility of the patient.
(d)To advise eligible employees to notif•; their dentist at the time of their first appointment that they are covered
by this Agreement and to provide their dentist with group identification and social security numiber.
(e)To permit CDS, by its auditors or ether authorized representatives, on reasonable advance written notice, to
inspect records cf EMPLOYER in order to verify the accuracy of lists of eligible ernploye�,?s prepared by EMPLOYER and
submitted to CDS.
2. CDS agrees:
(a)To advise participating dentists as follows:
(i) To submit a treatment plan, prior to rendition of service, showing the patient's dental needs and the
treatment necessary in the professional judgment of the dentist,and
(ii) To notify the eligible patient of all actions taken by COS with respect to such treatment plans,and
(iii) That such treatment plan need not be submitted prior to rendition of service in the case of emergency
services or in the case of brief routine procedures.
(b)To authorize such treatment Elan for coverage under the dental care p ogram provided f v this Agreement when
satisfied from the treatment plan and other data submitted by the dentist (1) that the patient is eligible hereunder, (2)
that the services proposed are included in the Schedule of Services covered by this Agreement set forth in Appendix "C"
attached hereto;and (3) that the total fees to be charged to both COS and the eligible patient do not exceed the dentist's
usual, customary and reasonable fees. Such authorization shall be for a reasonable period of time, but not longer than the
term of this Agreement
(c)To make no payment for any services rendered to a patient who is not eligible for dental care hereunder at the
time of rendition of the service, except to the extent of services performed during a period of an authorization is.ued by
COS pursuant to subparagraph(b)of this paragraph,and except for completion of single procedures commenced at a time
the patient was entitled to treatment by reason of such authorization.
(d)To make periodic: checks as to the adequacy of care provided by dentist: through local dental consultants and
committees of local den-6vis appointed by COS.
1
AMOK
3. (a)If ar,eligible patient is eligible for coverage under two or more CDS dental care programs,and More than one of
mid progmins provide coverage for a particular service, CDS will pay the aggregate sum payable under, all applicrA31e
pt:Warns, but not more than the lesser of the usual, customary and reasonable fee or the fee actually charged for such
service and will prorate the cost thereof between the applicable programs, provided, that no program shall be charged
with a greater amount than the amount for which it would be liable if such dual coverage did rot exist.
Wit an eligible patient is entitled to coverage under one or more insurance policies or prepaid health care plans
other than a CDS dental care program, then the benefits of this Agreement shall be provided only to the extent that the
funds obtained frmn such other insurance or plan are inadequate to provide full payment frtr the services which are berm-
fits provided by this Agreement.
(e)If an eligible patient is injured through the act or omission of another person CDS shall provide the benefits of
this Agreement only on condition that the eligible patient snail agree in writing:
(i) To reimburse COS to the extent of such benefits immediately upon collection of damages by him,whether
by action at law,settlement or otherwise,and,
(ii) To grant CDS a lie-i. to the extent of such benefits on any such action at law,settlement or right to recovery.
(d)ln no event shall the provisions of this paragraph 3 operate to increase the liability of CDS beyond the benefits
for which it might of-ierwnse be liable or. the event this paragraph did not apply.
4. Neither EMPLOYER nor CDS shall be liable for any act or omission by a dentist, his employees or agents,or any
person performing dental or other professional services under this Agreement.
5. Participating dentists shall be obligared to schedule and render all dental treatment for eligible patients in actor•
dance with the applicable ;t ndarck of the dental profession in their community and to charge no more than the usual,
customary and reasonable fee theref3r. CDS is authorized to exclude from participating in the services provided by this
Agreement any dentist who persistently fails to comply with the obligations of participating dentists hereunder.
6. Any controversy or claim arising out of or relating to this Agreement or the breach thereof, by or between either
or both parties to this Agreement, dentists, eligible patients or any of them, shall be settled by arbitration by a singie
arbitrator to be selected by the parties, and judgment upon the award rendered by the arbitrator may be entered in any
court having jurisdiction thereof.
7. In the even*, that any payment due pursuant to paragraph 1(b) of General Agreements is not paid when due, COS
may give written notice that payment is due, and if such payment is not received within 10 days after such notice, COS
may, at its option, terminate all further benefits and be released from all further obligations hereunder; provided,
however, that COS shall make payment to dentists for dental services authorized by CDS prior to termination and for
dental services which are rendered without prior authorization by a dentist prior to receipt by him if notice of such
termination of benefits. In the event of termination pursuant to this paragraph, EI'A'L_OYER shall remain liable to COS
for the full amount of all dentists statements pai,.' or otherwise discharged by COS, plus Twenty-Five Percent (25%) of
such amount (to compensate CDS for its administration of the dental program), IEss amounts actually paid by
EMPLOYER to CDS.
8 Both parties to this Agreement agree to consult to the extent reasonably practical concerning all material published
or distributed relating to this Agreement. No such material shall be published or distributed which is contrary to the
terms of this Agreement.
9- 3oth parties to this Agreement agree to permit and encourage the professional relationship between dentist and
patient to be maintained without interference.
10. If any portion co this Agreement or any Amendment thereof shall be determined by any arbitrator,court or other
competent authority to be illegal, void or unenforceable, such determination shall not abrogate this Agreement or any
portion thereof other ,,han such portion determined to be illegal, void or unenforceable, and all other portions of this
Agreement shall remain in full force and effect.
1 The parties agree that all questions regarding the interpretation or enforcement of this Agreement shall be governed
by the laws of the State of California, where the Agreement was entered into and is to be performed.
g a h M -2-
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DEFINITIONS
Eligible patient means an eligible employee and his eligible dependents(to be determined as provided in the Eligibility
Rules—Appendix "A").
Participating dentist means a dentist who is licensed to practice by the State of California and gees to render dental
care to eligible patients in accordance with standard terms and conditions applicable to dentist participation in COS
prepaid dental care programs, as established by the Board of Directors of COS consistent with the provisions of this
Agreement. Participating dentist also means any dentist outside of the State of California who is licensed to practice
dentistry by the state or other jurisdiction in which he practices and who agrees to render dental care to eligible patients
in accordance with the terms of this Agreement.
Single procedure means a dental procedure listed on the CGS Tattle of Allowances(attached hereto as Appendix "B")
to which a separate procedure number is assigned, e.g., a three-surface amalgam restoration of a single permanent tooth
(procedure 613) or a complete maxillary denture, including adjustments for a six-month period following installation
(procedure 700).
Usual, Customary and Reasonable fee means a fee which meets all of the following criteria, as determined by CD5
based upon confidential fee listings'filed with COS by member dentists and the findings of local dental society review
committees:
USUAL. Usual fees are those fees usually charged for a given service by an individual dentist to all his private
patients, i.e.,his own usual fee.
CUSTOMARY: A fee is Customary when it is within the range of usual fees charged by dentists of similar training and
experience for the same service within that same specific and limitea geographic area.
REASONABLE: A fee is Reasonable when it meets the above two criteria and when, in the opinion of the review
committee of the resoonsible dental society, it is justifiable considering the special circumstances of the particular case
in question.
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APPENDIX "A"
EUG1131LITY RULES
Effective July 1, 1973 ,all present,permanent employees of
CITY OF CUPERTINO
who have completed three (3) Ron th9Df continuous full-time employment with a minimum of thirty-
two (32) hoursper week are eligible under the Dental Care Service Agreement. Present permanent
employees not c aible on July 1, 1973, , and all future permanent employees will become
eligible on the first day of the month coincident with or next following three (3) months of
continuous full-time employment with a minimum of thirty-two (32) hours per week.
The dependents of eligible employees are eligible under the Dental Care Service Agreement. Dependents are lawful
spouse and unmarried dependent children to 19 or to 23 if enrolled as full-time student in an accredited school,college
or university. Children include step-children,adopted children and foster children,provided such children are dependent
upon the employee for support and maintenance.
An unmarried child 19 years or over may continue to be eligible as a dependent if he is incapable of self-support
because of physical or mental incapacity that commenced prior to reaching age 19, provided a physician's certificate
is subm tted within six months following his 19th birthday or the effective date of 'his Agreement.
Dependents in military service are not eligible.
Eligibility of employees shall terminate on the last day of the month in which full time employment has terminated.
Dependents shall remain eligible until the last day of the month coincident with or following termination of eliy>bility of
the employee or loss of dependent status, whichever shall occur first. Eligibility shall, in any event, terminate
immediately upon termination of this Agreement.
1-70-EN
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TA 'ES
ILE OF ALLOWAPA
fli YtAL
'LA. This is not a f,_e schedule. The amounts I+sled in this Table are cflowances which -ire made
toward usua! and customary fees. Usual and customary fees vary v.ith individ*,al den•al practices.
Ftec.
111111116 PMCW&M (R/R movols 4 RN WO no. iraci bar. (t31R tauoes By Rowel
ViSi05 A10 DRGNOW M.&I99) Age CVM AND NEOPLASM 4na�
Om Office visit for treatment and abetirvation of 260 Intraoral incision and drainage of abscess . ... .. 10.00
wiles to teeth and supporting strus d.re,Other 261 Extraoral incision and drainage of obsces ... .. 15.00 or B/R
Chars for routirm operative procedures IReqular 262 Excision pe►icoronai gingiva . .. .. . . .. .. .... 10.00
office hours0 4.00 263 Sialolithotomy: removal of salivary calculus,intro
Prolessioral visits after ham (Dentist may deer orally 33.00
payment an basis of:ervcies rendered as visits 264 Sialolithatomy:removal of salivary calculus.extra
whiehe at is greater) .•. .. • • .• • • •. • . • . 10.00 orally . . . .. . . .. . . .. . . . . . . . . . . ... . 100.00
040 Special consultation (by specialist for case pre- 265 Closure of salivary fistula . . ... . . .. .. .. . . . . 60.00
=.to ion when diagnostic procedures have been 266 Dilation of salivary duct ... .. . . .. . . . .. . .. 17.00
performed by general dentist) . . . .. . . . . . 10.00 270 Ruction of benign t tmor of soft time(2.5 cm
049 Prophylaxis-children ro age 14 . . ... .. ... . 6.00 or larger) 25.00
050 Prophylaxis-to include scaling and polishing . - . 9.00 271 Resection of malignant tumor .... ... . . . . . . B/R
061 Topical application of sodium fluoride (one treat- 275 Transplantation of tooth or tooth bud ..... . . 70.00
ment including prophylaxis under age 4)..... 12.00 276 Removal of foreign body from bone(independent
062 Topical application of stannous tluoride lone procedure). . . . . . . . . . . . . . . . . . . .. . . . SIR
treatment including prophylaxis - payment 277 Radical resection of bone for tumor with bore
limited to once each year to age 18) _ . . . .. . 14.00 graft... . . . . .. . . . . .. .. . . .. .. ... . B/R
080 Emergency treatment-palliative per visit . .. . . 5.00 278 Maxillary sinusotcmy for removal of tooth frag-
ment or foreign body ... ... . . .. . .. . ... 65.00 or B/R
fi6e a9Oseeratxea iessfuele exam and 7! psis 279 Closure of oral fistula of maxillary sinus .. .. ... 40.00 or BIR
�4Ta 280 Excision of cyst,small .. .. .. . . . ... . . . ... 25.00 or B/R
110 Single film . . . .... . . .. .. . . . . .. .. .. . . 8.00 281 Excision of cyst,large(2.5 cm or larger) . .-. . . or
III Additional,up to 12 film,,each 1.00 282 Sequestrectomy for osteomyelitis or bone abscess
112 Entire denture series, including examination con- superficial . . .. - .. - . 20.00 or B/R
sisting of at least 14 films (bite winT if 285 Condylectorny if temporomandibular joint. . . 300.00
necessary) 17.00 289 Meniscectomy)f tenporomandibular joint . . _ . . 250.00
113 Intra-oral, occlusal view, maxillary or mandib-
ular,each . .. . . . . . . . . . .. .. . .. . . . 4.00 MISCELLANEOUS:
114 Superior or inferior maxillary, extra oral one 290 Incision and -emoval of foreign body from soh
film 10.00 tissue . . . .. ... . . . .. . . .. .. . .. . .. .. 10.00 or B/R
115 Superior or inferior maxillary, extra oral, two 291 Frenectomy 25.00
films 15.00 292 Suture a`soft tissue wound or injury . ...... . . BiR
116 Bite wing films,including examination 293 Crown exposure for orthodontia . . . .. . .. . .. . 15.00
2 films . . . . . . .. . . . ... . . . . . .. .. .. 5.00 294 Injectic,. of sclerosing agent into temporomandib-
4 films 7.00 ular;oin
Additional films,each 1.00 295 Treatment trigeminal neuralgia by injection into
150 Biopsy of oral tissue .. . . . . . .. . .. . . . .. . . 8.00 second and third divisions 34.00
. . .. . . . . .. . . .
160 Microscopic examination . . . . . . ... . . . . .. 15.00
DRUGS 100-399)
ORAL SURGERY(200-299 300 Drugs administered by dentist -based on cost . .. B/P
-All hospital costs are toe respuns;hikily of the patient. ANESTHESIA 1400-449'
COS will allow for^.he procedures listed in this schedule. 4GO Anenhesia General 15.00
Additional fees charged by the dentist fur performing PERIODONTICS !450-499►
procedures in the hospital are the responsibility of the
patient. Special consultation(by specialist for case prewnta-
tiun when preliminary diagnostic procedures
-COS ahowancas'or General (films, models. etc i have been performed by
Anesthesia .. .. . . . . . . .. . . . . . . . . . .. .. ..See Procedure i/400 general dentist) - .. . . .. . .. . . . . see Procedure 0"
Any further charges for antahetics, anesthetists, or
anesthesiologists are the respo,sibility of the patient Prophylaxis fincludes scaling and polishing►.. See Procedure M056
451 Emergency rrealme-ft (Deriodontal abscess, acute
"'Allowances for procedures not listed m this schedule eriodontitis,etc) 10.Of,
will be aid at the rate listed in the Relative Value p
D 452 Subgmgival curretage, root planing per quadrant
Study as approved by the American Society of Oral (not ro h laxisl . .. . 12.00
P D Y
Surgeoets. Consultation (by specialist for rase presenta- 453 Correction of occluuon per quadrant ... . . . 12.00
tion when diagnostic procedures have been performed 472 Giagivectomy per^-tadrant(including post surgical
by general dentist). .. . . . . . . . .... .... . ..See Procedure 4040 visits)
473 Ginyivectomy, cswous or muco-gingnal surgery
EXTRACTIONS: per quadrant 6 acludes post surgical visits) . .. 60.00
200 Uncomplicated single, including routine post oper- 474 Gingivectomy, treatment per tooth(fesww than six
ative visits . . . . ... . . . 8.00 teeth) . . . . . .. . . .. .. . ... . . . .. . 10.00
. .
