Notes

Outline

Provident American Insurance Company Dental/Vision

Dental/Vision Overview Choice of Two Dental Plans Alpha/Omega Use Any Dentist Orthodontic Benefits Available Vision Benefits Included No Waiting Period for Preventative Dental Care Available as a Stand Alone Plan

Alpha               Omega - Benefits Calendar Year Max $1500 $500 (Class IV) Calendar Year Deductible $50 (X3) Preventative Waived Pretreatment Review $300 Covered Benefits Class I Preventative 100% Class II Basic 80% Class III Major 50% Class IV Orthodontia 50% Calendar Year Max $1000 Calendar Year Deductible $50 (X3) Preventative Waived Pretreatment Review $300 Covered Benefits Class I Preventative 100% Class II Basic 50% Class III Major 50% Class IV Orthodontia N/A

Alpha               Omega - Requirements Minimum Group Size 10 Employer Contribution 75% Participation Requirements Employee 75% (5+) Dependent 50% Usual, Customary and Reasonable Yes Minimum Group Size 2 Employer Contribution 75% Participation Requirements Employee 100% (2-4)  75% (5+) Dependent 50% Usual, Customary and Reasonable Yes

Vision Alpha               Omega MD Comprehensive Exam $75.00 OD Comprehensive Exam $60.00 MD Follow-up Exam $60.00 OD Follow-up Exam $60.00 MD Comprehensive Exam $37.50 OD Comprehensive Exam $30.00 MD Follow-up Exam $30.00 OD Follow-up Exam $30.00

Dental Vision - Takeover Benefits Takeover Benefits Takeover means that employees are given credit for waiting periods for like coverage's accumulated under an existing plan. This only applies to groups with Five or more eligible insureds

Dental/Vision - Premiums Premiums Initial 12 Months Rate Guarantee per Employee Unit Only Three Areas