Alpha Care Dental and Vision

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
M.D. Comprehensive Examination $75.00 $37.50	Trifocal Lens 45.00 22.50
O.D. Comprehensive Examination 60.00 30.00	Lenticular Lens (single) 45.00 22.50
O.D. Comprehensive Examination 60.00 30.00	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.