201 Each additional tooth,including routine post oper
ative visits .... .. . .. . . . . . . . . . . . . 6.00 ENDODONTICS 1500-5")
IO2 Surgical removal of erupted teeth ... . . .. . .. . 8;R Special consultation(by specialist for case presents
220 Post:operative visit(sutures and complications). . . 3.00 tion when diagnostic procedures have been
performed by general dentist) . ... .. . . .. let Procedure/040
IMPACTED TEETH(enclose film): 500 Pulp capping .. . . . .. . . .... . . . . . . .. 610
230 Removal of tooth Lott tissue) . . . .. .. .. .. 17.00 501 Therapeutic pulpotomy(in addition to restoration,
231 Removal of tooth(partially bony) . . . .. .. . . . 25,00 per treatment} 6.00
232 Removal of tooth(completely bony) . .. . . .. . . 40.00 or E,R 502 Vital pulpotomy. . . .. . . . . . . . . ... . . . . . . 12.Od
503 Remineralization (Caoh, temporary restoration)
ALVEOLAR OR GINGIVAL RECONSTRUCTION: per tooth .. . . . . . . . . .. . . .. . . . . . . .. '10.Of1
250 Alvrrolectomy ledentulous)per quadrant.. . .. . . 25.00
2ru2 Alveolectomy (in addition to removal of teeth) ROOT CABALS:
tsar quadrant 10.00 510 Culturing ranal .. . .. . .. . . . . . . .. . . .. . . 7.00
2% Alveopfasty with ridge extension,per arch. ... . . 42.00 511 Single rooted canal tooth therapy . . . . . .. .. .. 45.W
257 Nornoval of palatal taaus ... .. ... . . . .. .. . . 35.00 or 8/R 512 Bi-rooted tooth canal therapy . . . . . . .. . . . . . . 60.00
258 7hma,.al of mandibular tori per quadrant . . .. . . 35.00 513 Tri-rooted tooth canal therapy . . . .. . .. . .. .. 75.00
259 Excision off hyper plastic tissue per itch . . ... . . 32.00 530 Apicpatomy(including filling of root canal) . . . . $0.00
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14ae. Pose.
PMC&dup IBM natal Na Pi (@/A twaa.a ow PAWO
531 Apicaectotoy Grata procedure) ... ....... 35.16
Allottom s do rat dude feral rsiaation 702 Party acrylic upper or Iowa writtt gold or chrartal
or nummY montpoopwm cobalt aOoV tamps-wee ...... ...... 75.E
712 Teeth and dates-extra per unit...... ...... 5.00
KTOUTWE DEED(600-679) 703 Parma lower or upper with chrome cobalt alloy
AMALGAM RESTORATIONS PRIMARY TEETH: lingual or palatal bar and acrylic saddlas-base . iSO.00
800 Cavities involving oral tooth surface .......... 6.00 704 Teeth and clasps-extra per unit.. .. .. ...... SA
601 Cavities involving two tooth surfaces ... ...... 9.00 705 Simple stress breakers-extra ..... .. . .. ... 14.00
602 Cavities involvug thrn or mare tooth surfaces... 12.00 706 Stayptate-base. .. .... .. .. . .. .. .... .. 30.E
AMALGAM RESTORATIONS PERMANENT TEETH: 716 Teeth and clasps-extra par unit.. . .. .. ..... 3.00
611 Cavities involving one tooth surface .... . . .. . . 8 p0 720 Denture adjustment... . . . . . . .. .. .. ...... 4.00
612 Cavities involving two tooth surfaces .. . .. . . . . 11.JO 721 Office reline-cold cure-acrylic ... . . .. .... 16.00
613 Covilties involving three or more tooth surfaces.. . 15.00 722 Denture reline . . .... . . .. . . .. .... ...... 35.00
GOLD RESTORATIONS: 723 Special Have conditioning, per denture, in addi-
635 On tooth surface . .. .. . . .. . . . ... ... . .. 36.00 tion to reline-maximum 2 per denture ..... 16.00
636 Two tooth surfaces . . .. .. .. .. . . .. . . .. .. 40.00 724 Denture duplication(jump case)per denture .... 55.00
637 Three or more tooth surfaces . . . . .. .. .. . . .. 50.00
638 Onlsys extra per tooth .... .. .. .. ........ 10.00
SILICATE,ACRYLIC,PLASTIC RESTORATIONS: REPAIRS,DENTURES,ACRYLIC:
640 Silicate cement filling . ... . .. . . .. .... .. .. 9.00 790 Broken denture,repairing(no teeth involved) ... 12.00
645 Acrylic or plastic filling . .. . . .. . . .. .. . . . . 11.00 Replacing missing or broken teeth, each ad&
tional 3.00
RESTORATIVE DENTISTRY UNDER GENERAL ANESTHESIA Adding teeth to partial denture to replace ex-
(Spetdal cases only) (Handicapped Patients) tracted natural leeth:
649 long term operative cases performed under Gen- 793 First tooth . . . ... .. . . .. .
oral Anesthesia on hourly basis.' 794 First tooth with clasp .. . . . . . . . . . . . . . .. . 30.08
-One hour duration from beginning to end . . . . 75.00 795 Each additional tooth and clasp. . . . . . . ... . .. 5.00
-Two and one half hours,maximum .. . . . . . . 150.00 796 Partial denture repairs - based on time and
-Three and one half hours,maximum . . . . . . . 175.00 laboratory charges .. . . . . . .. . . . . .. ... . B/R
-Four or more hours .. .. . . . . . . . . . . . . .. 200.00
The above includes all operative procedures, ex-
tractions, pulpotomies, necessary treatments,stan-
nous fluoride and oral prophylaxis Fees for anes SPACE MAIIVTAINERS'800$99
thesiologists must be paid by patient. ( )
Allowances include all adjustments within tmr
CROWNS: months following installation.
650 Acrylic . . .. . . . . . . . . . . . . . .. . .. . . . . . . 60.03 800 Fixed space maintainer(hand type) .. . . . . . . . . 35.00
651 Acrylic with metal . . . .. .. . . . . . . .. . .. .. 75.00
652 Porcelain 75.00 REMOVABLE ACRYLIC SPACE MAINTAINERS:
653 Porcelain with metal . . . . .. .. . .. . . . . . . 100.00 801 With stainless steel round wire rest only . . . . ... 40.00
660 Gold(full). . . . . . . . . . . . .. . . .. . . . . . . . . 65.00 802 Stainless steel clasps and/ur activating vvires, in
663 )k Gold . ... . .. 60.00 addition per wire nr clasp . . . .I .. . . . . . . . . 5.00
670 Stainless Steel(primary) . . . . . .. .. . . . . .. . . 17.00 803 Study models .. . . .. . . . . . . . . . . . . ...... 5.00
671 Stainless Steel(permanent) . . . .. . . . . . . .. .. 20.00 EIO Removable inhibiting appliance to correct thumb•
672 Gold dowel pin .. . . . .. . . .. . . . . . . . .. .. 10.00 sticking . . ... .. . . . . . . . ... 40.00
COS does not pay for facings on crowns,posterior 832 Fixed or cemente f inhibiting appliance to correct
to 2nd bicuspids (if placed, fees must be paid thumbsucking .. . . .. . . . . . . . .. . .. .. . 40.00
by patient). Office visa for observation, adjustment and acti-
PROSTHETICS(680-7") (Includes Fixed Bridges) vation per visit .... . . . . . . . . . . . . ... . . 4.00
PONTICS:
680 Cast gold(sartitary) . . .. . . . . . . .. . . .. .. .. 40.00
661 Steele's facing . . ... . . . .. . . . . .. .. . . .. . . 45.00
682 Tru-Pontic Type . . .. .. .. .. .. . ... . . .. .. 55.00 FRACTURES AND DISLOCATIONS (9U0-999)
692 Porcelain baked to goad .. . . .. .. .. .. . . . . . . 80.00
693 Plastic processed to gold ... . . .. .. .. . . .. .. 55.00 900 Treatment of simple fracture of the maxilla,open
reduction . . . ... . .. . . . . .. .. .. ...... 700.00
REMOVABLE (UNILATERAL BRIDGES): 901 Treatment of simple fracture of the maxilla,closed
683 One piece casting, chrome cobalt alley class at reduction . .. .. .. . . . . . . .. . . .. ... ... 125.00
tachment (all types) per unit - including 902 Treatment of :simple fracture of the mandible,
pontics .. ... . . . .. .. .. .. .. .. .. . . . . 20.00 open reduction .. . . . .. . . .. . . . . . . .... 230.00
903 Treatment of simple fracture of the mandible,
RECEMENTATION: closed reduction.. . . . . . . . . . . .. .... . . 125.00
685 Inlay . . . . . . . . . . ...... . . .. . .. . .. . . .. 5.00 904 Treatment of compound or comminuted fracture
686 Crown .. . . . . . .. . . . . . . . . . ..... . . . . .. 5.00 of the maxilla,closed reduction. ... . . ..... 200.00
687 Bridge 10.00 905 Treatment of compound or comminuted fracture
of the maxilla,open reduction ... . . ... . .. 300.00
REPAIRS, CROWN AND BRIDGES: 906 Treatment of compound or comminuted fracture
690 Repairs-based on time and laboratory charges.. B/R of the mandible,closed reduction .. . .... .. 200.00
907 Treatment of compound or comminuted fracture
of the mandible,open ruction .. .. . . .... 300.00
910 Treatment of luxation (dislocation) of the man,
DENTURES: dible(uncomplicated) .. . . . .. .. . . .. . . .. 8.00
Dentures, partial dentures and reline allowances 911 Treatment of condyler fracture,open reduction .. 350.00
include adjustments for six month period follow- 912 Treatment of condyler fracture,closed ruction . 150.00
ing installation.Fees for specialized techniques 913 Reduction of dislocation of temporomendibular
involvingjoint precision dentures,personalization or .. .. .. .. ... . .. . . .. ... ....... 35.00
characterization must be paid by patient. 915 Treatment of molar fracture,simple,closed mouc-
tion . .. . . . . .. .. ... . .. ... . . . .. .... 100..00
700 Complete maxillary denture ............... 155.00 916 Treatment of malar fracture,simple or compound
701 Complete mandibular denture 155.00 depressed,open reduction . . . . . . . ....... 200.00
C15-:9e 14 70)
APPENDIX "C"
SCHEDULE OF SERVICES
Subject to the exclusions and limitations hereinafter set forth, the following is the Schedule of Services covered by the
within Agreement when rendered by a licensed dentist and when necessary and customary, as determined by the
standards of generally accepted dental practice.
I. BASIC BENEFITS:
Diagnostic
Procedures to assist the dentist in evaluating the existing conditions to determine the required dental treatment.
Preventive
Prophyiaxis once every six months
Topical application of fluoride solutions
Space maintainers
Oral Surgery
Procedures for extractions and other oral surgery including pre-and post-operative care.
General Anesthesia
When administered for a covered oral surgery procedure performed by a dentist.
Restorative
Provides amalgam, synthetic porcelain and plastic restorations for treatment of carious lesions. Gold
restorations,crowns and jackets will be provided when teeth cannot be restored with the above materials.
Endodontic
Procedures for pulpal therapy and root canal filling (treatment of non-vital teeth).
Periodontic
Procedures for treatment of the tissues supporting the teeth.
11. PROSTHODONTIC BENEFITS:
Procedures for construction of bridges, partial and complete dentures.
III. EXCLUSIONS
(a) Services for injuries or conditions which are compensable under Workmen's Compensation or Employer's
Liability Laws; services which are provided the eligible patient by any Federal or State Government Agency or are
provided without cost to the eligible patient by any municipality, county or other political subdivision, except as
provided in Section 12532.5 of the California Government Code.
(b) Services with respect to congenital or developmental malformations or cosmetic surgery or dentistry for
purely cosmetic reasons; including but not limited to: cleft palate, maxillary and mandibular malformations, enamel
hypoplasia, fluorosis, and anodontia.
(c) Prosthodontic Services or Devices (including crowns, and bridges) or any single procedure started prior to
the date the patient became eligible for such services under this Agreement.
(d) Prescribed drugs.
M)MMIMtt M"s.
ia2-S t-
ttta>�
r
IV. LIMITATIONS:
The benefits as outlined are subject t- the following limitations:
(a) X-rays:
Complete mouth x-rays are provided only once in a three (3) year period, unless special need is shown.
Supplementary bite-wing x-rays are provided upon request but not more than once every six (6) months.
(b) Prosthodontics:
Replacement will be made of an existing prosthodontic appliance only if it is unsatisfactory and cannot be
made satisfactory. Prosthodontic appliances (including partial and complete dentures, crowns, and bridges) will be
replaced only after five (5) years have elapsed following any prior provision of such appliances tinder any COS program,
(c) Optional:
In all cases in which the patient selects a more expensive plan of treatment than is customarily provided,
COS will pay the applicable percentage of the lesser fee.The patient is resl,.insible for the remainder of the dentist's fee.
(1) Partial Dentures. CDS will provide a standard cast chrome or acrylic partial denture or will allow the
cost of such prow dur2 toward a more complicated or precision appliance that patient and dentist may choose to use.
Any denture for which a charge is made which exceeds the customary fee shall he considered an optional service.
(2) Complete Dentures. If in the construction of a denture the patient and cientist decide on personal zed
restorations or employe specialized techniques as opposed to standard procedures, CDS will allow an appropriate amount
for the standard denture toward such treatment and the patient must bear the difference in cost. Any denture for which
a charge is made which exceeds the customary fee shall be considered an optional service.
