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ALPHA CARE DENTAL / VISION

Schedule of Benefits

CALENDAR YEAR MAXIMUM

 ALPHA PLAN

 OMEGA PLAN

Per Insured Person
            All Benefits
            Class IV Orthodontia Procedures

 
$1,500
$500

 
$1,000
N/A

 CALENDAR YEAR DEDUCTIBLE

 Per Insured Person
            Dental and Orthodontia Procedures
            Class 1 Preventive Procedures


$50 (X3)
Waived


$50 (X3)
Waived

 PRETREATMENT PREVIEW

 $300

 $300

 COVERED BENEFITS DENTAL

             Class I Preventive Procedures
            Class II Basic Procedures
            Class III Major Procedures
            Class IV Orthodontia Procedures

 100%
80%
50%
50%

 100%
50%
50%
N/A

 COVERED BENEFITS VISION

             Exams, Lenses, Frame

 See Schedule

 See Schedule

 MINIMUM GROUP SIZE

             Number of Employees

 10

 2

 EMPLOYER CONTRIBUTION

             Employee Premium

 75%

 75%

 PARTICIPATION REQUIREMENTS

                                     Employee

            Dependent

 75% (5+)

50%

 100% (2-4)
75% (5+)
50%

 USUAL, CUSTOMARY & REASONABLE FOR DENTAL

 Yes

 Yes

 PRIOR CREDIT FOR WAITING PERIODS See requirements below
(For groups 5 or more covered insureds.)

 Yes

 Yes

 PRIOR CREDIT: You and your employees are given credit for waiting periods for like coverages accumulated under your existing plan.

 VISION CARE Included with dental plan.

                                                                 Maximum Allowance
                                                                      For All Areas

                                                                 Maximum Allowance
                                                                      For All Areas

                                                                 Alpha                     Omega
                                                                 Plan                          Plan

                                                                 Alpha                     Omega
                                                                  Plan                        Plan

 M.D. Comprehensive                         
  Examination                                       $75.00                   $37.50

 Bifocal Lens                                             $35.00                   $17.50

Trifocal Lens                                             45.00                      22.50

 O.D. Comprehensive
  Examination                                         60.00                     30.00

 Lenticular Lens (single)                             45.00                      22.50

 Lenticular Lens (multi)                              56.50                      28.25

 M.D. Follow-up Examination               45.00                     22.50

 Contact Lens                                             25.00                      21.50

 O.D. Follow-up Examination                35.00                     17.50

 Frame                                                        50.00                      25.00

 Single Vision Lens                                 19.00                       9.50

 

Benefits for dental and vision will be combined and not exceed the calendar year maximum under the plan selected.  Prior plan description is required at time of group submission.

A Comprehensive Examination is limited to one procedure per 24-month period.  A follow-up Examination is limited to one procedure per 12-month period.

Lens(es) and Frame are limited to one set per 24-month period.  Contact lens(es) are limited to one set per 24-month period and are in lieu of all other eyewear benefits.

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