Provident American Insurance Company

Alpha Omega

•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