(3) Occlusion. CDS will allow the cost of restorations required to replace missing teeth. Procedures,
appliances or restorations necessary to increase vertical dimension and/or restore or maintain the occlusion are
considered optional, and the cost is the responsibility of the patient. Such procedures include, but are not limited to,
equilibration, periodontal splinting, restoration of tooth structure lost from attrition, and restoration for malalignment
of the teeth.
(4) Implants. If implants are utilized, CDS will allow the cost of a standard complete or partial denture
toward the cost of -,plants and appliances_constructed in association therewith. CDS will not provide surgical removal of
implants.
2,3 S .•A .2.
APPENDIX-U-
ORTHODONTIC BENEFIT RIDER
In consideration of the payments specified in paragraph 1 of the attached Agreement,and subject to all of the terms
and conditions thereof, except as herein otherwise specified, CDS agrees to provide Orthodontic Benefits to eligible
patients,as follows:
1. Orthodontics are defined n aii the necessary procedures of treatment by a licensed dentist for correction of
malposed teeth of an eligible dependent child.
2. CDS will pay or otherwise discharge 50%of the lesser of the Lv ual,customary and reasonable fees or the fees
actually charged for Orthodontics, provided that the amount payable tr,a dentist who is not a participating dentist shall
not exceed 5 % of the amounts for the corresponding services at forth in the Orthodontic Table of Allowances, a
copy of which is attached hereto, marked Exhibit 1 and incorporated herein by reference.
3. The maximum amount payable by CDS for Orthodontics rendered to an eligible patient shall be $SOO and
the limitations on maximum amounts payable during a calendar year, as specified in the attached Agreement, shall not
apply to Orthodontics.
4 Exchusions. In addition to the Exclusions and Limitations statee in Appendix C to the attached Agre:ment, the
following exclusions shall apply to Orthodontics:
(a)The obligation of COS to make monthly or other periodic payments for an orthodontic treatment plan will
cease upon termination,of treatment for any reason prior to completion of the case.
(Whe obligation of CDS to make monthly or other periodic payments for an orthodontic treatment plan begun
prior to the eligibility date of the patient will be calculated on the balance of the dentist's normal poyment pattern
remaining at the patient's m;tial eligibility date. The above mentioned maximum will apply fully to this amount.
(c)CDS will not make any payment for repair or replacement of an orthodontia appliance furnished under this
pr ogr a m.
obhoauon to make monthly ar other periodic payments for Orthodontics shall ferm,nate on the term;n
at;o:) date of th;s Agreement or on the date the eli tble dependent child reaches age tg or age 23, ;f a full time >tudent.
te+eiA ppatient shall b eligilne f r Orthodontic Benefits only.following
ve (�12) months continuous enrolment in the dental program provided lierebll
Dated- July 1 , 1973 California Dental Service..
- -,a
-40
• ���® aTA&�i r
CIA 2 13
EXHIBIT 1
TABLE OF ALLOWANCES FOR ORTHODONTICS
(To be used for cases submitted by non-participating'dentists)
A percentace of .he amounts listed in this table of allow4nces will be paid toward the charges of the dentist providing
orthodontic services in accordance with the terms and conditions of the applicable group dental care contract. Such
amounts will be paid periodically when dentist has completed services and upon proper presentation of staten<ent for
Prvices rendered.
PROCEDURES
Diagnostic
129 Orthodontic Survey including entire denture series
and all other films including cephalonvetrics and photos $ 25.00
125 Panagraphic Film 12.00
Extraoral Head Film
126 One Filr.i 8.00
127 Each Additional 4.00
Comprehensive Orthodontic Traatment
Permanent Dentition
850 Class 1 700.00
855 Class II 700.00
860 Class 111 700•00
"fixed DenQition
870 Class 1 400.00
871 Class If 400.00
872 Class Ill 400.00
Primary Dentition
6
875 Class 1 200.00
876 Class 11 200.00
877 Class III 2N).00
Appliances for Tooth Guidance
840 Removable 40.00
843 Fixed or cemented 50.00
Appliances to Control Harmful Habits
845 Removable 40.00
B47 Fixed or cemented 50.00
'Nonparticipating Dentist -- Dentist who does not agree to abide by the conditions governing dentist participation in
ailstornia Dental Service group dental care program.
Dental Services
Pei,
CALIFORNIA DENTAL SERVICE
A Nonprofit Corporation
COS GROUP # 1949
APPLICATION FOR DENTAL CARE SERVICE AGREEMENT
CITY OF CUPERTINO
herein called "EMPLOYER", hereby applies for a DENTAL CARE SERVICE AGREEMENT with CALIFORNIA
DENTAL SERVICE,herein called"COS",on the following terms:
1. Definitions:
A.Monthly Payment: The sum of $4 . 85 for each eligible single employee ,
the sum of $8. 70 for each eligible employee with one dependent ,
the sum of $13. 95 for each eligible employee with two or more
dependents.
B. Applicable Percentages:
xD Basic Benefits (as defined in Appendix "C"1 so %
Presthodontics(as defined in Appendix "C") so %
7XX Orthodontics (as defined 4n 50 %
Appendix D")
11. Benefits provided and limitations:
A.Subject to the terms and conditions herein specified, COS shall pay or otherwise discharge the applicable
percentage of the lesser of the usual, customary and reasonable fees or the fees actually charged fer services rendered to
an eligible patient during the term hereof and covered by this Agreement set forth in Appendix "C"attached hereto.
B. The amounts payable by COS for covered Basic and Prosthodontic services rendered by a participat+ng dentist in
California who is not a member of COS shall not exceed the applicable percentage of the:mounts shown for correspon-
ding services in the Table of Allowances,attached hereto as Appendix "B";and :ne amounts payable by COS for covered
services rendered by a participating dentist outside of California shall not exceed the applicable percentage of the
customary fees in California.
C. The amounts payable to a dentist who is not a participating dentist shalt not exceed the amount which COS
would pay to such a dentist on account of such services if he were a participating dentist, but not a member of COS.
Such payment shall be made only upon receipt by COS of evidence which it deems satisfactory showing the rendition of
covered services during a period in which the patient was eligible for care under the provisions of this Agreement and the
amount which the patient has paid or become obligated to pay therefor.Such payment may, in the discretion of COS,be
made to the eligible patient, to the dentist,or jointly to both of them.
®Di. The maximum amount payable by COS for Basic and Prosthodontic Services rendered to an eligible
patient in any calendar year or portion thereof ;hall be S 1 , 000. 00.
IJD2, The maximum amount payable by COS for Orthodontic Benefits(as defined in Appendix "C" )rendered
to.an eligible patient shall be S 500.00.
s-n-Nu-a -t-
' I
171E. COS shall not be obligated to pay for, or otherwise discharge, in whole or in par,, the first
S of fees for services rendered to each eligible patient during the term hereof and otherwise covered Uy
this Agreement, which fees shall be computed on the basis of the dentist's usual,customary and reasonable fees or fees '
actually charged or the Table of Allowances,whichever is applicable under the provisions of Sections 11 A and I i-B of this
Application. (Such deductible amount shall not exceed S for all eligible patients in a single family
consisting of an eligible employee and his dependents as defined in Appendix "A"attached hereto.) (Strike out wards in
parentfreses if inapplicable.)Such deductible amount shall apply:
Once each calendar year or portion thereof during w:rich this Agreement is in effect.
Once during -he term of this Agreement.
This deductible shall not apply to the following services:
The amount an eligible patient pays for the foregoing services shall not be applied towards satisfying the deductible.
IF. A patient shall be eligible for Prosthodontic Benefits only following such patient's continuous enrollment
in the dental program provided hereby for a period of months.
I G.
THE FOREGOING PROVISIONS DESIGNATED Or THROUGH G ARE APPLICABLE ONLY WHERE A
CHECK MARK HAS BEEN PLACED IN THE BOX PRECEDING SUCH PROVISION.
III. In the event that the number of eligible employees reported by EMPLOYER to COS pursuant to paragraph 1(a) of
General Agreements shall be less than 50 in each of any three consecutive months,COS shall,at its option,
terminate this Agreement upon written notice to EMPLOYER given not more than fifteen (15)days after receipt of the
List of Eligible Employees which indicates tha such grouind for termination exists.Such termination shall be effective as
of the last day of the month in which notice of termination is given,and COS shall make payment to dentists for dental
services authorized prior to termination and dental services which were rendered without prior authorization by the
dentist prior to receipt by him of notice of such termination of benefits.
IV. Any notice which is required or permitted to be given under the terms of this Agreement may be given by registered
or certified mail addressed to the parties at the addresses which are indicated below and shall be deemed to have been
giver. 48 hours after deposit in the mail with postage fully prepaid at any post office located in the continental United
States.The addresses of the partie•:;are as follows subject to change by written request:
(a)EMPLOYER CITY OF CUPERTINO
10300 Torre Avenue
Cupertino, California 95014
(b)CALIFORNIA DENTAL SERVICE
Director of Marketing
101 Howard Street
San Francisco,California 94105
D-n-av-a.POT-2 .2.
V. The term of this Arree a nt shall be J u 1 y 1 , 19 7 3. through
J un e 3 0, 19 7 S, and shall continue thereafter from year to year until terminates;as herein provided.
This Agreement may be terminated on any anniversary date by at least sixty (60) days' written notice of termination
given by the party desiring to terminate to the other party. In the event that CDS shalt desire to charge the rates or other
terms and conditions of this Agreement effective on an anniversary date,advice of such proposed changes may be given
with a notice of termination, and such notice of termination shall be effective only in the event that agreement is not
reached as to such changes. In the event that this Agreement is terminated pursuant to this paragraph, CDS is hereby
empov.^wed not to authorize treatment plans beyond such termination. An anniversary date shall mean
July 1 , 1975, and July 1 of each subsequent year.
The attached Definitions, Recitals, General Agreements and Appendices A, B, C, (and 11 D 11 )are each a part of
this Application and, upon acceptance hereof by CDS,this Application and the aforesaid documents shall constitute the
entire Agreement between EMPLOYER and CDS. All prior negotiations,representations and understandings are intended
to be merged herein. No modification of this Agreement shall be effective for any purpose unless in writing and signed by
both parties or their duly authorized representatives.
ACCEPTED: DATED: July 1 , 1973
CALIFORNIA DENTAL SERVICE: CITY OF CUPERTAy
ERESIDENT e) CITY MANAGER
By By
ASSISTAN VICE P DENT/CONTROLLER DIRECTOR, MINISTRATIVE SERVICES
(Title)
9-71-au-2.aT-a
•3-
RECITALS
CDS is a nonprofit corporation, organized and existing under Section 9201 of the Corporations Code of the State of
California, composed of members licensed to practice dentistry under the provisions of the Dental Practice Act. It is the
purpose of COS to provide dental care under programs with responsible entities so as to maintain the prime requisites of
an independent and responsible profession,i.e.,fee for services,free choice of dentists and preservation of dentist-patient
reWionship without lay control,interference,promotion or commercialization.
GENERAL AGREEMENTS
1. EMPLOYER agrees:
(a)To compik;, certify and furnish to COS on or prior to the first of every month commencing on the commence-
ment date of the term of this Agreement, a LIST OF ALL ELIGIBLE EMPLOYEES AND THEIR SOCIAL SECURITY
NUMBERS entitled to receive dental benefits hereunder. Eligible employees shall be determined according to the
Eligibility Rules-Appendix "A",attached hereto.
(b)To pay CDS monthly, commencing on the commencement date of the term of this Agreement,and on or before
the first day of each succeeding month, the monthly payment specified in Section I-A of the Application for Dental C.re
Service Agreement.
(c,To provide information to all eligible employees as to the existence and terms of this Agreement and the right
of eligible patients to receive care as provided herein from a dentist of each patient's choice, as such choice may be
exercised from time to time by a patient during the continued eligibility of the patient.
(d)To advise eligible employees to notify their dentist at the time of their first appointment that they are covered
by this Agreement and to provide their dentist with group identification and social security number.
(e)To permit CDS, by its auditors or other authorized representatives, on reasonable advance written notice, to
inspect records of EMPLOYER in order to verify the accuracy of lists of eligible employees prepared by EMPLOYER and
submitted to CDS.
2. CDS agrees:
(a)To advise participating dentists as follows:
(i) To submit a treatment plan, prior to rendition of service, showing the patient's dental needs and the
treatment necessary in the professional judgment c! the dentist;and
(ii) To notify the eligible patient of all actions taken by CDS with respect to such treatment plans,.jnr,
(iii) That such treatment plan need not be submitted prior to rendition of service in the case of emergency
services or in the case of brief routine procedures.
(b►To authorize such treatment plan for cove-age under the dental care program provided by this Agr.�ement when
satisfied from the treatment plan and other data submitted by the dentist (1) that the patient is eligible hereunder;(2)
that the services proposed are included in the Schedule of Services covered by this Agreement set forth in Appendix "C"
attached hereto;and (3) that the total fees to be charged to both CDS and the eligible patient do not exceed the dentist's
usual,customary and reasonable fees. Such authorization shall be for a reasonable period of time, but not longer than the
term of this Agreement.
(c)To make no payment for any services rendered to a patient who is not eligible for dental care hereunder at the
time of rendition of the service,except to the extent of services performed during a period of an authorization issued by
CDS pursuant to subparagraph(b)of this paragraph,and except for completion of single procedures commenced at a time
the patient was entitled to treatment by reason of such authorization.
(d)To make periodic checks as to the adequacy of care provided by dentists through local dental consultants and
committees of local dentists appointed by CDS.
9 7r W t
_N
3. (a)If an eligible patient is eligible for coverage under two or more COS dental care programs,and more than one of
said programs provide coverage for a particular service. COS will pay the aggregate sum payable under all applicable
programs, but not more than the lesser of the usual, customary and reasonable fee or the fee actually charged for such
service and will prorate the cost thereof between the applicable programs, provided, that no program shall be charged
with a greater amount than the amount for which it would be liable if such dual coverage did not exist.
(b)lf an eligible patient is entitled to coverage under one or more insurance policies or prepaid health care plans
other than a COS dental care program, then the benefits of this Agreement shall be provided only to the extent that the
funds obtained from such other insurance or plan are inadequate to provide full payment for the services which are bene-
fits provided by this Agreement.
(c)If an eligible patient is injured through the act or omission of another person COS shall provide the benefits of
this Agreement only on condition that the eligible patient shall agree in writing:
M To reimburse COS to the extent of such benefits immediately upon collection of damages by him,whether
by action at law,settlement or otherwise,and,
(oil To grant COS a lien, to the extent of such benefits on any such action at law,settlement or right to recovery.
(d)In no event shall the provisions of this paragraph 3 operate to increase the liability of C'1S beyond the benefits
for which it might otherwise be liable in the event this paragraph did not apply.
4. Neither EMPLOYER nor COS shall be liable for any act or omission by a dentist, his employees or agents,or any
person performing dental or other professional services under this Agreement.
5. Participating dentists shall be obligaL-d to schedule and render all dental treatment for eligible patients in accor-
dance wi-h the applicable standards of the dental profession in their community and to charge no more than the usual,
customary and reasonable fee therefor. COS is authorized to exclude from participating in the services provided by this
Agreement any dentist who persisterl!y fails to comply with the obligations of participating dentists hereunder.
6. Any controversy or claim arising out of or relating to this Agreement or the breach thereof, by or between either
or both parties to this Agreement, dentists, eligible patients or any of them, shall be settled by arbitration by a single
arbitrator to be selected by the parties, and judgment upon the award rendered by the arbitrator may be entered in any
court having jurisdiction thereof.
7. in the event that any payment due pursuant to paragraph 11b) of General Agreements is not paid when due, COS
may give written notice that payment is due, and if such payment is not received within 10 days after such notice, COS
may, at its option, terminate all further benefits and be released from all further obligations hereunder; provided,
however, that COS shall make payment to dentists for dental services authorized by COS prior to termination and for
dental services which are rendered without prior authorization by a dentist prior to receipt by him of notice of such
termination of benefits. In the event of termination pursuant to this paragraph, EMPLOYER shall remain liable to COS
for the full amount of all dentists' statements paid or otherwise discharged by COS,plus Twenty-Five Percent (25%) of
such amount (to compensate COS for its administration of the dental program), less amounts actually paid by
EMPLOYER to COS.
8. Both parties to this Agreement agree to consult to the extent reasonably practical concerning all material published
or distributed relating to this Agreement. No such material shall be published or distributed which is contrary to the
terms of this Agreement.
9. Both parties to this Agreement agree to permit and encourage the professional relationship between dentist and
patient to be maintained without interference.
10. If any portion of this Agreement or any Amendment thereof ,hall be determined by any arbitrator,court or other
competent authority to be illegal, void or unenforceable, such determination shall not abrogate this Agreement or any
portion thereof other than such portion determined to be illegal, void or unenforceable, and all other portions of this
Agreement shall remain in fill force and effect.
11. The parties agree that all questions regarding the interpretation or enforcement of this Agreement shall be governed
by the laws of the State of California, where the Agreement was entered into and is to be performed.
9-71-N Z_
DEFINITIONS
Eligible.atiW. means an eligible employee and his eligible dependents(to be determined as provided in the Eligibility
Rules—Appendix '"A").
Participating dentist means a dentist who is licensed to practice by the State of California and agrees to render dental
care to eligible patients in accordance with standard terms and conditions applicable to dentist participation in COS
prepaid dental care programs, as established by the Board of Directors of CDS consistent with the provisions of this
Agreement. Participating dentist also means any dentist outside of the State of California who is licensed to practice
dentistry by the state or other jurisdiction in which he practices and who agrees to render dental care to eligible patients
in accordance with the terms of this Agreement.
Single procedure means a dental procedure listed on the CPS Table of Allowances(attached hereto as Appendix "'r ")
to which a separate procedure number is assigned, e.g., a three-surface amalgam restoration of a single permanent toeth
(procedure 613) or a complete maxillary denture, including adjustments for a six-month period following installation
(procedure 700).
Usual, Customary and Reasonable fee means a fee which meets all of the following criteria, as determined by CDS
based upon confidential fee listings filed with CDS by member dentists and the findings of local dental society review
committees:
USUAL: Usual fees are those fees usually charged for a given service by an individual dentist to all his private
patients, i.e.,his own usual fee.
CUSTOMARY: A fee is Customary when it is within the range of usual fees charged by dentists of similar training and
experience for the same service within that same specific and limited geographic area.
REASONABLE: A fee is Reasonable when it meets the above two criteria and when, in the opinion of the review
committee of the responsible dental society, it is justifiable considering the special circumstances of the part'zular case
in question.
1-70-DD
a
APPENDIX "A"
ELIGIBILITY RULES
Effective July 1 , 1973 ,all present,permanent employees of
CITY OF CUPERTINO
who have completed three (3) mo n t h sof cont6uous full-time employment with a minimum of thirty-
two (3 2) burs oer week are eligible undet the Dental Care Service Agreement. Present permanent
emolovr,es not eligible on July 1 , 1973, , and all future permanent employees will become
elwoble on the first clav of the month coincident with or next following three (3) months of
c+>nthnuous full-time employment with a minimum of thirty-two (3 2) ho�Jrs per week.
The dependents of eligible employees are eligible under the Dental Care Service Agreement. Dependents are lawful
spouse and unmarried dependent children to 19 or to 23 if enrolled as full-time student in an accredited school,college
or university. Children include step-children,adapted children and foster children,provided such children are dependent
Upon the employee for support and maintenance.
An unmarried child 19 years or over may continue to be eligible as a dependent if he is incapable of self-support
because of physical or mental incapacity that commendd prior to reaching age 19, provided a physician's certificate
is submitted within sire months following his 19th birthday or the effective date of this Agreement.
Dependents in military service are not eligible.
Eligibility of employees shall terminate on the last day of the month in which full time employment has terminated.
Cependents shall remain eligible until the last day of the month coincident with or following termination of eligibility of
.he employee or loss of dependent status, whichever shall occur first. Eligibility shall, in any event, terminate
immediately upon termination of this Agreement.
1-70-EN
TAAE OF ALLOWANftS Apmm is
This is not a fee s heduit The amounts !3r!ed *his Ta�Ie are cllcaarees which are made
toward usual and r_ustemrry fees.Usual and c--,,ornery fees vary WTI'. individual de^tal practices.
((m 1tRMt4 No. proceb ee (IM etas ft PA ei 0
10=AND DIAIGN10 C i028 ") CYSTS AND NEOPLASMS.
M Office visit for osatsttent end obasinvatfon of 260 Immoral incision and drainage of abscess . .. . .. 10.00
atjsssies to arm flow 1pportiag structure,other 261 Extmoral incision and drainage of abscess 15.00 or B1R
thin for toutie operative pnkadureis IRegular 262 Excision pericoronal gingiva ... . . .... . . .. .. 10.00
office hovrW .. ... . .. .. .. . . . .. .. .. 4.00 163 Sialoiithotomy: removal of salivary calculus,intra-
MO Professional visits attar hours 106ntist may elect orally .. . ... . ...... . . . .. . . . . . . .. . 33.00
payrltem on basis of services renderer or visits 264 Siafolithotomy:removal of salivary talculuiL extra
Whiehawir is greater) 10.00 orally ... . . .. .. . . .. . . . . . .... . . . . 100.00
040 Special wrttuhation (by specialist for case pea- 265 Closure of salivary fistula ... . . .. . ... .. . . . . 60.00
sentation when diagitostic procedures have been 266 Dilation of salivary duct 17.00
perfornced by general dentist) . .. . 10.00 270 Resection of benign tumor of soft tissue(2.5 cm
049 Prophylaxis children to age 14 .. . .. . ... . . 6.00 or larger) 26.00
050 Prophyfas.is-to include scaling and polishing . - . 9.00 271 Resection of malignant tumor .,. ... . . ., . B/R
061 Topical application of sodium fluoride (one treat 275 Transplantation of tooth or tooth bud .. . . . . . . 70.00
meet inr'iding prophylaxis under age 4) . . . .. 11.00 276 Removal of foreign body from bone(independent
062 Topical epplication of stannous fluoride (once procedure). . . . . .. .... .. .. . . . . . . . . . . B/R
treatment including prophylaxis - payment 277 Radical resection of bone for tumor with bone
limited to once each year to age 18) . . . ... . 14.00 graft...... . . . . . ... . . . . . .. . . . . . . SIR
030 Emergency treatment-palliative per visit 5,00 278 Maxillary sinusotomy for removal of tooth fr*
ment or foreign body .. . .. . .. . .... .. . . 65.00 or SIR
Ft7ta include exam and diagnosis 279 Closure of oral fistula of maxillary sinus . . . ... . 40.00 or SIR
280 Excision of cyst,small 25.00 or 6JR
110 Single film . . . ... ... . . . .. .. . . . . . .. . . 4.00 281 Excision of cyst,large 12.5 cm or larger) . .. . . . 7500 w SIR
III Additional,up to 12 films,each . . . . . . . . . - . 1.00 282 Sequestrectomy for osteomyelitis or bone absc
112 Entire denture series, including examination con superficial _ 20.00 or B1R
silting of at least 14 fibns (bite wings if 285 Condylectoary of temparomandibular joint.. . .. 300.00
necessary) ,, . , , ,, ,, , . 17,00 289 Meniscertomy of terporomandibular joint . .. . . 250 00
113 Intra vital• occlusal view maxillary or mandib-
ular,each 4,00 MISCELLANEOUS-
114 Superior or inferior maxillary, extra oral, one 290 I�,r,rvnn and removal of foreign body from soh
film 10.00 tissue ...... .. . . . . .. 10.00 or B/R
115 Superior x interior maxillary, extra oral, two ?91 Frerectomy 25.00
films . . . 15,00 292 Suture of soft tissue wound or injury . .. . . . . . . B/R
116 Bite wing films,including examinmion 293 Crown exposure for orthodontia . . . .. . . .. . .. 15.00
1 films 5.00 294 Inlection of sclerusing agent into temporomandib-
4 films TOO ular mint . . I . .... . . . . . . . . . . . . . . 30.00
Additional films,each 1_00 295 1 reetnient t-igeminal neuralgia by injection into
150 Biopsy of oral tissue 800 second and third divisions .... . . . . . .. 34.00
160 Microscopic examination 15.00 DRUGS '300-399;
ORAL SURGERY f200 M 300 Drugs administered by dentist-based on cost. . . B/R
-All hospital costs are ne responsibilry of the patient ANESTHESIA 400.449
COS will allow for the procedures listed.r this schedule 400 A,erhesia. General 15.00
Additional fees charged bit the dentist for performing pERIODONT�CS 1450-499I
procedures in the hospital are the respowabdity of the
patient. Special consultation(by specialist lot case presenta-
tior, when preliminary diagnostic procedures
-COS allowance tot General ffilms, models, etc.) have been performed by
Anesthesia , . . . . . See Procedure d400 aeneral dentist; see Procedure 0040
Any further charges for anesthetics, anesthetists, or
anesthesiologists are the responsibility of the patient Prophyldxis(includes scaiinq and polishing) . . See Procedure 0050
451 Finer?ency treatment (periodontal abscess, acute
`Allowances for procedures not listed in this schedule peri:cfonrms,etr,.) .. 10.On
will be paid at the rate listed in the Relative Value 452 Subgingival c uretage root planing per quadrant
Study as apprryved Dy the American Society of Ora! (not prophylaxis) ., 12.00
Surgeons. Consultation (by specialist for case presenta- 453 C:rrecnon of occlusion per quadrant . . . . 1210
Lion when diagnostic procedures have been performed 472 GingivecTorny per q;,ad•ant(including post surgical
by general dentist) . . . . . . See Procedure#W, :isits) 50.00
412 Girgrverronry osseous or mumgingival surgery
EXTRACTIONS: per quadrant'iacludes post surgical visits) . .- 60.00
200 Uncomplicated single, including routine post oper 474 Gingivectomy, treatment per tooth(fewer than six
alive visits 800 teeth) . ... . -. ... 10,00
201 Each additional tooth,including routine post oper
alive visits . 6.00 ENDODONTICS f500-599)
202 Surgical removal of erupted teeth Bi R Special consultation iby specialist far casepresenta-
220 Post-opwative vest(sutures and complications) 3,00 lion when diagnostic procedures have been
performed by general dentist) . . . . . . . . see Procedure/W0
IMPACTED TEETH iuxlose film): 500 Pulp capping 6.00
230 Removal of tooth(soft tissue) . . . . . . . . 1700 501 Theiapeuuc pulpotomy(in addition to restoration,
231 Removal of tooth(partially bony) . . . _ - 25,00 per treatment) 6.00
232 Removal of tooth(completely bony,' 40.W or 3 R 502 Vital pulpotom). . . . . . 12,00
;03 Remmeralilation (Caoh, temporary restoration)
ALVEOLAR OR GINGIVAL RECONSTRUCTION: per tooth . . .. . .. . . . . .. .. 10.00
260 Alveolatomy(edentulous)per quadrant. . 25.00
252 Ahrsolectomy (in addition to removal of teeth) ROOT CANALS:
per quadrant . .. .... . . ... . . . 10.0C 5.10 Cuftur;ng canal 7.00
256 Ahreopinsty with ridge extension,per arch - .. 42.00 511 Single rooted canai:uotti therapy 45-00
257 Removal of palatal tors . . ... .. .. . .. .. . . 35.00 or 81R $12 Bi-rooted tooth canal therapy .. .. ... . . .-. 60,00
I58 Rommel of mandibular tort per quadrant 35.00 513 Trt-rcated toott,canal theresiv ... .. . . . . . . 75.00
299 Excision of hypsr pttstic time per arch . .. .. . . 32-00 530 Apicoectomy(:ncluding filling of root Canal). . . . 50.00
0
POea POOL
Ile. PO63111111011ae Will was By Repo) Na PratteAtttem OM esas By Rapsto
Aflaltaea
531 Ap tonry(uperate procedure) . . ,.... ... 36.00Allowances do not include final restoration 702 Parties acrylic upper or lower with gold or chrotna
or ae my afth 890Y cb m-ban .... . ..... .. . . 75.00
712 Taerh and clams-extra per unit... ........ . &DO
IWOUTIVE DENTISM 160M79) 703 PerVA Iowa, or upper with chrom comet an"
AMALGAM RESTORATIONS PRIMARY TEETH: lingual or palatal bar and acrylic sadder-base . 150.00
60D Cavities invnlvstg one tooth surface . . . . . .. . .. 6.00 704 Teeth and clasps-extra per unit.. .. .. .. .... 5.09
6D1 Cavities itt nNin,•,two tooth surfaces .. . .. ... . 9.00 705 Simple stress breakers-extra .. ... ... . . . .. 14.00
602 Cavities itwolving three at more tooth surfaces. .. 12.00 706 Steyplate-base... . . . . .. . . .
. . . . . . . .. ..
AIUhLGAM RESfORA.BONS PERMANENT TEETH: 716 Teeth and class-extra per unit.. . . . ... . . .. 3,00
611 Cavities involving one tooth vhrface . . .. ..... . 8.00 720 Denture adjustment. .. .. . . . . . . . . .. .. . . . . 4.00
612 Cavities involving two tooth surfaces . . . .. .. .. 11.00 721 Office reline-cold cure-acrylic .. . . . .- .. . . 15.00
613 Cavities involving three or more tooth surf em. , . 15.00 722 Denture retire . . . . . ... .. .. . . . . .. .. .. .. 35.00
GOLD RESTORATIONS: 723 Special tissue conditionin
g, per denture, in adds~
635 One tooth surfs:* 35.00 tion to reline maximum 2 par denture .. ... 16.00
636 Two tooth surfaces . . . . .. ... . .... .. .. .. 40.00 724 Denture duplication(jump case)per denture .. . . 55.00
637 Three or more tooth surfaces .. .. . ... .. .. .. 50.00
638 Onlays extra per tooth .. .. .. .. . . .. .. .... 10.00
SILICATE,ACRYLIC,PLASTIC RESTORATIONS, REPAIRS,DENTURES,ACRYLIC:
640 Silicate cement filling 9.00 790 Broken denture,repairing(no teeth involved) . . . 12.00
645 Acrylic or plastic filling . . . . . . 11.00 Replacing missing or broken teeth, each adder
tional . .. .. . .. . .. ... . . . . . . . . . . . . . 3.00
RESTORATIVE DENTISTRY UNDER GENERAL ANESTHESIA Adding teeth to pzrtial denture to replace ex-
ISpecial cases only) (Handicapped Patients) tracted natural teeth:
649 Long term operative cases pzrformed under Gen- 793 First tooth . ... .... .. .. .. . . . . . . .. . . . . 25.00
oral Anesthesia on hourly basis' 794 First tooth with clasp . . . .. . .. . .. . . . . . . .. 30.08
-One hour duration from beginning to end 75.09 795 Each additional tooth and clasp. . . . . .. .. . . . . 5.00
-Two and one half hours,maximum 150.00 796 Partia denture repairs - based on time and
-Three and one half hours,maximum 175.00 laboratory charges B/R
-Four or more hours . . 200.00
The above inclLJes all operative procedures, ex
tractions, pulpotomres, necessary treatments,stan-
nous fluoride and oral prophylaxis Fees for anea
thesiologists must be paid by patient SPACE MAINTAINERS(11M")
Allowances include all adjustmenhts within six
CROWNS: months following installation.
650 Acrylic . . . . . 60.00 800 Fixed space maintainer)band type) .. . . . . . . . . 35.00
651 Acrylic with metal 75.00
652 Porcelain . . . 75.00 REMOVABLE ACRYLIC SPACE MAINTAINERS:
. . . . . . . . . . .
653 Porcelain with metal . . . 100.00 801 With stainless steel round wire rest only .. . . . . . 40.00
660 Gold(full) . . 65.00 802 Stainless steel clasps and!or dctivating wires, in
663 Gold . . . . . .. .. . . . 60.00 addition per wire or clasp.... . .. .. . . .. . . 5.Ou
670 Stainless Steel(primary) . . . 17.00 803 Study models . .. . . .. . .. . . .. . . . . . . . . . 5.00
671 Stainless Steel(permanent) . . 20.00 810 Removable inhibiting appliance to correct thumb-
672 Gold dowel pin 10.00 sucking .- .. .. . . .. . . .. 40.00
COS does not pay tnr facings on crowns,posterior 832 Fixed or cemented inhibiting appliance to cormact
to 2nd bicuspids (if placed, fees must be paid thumbsucang . . . . . . . . . . . . . . . . . . .. 40.00
by patient). Office visit 'or observation, adjustment and acti-
PROSTHETICS(68&799) (Includes Filled Bridges) vation per visit 4.00
PONTI CS:
680 Cast gold(sanitary) 40,00
681 Steele's facing . , . . 45.00
682 Tru-Ponta Type .. .. . 55 00 FRACTURES AND DISLOCATIONS 90 "9
692 Porcelain baked to gold . . . 80.00
93 Plastic processed to gold 55.00 90C Treatment of simple fracture of the maxilla,open
reduction 200.DO
REMOVABLE (UNILATERAL BRIDGES): '0: Treatment of simpl4 trectrre of the maxilla,closed
683 One piece casting, chrome cobalt alloy clasp at reduction 125.00
tachment (all types) per unit - inclucrrrtg 902 Treatment of simple fracture of the mandible,
pontics 20.00 open reduction .. . .. . . . . . . . . . . . ... . . 230.00
96, Treatment of sample fracture of the mandible,
RECEMENTATION: closed reduction . . . . .... .. . . . . . .. . . . 125.00
685 In:ay . . . . . 500 904 Treatment of compound or comminuted fracture
686 Crown 5.00 of the maxilla,closed reduction. . . . .. . . . . . 200.00
687 Bridge .. . . 10.00 905 Treatmpn: of compound or comminuted fracture
;i the maxilla,open reduction . . . . . ... . . . 300.00
REPAIRS, CROWN AND BRIDGES: 906 treatment of compound or comminuted fracture
690 Repairs-based on time and laboratory charges 81 R of the mandible,closed reduction ... . . . . . . 200.00
907 Treatment of compound or comminuted fracture
o1 the mandible,o,vn reduction . . . . ..... . 300.00
910 Treatment of luxatiot (dislocation) of the man,
DENTURES: dible(uncomplicatadl ..... . . .. . . .. .. . . 8.00
Dentures, partial dentures and reline allowerices 911 Tsvalment of condyfar fracture,open reduction .. 350.00
include adjusttments for sax month period follow 912 Treatment of condyler fracture,closed reduction . 160.00
ing installation.Fees for specialty d techniques 913 Reduction of dsstocation of temporomaridibular
involving precmon dentures, luwutthatization W joint .. ... . .. .. . . .. . . . . 35.00
characterization must be paid by patient. 915 Treatment of motor fracture,simple,closed reduc-
tion .. .. . . .. . ..... .I. .. . . . .. . . .. 100.00
71I0 Complete maxillery denture 155.00 915 Treatment of malem fracture,simple or compound
701 Complete mandibular denture 155.00 depressed.upon reduction 200.00
APPENDIX "C"
SCHEDULE OF SERVICES
Subject to the exclusions and limitations hereinafter set forth, the following is the Schedule of Services covered by the
within Agreement when rendered by a licensed dentist and when necessary and customary, as determined by the
standards of generally accepted dental practice.
I. BASIC BENEFITS:
Diagnostic
Procedures to assist the dentist in evaluating the existing conditions to determine the required dental treatment.
Preventive
Prophylaxis once every six months
Topical application of fluoride solutions
Space maintainers
Oral Surgery
Procedures for extractions and other oral surgery including pre- and post-operative care.
General Anesthesia
When administered for a covered oral surgery procedure performed by a dentist.
Restorative
Provides amalgam, synthetic porcelain and plastic restorations for treatment of carious lesions. Gold
restorations, crowns and jackets will be provided when teeth cannot be restored with the above materials.
Endodontic
Procedures for pulpal therapy and root canal filling (treatment of non-vital teeth).
Pe-riodontic
Procedures for treatment of the tissues supporting the teeth.
11. PROSTNODONTIC BENEFITS:
Procedures for construction of bridges, partial and complete dentures.
Ill. EXCLUSIONS
(a) Services for injuries or conditions which are compensable under Workmen's Compensation or Employer's
Liability Laws; services which are provided the eligible patient by any Federal or State Government Agency or are
provided without cost to the eligible patient by any municipality, county or other political subdivision, except as
provided in Section 12532.5 of the Caiiforrna Government Code.
(b) Services with respect to congenital or developmental malformations or cosmetic surgery or dentistry for
Purely cosmetic reasons, including but not limited to- cleft palate, maxillary and mandibular malformations, enamel
hypoplasia, fluorosis, and anodontia.
ic► Prosthodontic Services or Devices (including crowns, and bridges) or any single procedure started prior to
the date the patient became eligible for such services under this Agreement.
(d) Prescribed drugs.
XIM XOM"1094MMs.
1 72-S A-
Ili. LIMITATIONS:
The benefits as outlined are subject to the following limitations:
fa) X-rays:
Complete mouth x-rays are provided only once in a three (3) year period, unless special need is shown.
Supplementary bite-wing x-rays are provided upon request but not more than once every six 161 months.
(b) Prosthodontics:
Replacement %-A.If be made of an existing prosthodontic appliance only if it is unsatisfactory and cannot bit
made satisfactory. Prosthudontic appliances (including partial and complete dentures, crowns, and bridges) will be
replaced only after five (5) years have elapsed following any prior provision of such appliances under any CDS program.
(c) Optional:
In all cases in which the pa•ient selects a more expensive plan of treatment than is custornarily provided,
CDS will pay the applicable percentage of the lesser fee. The patient is responsible for the remainder of the dentist's fee.
(1) Partial Dentures- CDS rail! provide a standard cast chrome or acrylic partial denture or will allow the
cost of such procedure to1•aard a rr r,-e implicated or precision appliance that patient and dentist may choose to use.
Any dentine for which a charge s mad- 0 ich exceeds the customary fee shall he considered an optional service.
(2) Complete Dentures 14 ,n the ,r.nstruction of a denture the patient and dentist decide on persona .zed
restorations or empioyP stJiPc+a'I.tetf teeµ. saes as opposed to standard procedures. CDS woo a, ovv an appropriate amount
for the standard dentur(r to.*--d ,uc- • eatment and the patient must bear thF difference in cost. Any denture for which
a charge is made which excel-cis the ci_,'c mar� fee shall be considered an optimal service.
(3) Occlusion. CDS ailt3 the cost of restorations required to replace missing teeth. Procedures,
appliances or restoration, 'o in( ease vertical dimension and;Or restore o, rniaintain the Occlusion are
considered optional, and the '_O't •r r:taplmsibility of the patient. Such procedures irciude, but are not limited to,
equilibration, penodont,sl sp!wTo,g, -zstorat,on of tooth structure lost from attrition, and restoration for malalignment
of the teeth.
'4i Implants. 0 innolants are ,inlized, CDS will allow the cost of a standard complete or partial denture
toward the cost ut ,wPlants ind appi ar:u s constructed in association the-cwith. CDS will not Grovide sung_ gal removal of
implants.
2 73 S .,A. .2-
s
APPENDIX -D-
ORTHODONTIC BENEFIT RIDER
In consideration of the payments specified in paragraph 1 of the attached Agreement,and subject to all of the terms
and conditions thereof, except as herein otherwise specified, CDS agrees to provide Orthodontic Benefits to eligiblt
patients,as follows
1. Orthodontics are defined as all the necessary procedures of treatment by a licensed dentist for correction of
malposed teeth of an eligible dependent child.
2. CDS will pay or otherwise discharge 5 0%of the lesser of the usual,customary and reasonable fees or the fees
actually charged for 0rthodon'tics, provided that the amount payable to a dentist who is not a participating dentist shah
not exceed 5 0 of the amounts for the corresponding services set forth in the Orthodontic Table of Allowances, a
copy of which is attached hereto, marked Exhibit 1 and incorporated herein by reference.
3. The maximum amount payable by CDS for Orthodontics rendered to an eligible patient shall be $5 00 and
the limitations on maximum amounts payable during a calendar year, as specified in the attached Agreement, shall not
apply to Orthodontics.
4. Exclusions. In addition to the Exclusions arrd Limitations stated in Appendix C to the attached Agreement, the
following exclusions shall apply to Orthodontics:
(a)The obligation of CDS io make monthly or other periodic_ payments for an orthodcintic treatment plan vv,;l
cease upon termination of Treatment for any reason prior to completion of the case-
(b)The obligation of ^DS to make monthly or other periodic payments for an orthodontc treatment plan bt�,qun
prior to the eligibility date of the patient will be calculated on the balance of the dentist's normal payment pa—ern
remaining at the patient's initial eligibility date. The above mentioned maximum will apply fully to this amoun?.
(c)CDS wid not make any payment for repair or replacement of an orthodontic applianca furnished under this
program.
(d)CDS's obligation to make monthly or other periodic payments for Orthodontics shall terminate on th? terrr.,n
ation date of this Agreement or on the date the eligible dependent child reaches age 19 or age "11, of a full ume student
5 . A ppatient shall. be eligible for Orthodontic Benefits only following
twelve (12) months continuous enrollment in the dental program providedP:•eb
Dated' J u l y 1 , 197 3 California Dental Serv-ce
i ` s
ER"IDENT
?Vl�lfr�s�d(IXBtm�6>��%r1���r
LTA Z-73
Ask
�r
EXHIBIT 9
TABLE OF ALLOWANCES FOR ORTHODONTICS
(To be used for cases submitted by non-partirpating* dentists)
A percentage of the amounts listed in this table of allowances will be paid toward the charyPs of the dentist providing
orthodontic services in accordance with the terms and conditions of the applicable group dental care contract. Such
amounts will be paid periodically when dentist has completed services and upon proper presentation of statement for
services rendered.
PROCEDURES
Diagnostic
129 Orthodontic Survey including entire denture series
and ail other films including cephalor aetrics and photos 5 25.00
125 Panagraphic Film 12.00
Extraoral Head Fiim
126 One Film 8.00
127 Each Additional 4.00
Comprehensive Orthodontic Traatment
Permanent Dentition
850 Class t 700.00
855 Class II 700.00
860 Class III 700.00
Mixed Dentition
870 Claws 1 400.00
871 Class II 400.00
872 Class III 400.00
Primary Dentition
875 Class 1 200.00
876 Class 11 200.00
877 Class 111 200.00
Appliances for Tooth Guidance
840 Removable 40.00
a43 Fined or cemented 50.00
Appliances to Control Harmful Habits
845 Removable 40.00
841 Fixed or cemented 50.00
'Non-participating Dentist — Dentist who does not agree to abide by the conditions governing dentist participation in
California Dental Service group dental care program.
s
T
CALIFORNIA DENTAL SERVICE
A Nowafit Corwation
CDs GROUP #1949
APPLICATION FOR DENTAL CARE SERVICE AGREEMENT
CITY OF CUPERTINO
herein called "EMPLOYER," hereby applies for a DENTAL CARE SERVICE AGREEMENT with CALIFORNIA DENTAL
SERVICE,herein called"CDS,"on the following terms:
1. Definitions:
A. Monthly Payment the sum of $8.69 for eack. eligible single employee,
the sum of $15 .31 for each eligible employee with one eligible depend-
ent, the sum of $24.69 for each eligible employee with two or more
eligible dependents .
B, Applicable Percentages:
Basic Benefits (is defined in Appendix "C") shall be 70% during tI.- ,irst calendar year of an eligible patient's
eligibility. Provided the eligible patient has utilized available Basic Benefits during the calendar year in which the Applicable
Percentage was 70%. the Applicable Percentage for Basic Benefits shall be increased to 80% for care rendered during the next
succeeding calendar year of eligibility;and the Applicable Percentage for Basic Benefits shall increase to 90'/Ij in the calendar year
succeeding a period in which the Applicable Percentage was 80%and the Applicable Percentage for Basic Benefits shall increase
to 100% in the calendar year succeeding a period in which the Applicable Percentage was 90%. If during a calendar year of
eligibility an eligible patient c1ces not utilize available Basic Benefits, the Applicable Percentage for Basic Benefits rendered
during the next succeeding calendar year shall be reduced by ten percentage points, bz:t in no event to less than 70%. (For
example, if during a period in which the Applicable Percentage was 90% the eligible patient fails to utilize available Basic
5ib;)of its the Applicable Percentage for the succeeding calendar year shall be 80%). CDS shall waive the consequences of failure
o4 ar: eligible patient to utilize available Basic Benefits during any calendar year if it finds, ir, its sole discretion, that such failure
was due *,, extenuating circumstances and that the subsequent condition requiring dental care was not caused by such fz lure.
Prosthodontics (as defined in Appendix "C") 50%
Dental Accident (as deited in Appendix "C") 100%
if B?rief is provided and Ism,:rat ins:
A. Subject to the terms :-)d conditions herein specified, CDS shall pay or otherwise discharge the applicable percent-
age Of O'P Of the usual, and reasonable fees or The fees actually charged for services rendered to an eligible
pml?ril (J,j, no -,e i-im hereof and --jvered by this Agreement set forth in Appendix "C" attached hereto.
B T-,.- arricionts payab- L, CDS for covered Bz,;ic and Prosthodontic services rendered by a c)ar-�,cipating dentist w
Cal,fo— a s not a member r,` CDS shall not exceed the applicable percentage of the amounts show,,i for corresponding
SpfVjres Table of Allowances, attached hereto as Appendix "B"; and the amounts payable by CDS for covered service:
j,jtside (if California shall no,, exceed the applicable percentage of the customary fees it
Californ,-,
C T 81MOLM'S PaYapf5 dCMIST who is not ;,, participating dent) t shall not exceed the arncu�t which CDS\,,vou(d
pay TO Sjcr a rieritist on account such seivict!5 if he �.veie a participaiing dentist, but not a member Of CDS. Such payment
-
,hall be mad: only upon receipt b,, CDS of evidence which it deems satisfactory showing the rendition of covered services during
a period -i vih:ch the patient was - cpble for COSe under the provisions of this Agreement and The amount vhich the patient has
paid or becoryie obligated to pay ;?refOr. Such payment may, in the discretion of CDS, be made to the ehgib!e patient, to the
dentist, or jointly to both of them.
D, The maximum amo_jr,* payable by CDS for Basic, Prosthodonlic and Denial Accident Benefits rendered to arr
eligible patent in any calendar yea, jr 000rtion 'thereof shall be $1,000-00.
F-1 E, CDS shall not be obligated to pay for, or Otherwise discharge, in whole or in part, tie first S50-00 of fee-, for
covered services rendered to each >rg b1e patient during the term of this Agreement which fees shall be comp.,ited on the basis of
the dentist's usual, customary and reaSO`1d1Ae fees Or fees actually charged or the Table of Allowances,v.-ichever is applicable
under the provisions of Sections II-A and 11-8 oY this Application.
ElF. The deductible specti,ed in Section H-E above shall not apply to services rendered To eligible dependent children as
defined in Appendix "A"attached hereto.
SECTIONS II-E AND II-F ARE APPLICABLE ONLY WHERE A CHECK MARK HAS SEEN PLACED IN THE BOX
PRECECING SUCH SECTION.
3-74 NU-11`4
II1. In the event that the number of eligible employees reported by EMPLOYER to CDS pursuant to paragraph 1(a) of
General Agreements till be less than S0 in each of any three consecutive months,CDS shall,at
its option, terminate this Agreement upon written notice to EMPLOYER given not more than fifteen (15)days after receipt of
the List of Eligible Employees which indicates that such ground for termination exists.Such termination shall be effective as of
the last day of the month in which notice of termination is given, and CDS shall make payment to dentists for dental services
_ authorized prior to termination and dental services which were rendered without prior authorization by the dentist prior to
receipt by him of notice of such termination of benefits.
IV. Any notice which is required or permitted to be given under the terms of this Agreement may be given by registered or
certified mail addressed to the parties at the addresses which are indicated below and shall be deemed to have been given 48
hours after deposit in the mail with postage fully prepaid at any post office located in the continental United States. The
addresses of the parties are as follows subject to mange by written request:
(a) EMPLOYER
CITY OF CUPERTINO
10300 Torre Avenue
Cupertino, California. 95014
(b) DESIGNATED AGENT OR REPRESENTATIVE
(c) CALIFORNIA DENTAL SERVICE
Director of Marketing
P,0_ Box 7736
San Francisco,Cal forn,a 94120
V. The term of this Agreement snail to July 1 , 1974 through June 30 , 1976 and she
continue thereafter from year tc -at .i^z l terminated r here n provided. This Agreement may be t.ermir ated or, it
anniversary date by at least sixty (60) dais' wrmpri notice of termination given by the party d-s7nng to terminate to the Gthe
oarty. In the event that CDS shalt de re :o change the rates or other terms and condit::ins of this Agreement Ofect,fr; oil ar
anniversary date, advice of such pro(y sed changes may he given vn*h a notice of terminat!e�, and such notice of :ermifiatrt>r
shall be effective only the event -na, agreement is not reached as •o such changes. Ir - e event that -h s
-erminated pursuant to to s paragraph, CDS s'neretiv Empovvele-d rr"f u1horl7p treatment G a 5lieyOn(j Stich ?_="^,net )*'. A'"
anniversary date shall mean July 1 , 19 76 arxl July 1
of each subsequent year
The attached Defin,ti^ns, Rec tais. General Agreements a-y-- Apotr-,nd:ces A., B.C. ra,,rt are eerh a ;)art o'
-i,s Application and, upon acceptance '-ereox by CDS, this At j''CC. 1 artci th-r afar-s i d Shall ln�- I111r-•
Agreement between EMPLOYER and CDS Ali orlor negotrattons, jnd unders... ,r; -qs are int -)ded �o be merger;
herein. No modification of this Agreement shall be effective for a,,, oi' x0s?anless n•:tr . 'q=^ra ; gnftd by both part+es or the—
duly authorized representatives.
ACCEPTED: DATED July I , 1974
C..LIFORNIA DENTAL SERVICE: CITY OF CUPER 0 :
B BY
(Title)
f
BY . WD BY
(Title)
AS IS`P VICE EBR/CO
3-76-NU-iN 2
i
RECITALS
CDS is a nonprofit corporation,, organized and existing under Section 9201 of the Corporations Code of the State of
California, composed of members licensed to practice dentistry under the provisions of the Dental Practice Act. It is the
purpose of CDS to provide dental care under programs with responsible entities so as to maintain the prim requisites of an
independent and responsible profession, i.e., fee for services, free choice of dentists and preservation of dentist-patient
relationship without lay control, interference, promotion or commercialization.
GENERAL AGREEMENTS
1. EMPLOYER agrees:
(a) To compile, certify and furnish to CDS on or prior to the first of every month commencing on the
commencement date of the term of this Agreeient, a LIST OF ALL ELIGIBLE EMPLOYEES AND THEIR SOCIAL
SECURITY NUMBERS entitled to receive dental benefits hereunder. Eligible employees shall be determined according to
the Eligibility Rules — Appendix "A",attached hereto.
(b) To pay CDS monthly, commencing on the effective date of the tern of this Agreement, and on or before the
first day of each succeeding month, the monthly payment specified in Section 1-A of the Application for Dental Care
Service Agte<-ne* and to bear the expense of such payments without withholding or otherwise charging the Eligible
Employees for Coverage of themselves or their dependents.
(c) To provide mfoimat�or: to all el,g.bie employees as to the existence and terms of this Agreement and the right
of eligible pat emits to receive care as oro nded here , from a dentist of each patient's choice, as such choice may be exercas^�f
from time to i —e by a patient dur,nr, :-e cont.r.ued rriig,bility of the patient.
(d) To adr se eligible r:mo;o;ees to not:f l their dentist at the time of their first appointment that they are covered
by this Agreerne^t and to provide the,, rf?nrst with group identification and social security number.
(e) To permit CDS, by its auditors or other authOnzed representatives, on reasonable advance written notice, to
inspect records of EMPLOYER in ord.r to verify the accuracy of lists of eligible employees prepared by EMPLOYER and
submitted to CDS.
2. CDS agrees:
(a) To advise participating dentists a',, fOIIO•,':
W To submit a treatment plan, prior to rendition of service, showing the patient's dental needs and the
treatment necessary in the professional Judgment Of the dentist;and
(H) To notify the eligible patient of all actions taken by CDS with respect to st ") treatment plans;and
(ill) That such treatment plan need not be submitted prior to rendition of s ce in the case of emergency
services or in the case of brief routine procedures.
(b) To authorize such treatment plan for coverage under the dental care prograrn provided by this Agreement
when satisfied from the treatment plan and other data submitted by the dentist (li that the patient is eligible hereunder;
(21 that the services proposed are included in the Schedule of Services covered by this Agreement set forth in Appendix "C"
attached hereto: and (3) that the total fees to be charged to both CDS and the eligible patient do not exceed the dentist's
usual, customary and reasonable fees. Such authorization sha'' be for a maximum period of sixty (60)days from the date of
authorization by CDS, but not longer than the term of this Agreement.
(c) To make no payment fcr services rendered to a patient who is not eligible for dental care hereunder at the
time of rendition of service, except to the extent of services performed during a period of an authorization issued by CDS
pursuant to subparagraph lb) of this paragraph, and except for completion of single procedures commenced at a time the
patient was entitled to treatment by reason of such authorization.
(d) To make periodic checks as to the adequacy of care provided by dentists through local dental consultants and
committees nf local dentists appointed by CDS.
5-74-N-1
.4
3. Ia)if an eligible patient is eligible for coverage under two or more CDS dental care programs,and more than one of
said programs provide coverage for a particular service, CDS will pay the ague sum .payable urn all appficdfie
prams, but not more than the teaser of the usual, asatsmmy and reasonable fee or the fee actually charged for such
sesvtm and will prorate the cost thereof between the applicable programs, provided, that no program shall br: dta"
with a greater amount than the amount for which it would be liable if such dual coverage did not exist.
Ib) If an eligible patient is entitled to coverage under one or more group insurance policies or group prepaid health
car,, programs, other than a CDS dentai care program, then the benefits of this Agreement shali be provided as follows:
(i) If the otter policy or program(s) primarily cover services or expenses other than dental care, then this Agree-
ment shall be primary.
(ii) if the other coverage is by a dental insurance policy or prepaid dental care program,the policy or program
covering the patient as an employee shall be primary over the policy or program coverrnp*I,!,t patient as a dependent and
the policy or program covering the patient as a dependent child of a male person shah :,e primary over the policy or pro-
gram covering the patient as a dependent of a fernale person.
If the program provided by this Agreement is "primary", as provided above, CDS shall provide benefits without
regard to any other policy or program, and if the program provided by this Agreement is not "primary", CDS sihall
provide benefits only to the extent that the benefits obtained from such other insurance or program are inadequate to
provide full payment for the services which are benefits provided by this Agreement.
(c)it an eligible patient is injured through the act or mission of another person CDS shall provide the benefits of
this Agreement only on condition that the eligible patient shall agree in uniting:
W To reimburse CDS to the extent of such benefits immediately upon collection of damages by him,whether
by action at law,settlement or otherwise,and,
(ii) To grant CDS a lien,to the extent of such benefits on any such action at law, settlement or riglht to recovery.
(d)In no event shall the provisions of this paragraph 3operate to increase the liability of CDS beyond the benefits
for which it might otherwise be liable in the event this paragraph did not apply.
4. Neither EMPLOYER nor CDS shall be liable for any act or omission by a dentist, his employees or agents,or any
person performing dental or other professional services under this Agreement.
5. Participating dentists shall be obligated to schedule and render all dental treatment for eligible patients in accor-
dance with the applicable standards of the dental profession in their com.- unity and to charge no more than the usual,
customary and reasonable fee therefor. CDS is authorized to exclude from participating in the services provided by this
Agreement any dentist who persistently fails to comply with the obligations of participating dentists hereunder.
6. Any controversy or claim arising out of or relating to this Agreement or the breach thereof, by or betvreen either
or both parties to this Agreement, dentists, eligible patients or any of them, shall be sett;�d by arbitration by a single
arbitrator to be selected by the parties, and judgment upon the award rendered by the arbitrator may be entered in any
court having jurisdiction thereof.
7. In the event that any payment due pursuant to paragraph 1(b) of General Agreements is not paid when due,COS
may give written notice that payment is due, and if such payment is not received within 10 days after such notice, CDS
may, at its option, terminate all further benefits and be released from all further obligations hereunder; provided,
however, that CDS shall make payment to dentists for dental services authorized by CDS prior to termination and for
dental services which are rendered without prior authorization by a dentist prior to receipt by him of notice of such
termination of benefits. In the event of termination pursuant to this paragraph, EMPLOYER shall remain liable to COS
for the full amount of all dentists' statements paid or otherwise discharged by COS,plus Twenty-Five Percent (25%)of
such amount (to compensate CDS for its administration of the dental program), less amounts actually paid by
EMPLOYER to CDS.
8. Both parties to this Agreement agree to consult to the,extent reasonably practical concerning all material published
or distributed relating to this Agreement. No such material shall be published or distributed which is contrary to the
terms of this Agreement.
fi-74-N -2-
9. Both parties to tAis Agent agree to permit and encourage the professional relationship between dentist and
patient to be mainudned without interference.
10. if any portion of this ftnm herht or any Amendment thereof shall be determined by any arbitrator,court or otter
competent authority to be illegal, void or unenforceable, such determination shall not abrogate this Agreement or any
portion thereof other than such portion determined to be illegal, void or unenforceable, and all other portions of this
Agreement shall remain in full force and effect.
t i. The party agree that all questions regarding the interpretation or enforcement of this Agreement shall be governed
by the laws of the State of Califcwnia,where the Agreement was entered into and is to be performed.
8-7I•N
-3-
DEFINITIONS
Elite patient means an eligible employee and his eligible dependents(to be determined as Fwavided in the Eligibility
Rules Appendix "A").
Particiviating dentist means a dentist who is licensed to practice by the State of California arni agrees to render dental
care to eligible patients in accordance with standard terms and conditions applicable to dentist participation in COS
prepaid dental care programs, as established by the Board of Directors of COS consistent with the provisions of this
Agreement. Participating dentist also means any dentist outside of the State of California who '-s licensed to practice
dentistry by the state or other jurisdiction in which he practices and who agrees to render dental care to eligible patients
in accordance with the terms of this Agreement.
Single procedure means a dental procedure listed on the CD:. Tevle of Allowances(attached hereto as Appendix ""3-)
to which a separate procedure number is assigned, e.g., a three-_t rface amalgam restoration of a single permanent too-h
(procedure 613) or a complete maxillary lenture, including adjustments for a six-month period following in-tallatiof.
(prop-lure 700).
Usual, Customary and Reasonable fee means a fee which meets all of the following criteria, as determined by CDS
based upon confidential fee listings filed with CDS by member dentists and the findings of local dental society review
committees:
USUAL: Usual fees are 'r r;e fees usua ct,arged for a given service by an individual dentist to all his private
^atients, i.e.,his own usual `
CUSTOMARY: A fee is C.i-tomary when it is within the range of usual fees charged by dentis:% similar tr lining and
experience for the same service within that same specific and limited geographic area-
REASONABLE: A fee is Reasonable when it me.--ts the above two _riterva and when, in the ooinior, of the u>vrew
committee of the responsible dental society, it IS Iusnfla0le considering the special circum :,aces of the particular case
I3 question.
1-70-DD
APPENDIX -A"
ELIGIBILITY RULES
E ffective July 1 , 1974 ,all present,permanent employees of
CITY OF CUPERTINO
who have completed three(3)months of continuous full-time employment with a minimum of t h i r t y-
t w O (3 2) hours per week are eligible under the Dental Care Service Agreement. Present permanent
employees not eligble on July 1 , 1974 ,,d all future permanent employees will become
eligible on the first day of the month coincident with or next following three (3) months of
continuous full-time employment with a minimum of thirty-two (32) hours per week.
The dependents of eligible employees are eligible under the Dental Care Service Agreement. Dependents are lawful
spouse and unmarried dependent children to 19 or to 23 if enrolled as full-time student in an accredited school, college
or university. Children include step-children,adopted children and foster children, provided such children are dependent
upon the employee for support and maintenance.
An unmarried child 19 years or over rmy continue to be eligible as a dependent if he is incapable of self-support
because of physical or mental incapacity that commenced prior to reaching age 19, provided a physician's certificate
is submitted within six months following his 19th birth&y or the effective date o' this Agreement-
Dependents in military service are not eligible.
Eligibility of employees shall terminate on the last day of the month in which full time employment has terminated-
Dependents shall remain eligible until the last day of the month coincident with or following termination of eligibility of
the employee or loss of dependent stratus, whichever shall occur first- Eligibility shall, in any event, terminate
immediately upon termination of this Agreement.
1-70-EN
�► � TOE OF ALLOWMAW&S APPE
+e..+ l' . le ! w ices wf,; ore -ode
This �a no: a fee scheaule. Tie ar�.�a+rms ,+s'td %n his Tab _ ,:re :.! q ax_ c'
toward usual and =ustor,Cry fees. Usual and castor-ary feet vory ,with ndiriduol dereal practices.
'AskML ON■s LV No i It (i>m!il�A1r
AM ii M cVS1 AM NEMMM'
i On" Alif br 1101111lome ad a ktrw"Memon WA of alas ......
> girl at tRs,itltu 261 E:tto4tral moll dtzew of tl9eas ..... tS.M t
Bse file eater df ter 1S2 Erse i*on Doi= 00 ..... .. ........
tam
rDl ................... . 4.OD 2S3 :n> of UDMy
fi20 r1@J bW gift tdw fttl m lathy adult era" ............... .. ...... .... US
"pow a ba)t of seslrao waft"or a" ISO Siskmarototor tanaotsf of taliaary t a I I Lasw
11110 16 .... ........... 10.8l3 011111 two
an Spam awdftwes ft fair taiie PM d&S Closing of 8111 sty fishft... .. . ....I.... .. MA
mamma"aim ilea been 266 Dilation of tmirary Gent ... . ... ..........
pu ft ,ee fir VM9 , ,* ,I IOAO 270 Reaction of bampa tumor of Matt bass(2_6 ant
00 - to8P 14 ........... too or ) .............. . .. .... . ...
me -to Wbb solib"asd poliefting . .. 100 271 Rhraction of malignant tumor .._. .. . . .. .. 6/R
M Topw approuwn a:MAam tar am- 77S Trartipjanation of torch or toots bad .... . .. . IQAO
am bakmfol pap4taxis o dir ap 4). . . . . 12.00 176 Rwwwal of foreign bOdV from boa('
004 TopkA 499ftMfi0a of UVAM tArtxia long procedure) ..... .. .. . . ... ... .... . WR
is - payment 277 Radical rmewn of {mtta for tumor with boom
Marco am�ten to age Is 14.00 graft. .... .. .. .................. 6/R
OE0 Erb ttotsttectt-ptdrutwe per wart 5.00 278 Maxillary tinumtonnl for removal o1 tooth ftft
mein or foreilpr body .......... .... . .. 65.00 or 6/R
279 Closure of Opal fistula of maaiftary siaM ....... 4D.ODOf WR
FIN 420�111 iaR`de gas lead sfisaptl1111 160 Excision of cyst.trnall . ........ ....... .. MOD or 6/R
110 sir4b film . . _... . . ..... ... . . ...... M! 281 Excision of cyst,large(2.5 can or larger) . .... .. TLOOOr 6/111
III Additional,00 to 12 fours,melt+ 1,00 282 SOequevOectomy for osteomyeEitis or fmrae sb�
112 Entire demur a 110M W%*d1ng earnertatran eons superficial .. . . . . ... .. 20.00 or 6/R
tatirt0 of at tau 14 f6m (bite wings d 285 ,^,ondylectomy of learporomandibular joint. .. . MOD
rtasawy) 11.00 289 Menarectomy of temporonnandibulsr i0att ..... ZKOD
113 lava-anal, oeritrsal crew, rn"di ry or Oatdib.
air.each COO IMSCEIiANEOUS:
114 Sulperwit or adwior maxdlarV. extra oral, we 290 Incision and removal of fomign body from Wh
tam 16.00 tiastta .... . . ........ ........ .... .. MOD of SIR
Ills Ses9WW OF whriar maxillary, extra arm. two 2191 frenectomy 25.00
fila" MOO 232 Suture of soft tissue wound or injury 6/R
116 am aria{f*m encbr"esarnutelton 293 Gown exposure for orthodontia ...... ... . . . 16.00
® 2 fly 5.00 294 injection of sclerosing agent into tem+poromandif►
4 Rill 7.i)D utar faint 31100
AddI9061101 fdmnt,ends 1.00 295 Treatment trtgemmal neuralgia by injection into
ISO Boom of oral try 8.00 second and third c1mrsi;.ns .. .... .. . .. .. 34.00
ISO waroarmw no-nation 15.00 DRUGS 1300-3991
ONAL StMMRY IMM 300 Drugs admi,•,ttemd by dentist-based on cost SIR
+••As tjoWtat costs are the rwponsebr,ty Aerro patient ANESTHESIA 140-4491
COS or"atmw tot the procedures I,stri in Ines scheduie 40C anesthesia General t4.00
Additional foes charged by the eenttst tot perfetrtrl-N PERIODONTICS{450 d991
0 the hospis ti re the rmponubdrty of the
Patient- Special consultation(by specialist for catapresennt&
lion when preliminary diagnostic procedure
'COS aseawanc sfor Ger+ere, etilm., models. etc.) have been performed by
An=M=a See Procedure 0400 general dentist). . . _ site p►txedsue f040
Any fasttwr ctl,-Vn fir rresftai s attesthetrsts• or
aria"►e re ponwbrfirs of the patent Prophylaxis(includes scaling and polishing).. .See Procedure 8050
451 Emergency treatment (periodontal abscess, acute
*"A4ikanes tot procedures s,:r tilted en ih.s schedule periodontilts,etc.) .. 10.00
win be pad of the tote Ituetd ,n the Retatrve Value 452 Subgnngwai curretage, root rbaning per quadrant
Study as ap+,trove,: toy the t mereCan Sratsty Of Deal not prophylaxiai , .. .. .. . . 12.00
sorywm Consultation (by specialat for Case presents- 453 Correction of occlusion per Quadrant 11100
tran taftri diagnostic procedures have been performed 472 utngevectomy per quadrant(including post a
by low 40016$3). See Procedure MAD watts) .ct . . .. .... .. .. . ... . 50 00
473 Gengrveomv, osseous or muco-gingival surge"
EXTwACTI&rW_ per quadrant(includes post Sun*al vests) . . . 60•110
200 Uraeatoplicatead single.including foullne post ogee 474 Gerugveetomy,treatment per tooth(fewer than six
Wo"riots 8.00 teeth) .... ......... 10 00
lay Each aadtttotu:tooth.including routenr poll Doer 5.00 ENiD000NTICS 1 599J
"visits . . . . .
Zr- &WOCSI remainl of erupted teeth SIR Specul cony:etatron(by specialist for Cast prftwMs-
120 post-opaative vmt(sutures and comptecatsons) 3.00 Oon when dtagna tic ptowduta have been
performed by general dentat) . . . .. . .. sae Proeedrpr.Ma
IWACTTi:O TEETH fasalase cilia): 500 pulp capping . . ... . .... . . ... &00
230 Rem-Val of tooth Isoh tissue) 17.00 $01 Therapeutic pulpotomy(in addition to restarts=iatll,
131 Rasnovat of lath(partially bony) . 25.00 Per treatment) . . . .. .. ... . 6.00
232 Removal of tooth(comp or bony 40.00 SIR M Vital pulvt . .
otomy. . .. . .. . .. .... 11.00
CO3 Remurer h1slron tC h, temporary rMaratioa)
ALVEOLAR OR GINGIVA)RECONSTRUCTION: Per tooth . . .... . .... 10.00
2b0 Alrael•ttomy(edetttulousl par quadrant 25.00
M Aftrt4 kaorny (its addition to removal of teeth) ROOT CANA15:
Par t . . 1000 510 Cutivnnq catad 7.00
2!Ni Afaeopfity with ridge extension.pet wh 42 00 511 S,ngie rooted canal tooth therapy 45.00
$7 11omwial of paw totes .. . . ..... ... 35 00 or W R )12 at rooted tootty canal tt eraoty . ff0M
25f Par Aa4 of mandibular tori pat quadrant 35.88 613 TOM-tooted rood+csrwl t:t r .. . MOD
Eaxisat of Qyper tllastic tills par arch 32.00 530 Apecaftto"(urcb:dbtsg)fining Of 9001 canal) MAO
OWL
6L NXIIiiiiIii;IV RWd GL
.. ........ ]SAM
Aftaieiiic:iis do at vide* fffld FNM~ M ftno nr&OWN or Imw so 00 or demo
192"C11111111"issulamisgus awft aftv Claim-hm ..... SA
In*said dxX-ems W a*.................. ... so
703 1`1111"till ilea OF 90Pff aft -I I I cdO dbv
ASUM03MMATIMPNEUM TEEM fir*0 or p&W bw and=IV*aWn-bw . WAS
MI'd 1lieu 21MIllartm ........ .. 6-00 J04 Tathaddnp-sistra per airs............ so
......... 9.00 M Simple arm brsakm-acret8'd Caches ............. am
bom"Mu W MM toga Oda=... 12-M 706 Smypkn-bma.. .......... ......... . 36M
AnAte"jEt""TIM PEIVARMW TEETH: 716 Tafth and cbW-astral pus unit............ &OD
III clown iwA*A"are we*11111hiall . ... .. . .. . LOD M am*"849ame 440
W2 Cinkin wish"tso moth so ... .. . .. 11-00 721 office now-cold cum-MY* .......... . 115A
613 Ca Nn. am or man tooth surfacia; 15.00 rn 0&,ftffi rdine .. .. .................... XK
COLDRESTOM110ft rn SPUM tme corAlitmalm pw delaftv%in sKs-
436 On tooth an ...... .. ..... 35.00 tie to mfin-maximarm 2 par denn..... ran
as TWO toom surfam -- I. . . .. . . .... ... . .. 40-00 724 Defflum dtipliertion(omp cm)pw ftoon
437 Three or more two wrist .. ... .. ...... 50.00
on Oak"extra per tooth .. .. .. .. .. .. . . . . .. 10.00
DLICATE,ACRYLIC,PLASTIC RESTORATIOW. REPAIRS,DENTURES,ACRYLIC:
640 Silligm Wawa filling ... .. .. ...... .. .. . 9M 790 Orc*er demure,repairing(no teeth invokma lzAO
645 Aovfic or plastic filiting . .. . . .. .. . ... . 11.00 Replacing missing or broken tooth, nth nlid�
tional . .. .. .. . ... .... . ...... .... too
RESTORATIVE DENTISTRY UNDER GENERAL ANESTHESIA Adding teeth to partial denture to M)fto
o:-
(Spatdel am only)(Handicapped ligliants) tracted natural teeth,
649 Long term openstane cm performed under Ge- 793 First tooth .� � am
pal Anesthesia on litudy base 794 First tooth with clasp .. . .. . .. ... ...... .. 30.0111
One hour duration frovi,beginning to end 7!.00 795 Each additional tooth and clasp... . . .. .. .. .. S'DO
-Two aid one half hours.rmwimum IS&OO 7% Partial demure repairs - bswd on time and
-T"antlonehatfliuum,maximum 175.00 laboratory charges .......
-Four or more hews .... ..... . . . .. . 200.00
The above includies all operative procedures, ex-
tnectiorm Pulpoto-ses, necessary*rmmvft aian-
nous fluoride and oral prophylaxis. Fan for anes,
if o;ins must be Paid by Patient. SPACE MAINTAINERS(800-8")
Allowances include all adj wsnen within six
CROWNS: months following installation.
650 Acrylic . . .. . . . . .. .. 60.00 am Fixed%pact,maintainer(band type) .. ...... .. 34.00
651 Acrylic with metal . . . . . . . . . . . . . . . .- 75.00
652 Porcelain ... - , � � � . . . . ... . 75.00 REMOVABLE ACRYLIC SPACE MAINTAINERS
653 Porcelain with metal 100.00 Sol With stainless steel round wire rest only .... . .. 4u.uto
669 Gold(full) 65,09 802 Stainless steel clasps andior activaltiiing wines. in
663 %Gold _ . . .. .. . 60.00 addition per wire or clasp . .. ... . ...... . 5.00
670 Stainless Steel(primary) 17.00 803 Study m9dets ' ' I .... ... . 5,00
671 Stainless Steel(permanentj 20.00 810 Removable inhibifinq appluince,to correct thumb
672 Gold dowel pin 10.00 u;cking 40.010
COS don not pay for facings on crowns.posterior 832 Fixed or cemented inhibiting appliance to correct
to 2nd bicumich (if placed. fees must be;aoc thumbsuciting - . . . . .. . ... .. . .. ... 40.00
by pstient). Otlw-e vtvi for observation, adjustment and actim
M PROSTCS(680-7991 (Indudes Filled&*m; nation per visit 400
PONTICS:
SM Cast gold(sanitary I ... . ... . 40.00
Sul Steeft's facing 45.00
682 Tru-Pontic Type 55.00
W Porcelain baked to gold 80.00 FRACTURES AND DISIOCATIONS,(900-9")
693 Plastic processed to gold 55.00 900 Treatment of sinVie fracture of fee nimft.OW
reduciron 2911-00
REMOVABLE (UN Treatment BRIDGES): 901 . L . ... .... .. . .. . .
. eatment of simple fracture of the maxills,u/ooee
683 One peace casting, chrome cobalt alloy ciasp at- reduction * ' *' "*. . ....
. 12S-00
tachment (all types! per unit - mciuding 902 Treatment of simple fracture of the mand".
pontics . . . . . . . . . .. .. . 20.00 own reduction ' ' * ....fee .... 230.00
903 Treatment of simple tracture of marglible.
RECEMENTATION: closed reduction. . . . .. . _....... 1211-00
linlay . . . . ... . 5.00 904 Treatment of compound or comminuted fracture
an crown 5.00 of the rrazilla,closed reduction... . . .... .. moo
687 Bridge 10.00 995 Treatment of compound or commmuted fracture
of the maal;!a,oven reduction ..... " ' ' MOO
REPAIRS,CROWN AND BRIDGES: 906 Treatment of compound or comet muted frectume
690 Repairs-based or time and laboratory charges P/H of the mandible,closed r--duction ... .... .. 200.00
307 Treatment of compound or comininuteal firactura
of the mandible,open reduction .... ... ... 360.00
910 Treatment of luxation JdatocationI of a*wall,
Or,'ITUNES: dibie(uncomplicated) . .. .... .... . . . . .. too
Ot'Atures, partW- #,e,Wres and reline allow 911 Treatment of condvlar frarfin,opro reduistion .. 3NAO
include adjustments for six month period fob 912 Treatment of conowler trectum doted ndaction . 11M.00
Wq irgalillatioa-Few for specialized technioues 913 Reduction of dislocation of urnporowAmidbulw
involving pirectsion dentufft petsonehza5on or joint .. .... . . .... WOO
chailacteiraffe-triAm mug be paid by patient 915 Treatment of malar I racture.sixigille,dond mduc-
Mr. .... . .. . . IMAO
IM Complete mnwmv demure ............... :55.00 C16 Treatmellt rf meter fracture.simple or compound
701 CQM*W maridibulair denture ..... .. ... i55.00 depressed,oven reduction .. . . .. . ...... .
C05,291 14 72)
APPENDIX"C"
SCHEDULE OF SERVICES
Subject to the exclusions and limitations hereinafter set forth, the `allowing is the Schedule of Services covered by the
within Agreement when, rendered by a licensed dentist and wher nem.;ary and customary, as determined by the standards
of generally accepted dental practice.
1. BASIC BENEFITS
Diagnostic
Procedures to assist the dentist in evaluatrnt;the existing conditions to determine the required dental treatment.
Preventive
Prophylaxis once every six months
Topical application of fluoride solutions
Space maintain,rs
Oral Surgery
Procedures for extractions and other Oral surgery including pre- and post operative care.
General Anesthesia
When administered for a covered oral curgen, procedure performed by a dentist.
Restorative
P!ovides amalgam, synthetic porcelain and plastic restorations for treatment of carious lesions, Gold restoratrors,
crowns and jackets will be provided when teeth cannot be restored with the above materials.
E ndodontic
Procedures for pulpal therapy and root canal filling (treatment of non•vra: teeth).
Perk-Adontie
Procedures for treatment of the tissues supporting the teeth.
li PROSTHODON''TiC BENEFITS-
P,tt-edures to- construction of txrdoe,,, partial and complete dentures.
Ill. DENTAL ACCIDENT BENEFITS
P,ocrtiftsres far dental treatment and d agnosrs rendetad w,thrn 180 days foliowing the date of an accident for
conditions caused, d,;ectly and independently of a!! other causes, by external, violent and accidental nu ans;provided. that
any charges for which benefits or services are provided for an eligible patient under any group, franchise, Blue Cross, Blue
S74eld or other insurance or prepayment plan arranged through an employer, union, trustee or association shall not be
covered gay this section,
IV. EXCLUSIONS.
(a) Services for injuries or conditions which are compensable under Workmen's Compensation or Employer's Liability
Laws, services which are provided the eligible patient by any Federal or. State Government Agency or are provided without
cost to the eligible patient by any municipality, county or other political subdivision,except as provided in Sectiol-I 12532.5
of the California Government Code.
(b) Services with respect to congenital or developmental malformations or cosmetic surgery or dentistry fnr purely
cosmetic reasons; including but not limited to- cleft palate, maxillary, and mandibular malformations, enamel hypoptasia,
fluoro.,rs,and anodortia.
1-
t
Ic) Prosthodontic Services or Devices (including crovms and bridges) or any single procedure started prior*o the date
the patient became eligible for such services under this Agreement.
i.
(d) Prescribed drugs.
(e) Orthodontic Services.
(f) Experimental Procedure-.
V. LIMITATIONS:
The bervaits as outlined are subject to the following limitations:
(a) X-rays:
Complete mou h x-rays are provided only once in a three (3) ,ear period, unless special need is shorn_
Supplementary bite-wing x-rays are provided upon request but not more than once every six (S) months.
(b) Crowns.Jackets and Gold Restorations:
Replacement will be made only after five (5) years have elapsed following an} prior prov_oo" of crowns, jackets or
gold restorations under any CDS program.
(c) Prosthodontics:
Prosthodontic appliances (including but not limited to partial and complete 62ntures .d ` xed bridges) v.rll be
replaced only after five (5) years have elapsed following any prior provisio- of such appliances j-d_r anv CDS program,
except when, CDS determines that there is such extensive loss of remaining teeth or change in ;,p, �-t ng tissues -hat the
existing appliance cannot be made satisfactory. Replacement will be made of a prosthodontic app+ a-ce not provided under
a CDS programs only if it is unsatisfactory and cannot be made satisfactory.
(d) Optional:
In all cases in which the patient selects a more expensive plan of treatment than is custor-jar y provided, CDS will
pay the applicable percentage of the lesser fee. The patient is responsible for the remainder of the oe-- st's fee.
(1) Partial Dentures. CDS will provide a standard cast chrome or acrylic ;:areal denture D, -,dl allow t-e cos: of
such procedure toward a more complicated or precision appliance that patient and dentist may c�iaose to use. An* is-iture
for which a charge is made which exceeds the customary fee shall be considered an optional service.
(2) Complete Dentures. If in the construction of a denture the patient and dent�st decide on personalized
restorations or employ s,+ecialized techniques as opposed to standard procedures, CDS )rill allow an aapropriate amount for
the standard denture toward such treatment and the patient must bear the difference in cost. A-y denture for vrhich a
charge is made which exceeds the customary fee shall be considered an optional service.
(3) Occlusion. CDS will allow the cost of restorations required to replace missing teeth. Priced:,res, appliances or
restorations necessary to increase vertical dimension and/or restore or maintain the occlusion are considered optional, and
the cost is the responsibility of the patient. Such procedures include, but are not limited ^o, equG;bration, pernodontal
splinting, restoration of tooth structure lost from attrition, and restoration for malalign went of the Teeth-
(4) Implants. If implants are utilized. CDS will allow the cost of a standard complete or partial denture toward the
cost of implants and appliances constructed in associated therewith.CDS will not provide surgical removal of implants.
3-74-5••A•'
a'3RTHO'OONTIC BENEF11 RIDER
In consideration e` the payments specified in paragraph 1 of the attached Agreement, and subject to all of the terms
and conditions thereof, except as herein otherwise specified, CDS agrees to provide Orthodontic Benefits to eligible
patients,as follows:
1. Orthodontics are defined as procedures of treatment by a licensed dentist for correction of malposed teeth of an
eligible dependent child.
2. CDS will pay or otherwise discharge 50 �*of the lesser of the usual,customary and reasonable fees or the fees
actually charged for Orthodoi-tics, provided that the amount payable to a dentist who is not a participating dentist shall not
exceed SO %of the amounts for the corresponding services set forth in the Orthodontic Table of Allowances, a
copy of which is attached hereto, marked Exhibit 1 and incorporated herein by reference,
3. The maximum amount payable by CDS for Orthodontics rendered to an eligible patient shall be $S 00 and
The limitations on maximum amounts payable during a calendar near, as specified in the attached Agreement, shall not
apply to Orthodontics.
4 Exefu,ions. In addition to the Exclusrorrs and Limitations stated in Appendix C to the attached Agreeme-t, the
following exclusions shall apply to Orthodontics:
(a) Tl e obligation of CDS to make monthly o- outer periodic payments for an orthodontic treatment plat, will
cease upon ter n,nation of treatment for any reason prig to completion of the case.
(b) The obligation of CDS to make monthi e or other periodic payments for an orthodontic treatment plan begun
prior to the gibility date of the patient will be calculated on the balance of the dentist's rlorm,;--' aa�ment oattern
rema.ning dt the patient's initial eligibility date-The above mentioned maximum will apply fully to th s wort.
(c) CDS will not make ant+ payment for repay; or replacement of an orthodontic appliance f..•'- sH ed -der this
program.
(d) CDS's obligation, to make monthly or otner periodic payments for Orthodontics sham rerm.nate .1, the
termination date of this Agreement or on the date the eligible dependent child reaches age 19 or age 23. ` a `. Ii tame
student.
S . A patient shall b� eligible for Orthodontics only following such
patient ' s continuous enrollment in the dental program provided hereby
for a period of 12 months .
6 . The period during which an eligible patient was enrolled i, the
dental care program provided by the .Agreement dated July 1 , 1973 ,
between EMPLOYER and CDS shall be included in computing the 12-month ,
period specified in paragraph S .
Dated: July 1 , a974 CALIFORNIA DENTAL SERVICE ;
PRESIM-WT
J -
1s�'r rcE /
CTA 8-`4
EXHIOIT 1
TABLE OF ALLOWANCES FOR ORTHODONTICS
(To be used for cis submitted by non-participating` dents)
A percentage at the amounts listed in this table of allowances will be paid toward the charges of the dentist providing
orthodontic services in accordance with the terms and conditions of the applicable group denial cave 000tract. Such
amounts will be paid periodically when dentist has completed services and upon proper presentation of stternent for
services rendered.
PROCEDURES
Diagnostic
129 Orthodontic Survey including entire denture series
and all other films including cephalometrics and photos S 25.00
125 Panagraphic Film 12.00
Extraoral Head Film
126 One Film 8.00
127 Each Additional 4.00
Comprehensive Orthodontic Traatment
Permanent Dentition
850 Class 1 700.00
855 Gass 11 700.00
860 Class 111 700.00
Mixed Dentition
870 Gass 1 400.00
871 Class If 400.00
872 Gass IIi 400,00
Primary Dentition
875 Class I 200.D0
876 Class If 200.00
877 Class oil 200.00
Appliances for Tooth Csu+dance
840 Removabi a 40.00
843 Fixed or cemented 50.00
Appliances to Control Harmful Habits
845 Removable 40.00
847 Fixed or cemented 50.00
'Icon-participating Dentist — Dentist who fires not agree to abide by the conditions governing dentist participation in
California Dental Service group dental care program.
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