THE MTA PREFERRED PROVIDER DENTAL PLAN

1 THE. MTA PREFERRED PROVIDER DENTAL plan . Now you can have comprehensive DENTAL coverage at a cost you can afford! Even if you are having extensive DENTAL work done now, or you or a family member may need DENTAL care, the MTA DENTAL plan allows you to start receiving benefits immediately upon your effective date. You get all the advantages of group DENTAL coverage, but on a private appointment basis, from a participating doctor of your choice. The typical family could save hundreds, even thousands of dollars on the cost of DENTAL care. For example, many services such as office visits, examinations, cleanings and most x-rays are provided at NO CHARGE. Other procedures are at greatly reduced fees, such as fillings, crowns, dentures, orthodontics (braces), periodontics (gum treatments) and endodontics (root canal therapy). There are NO waiting periods, pre-existing condition limitations, or even claim forms to complete!

2 Other special features include no deductibles, no lifetime or annual limits on benefits or the number of office visits. What is my monthly cost? Applicant Applicant Applicant Only +1 + 2 or more $16 $22 $28. There is also a one-time $25 application fee. See application inside for payment options and enrollment instructions. If, for any reason, you are not completely satisfied with the plan , the plan will refund your initial payment if your written notice, Certificate of Coverage and ID card are returned during the first 30 days of coverage. However, you will have to pay the dentist his or her usual fees for any services rendered. The application fee is not refundable. Once coverage has been in force for more than 30 days, no fees are refundable. For more information, call: Employee Security, Inc. 1-800-638-1134. Or visit us on the web at: Important Questions & Answers about the MTA PREFERRED PROVIDER DENTAL plan WHO IS ELIGIBLE?

3 MTA DENTAL plan subscribers and their legal dependents. Dependent children can be covered as long as they are under 19, or full time students, to age 23. Coverage of a child who attains age 19 will be continued while he or she is incapable of self-sustaining employment by reasons of mental incapacity or physical handicap. Children may take out their own individual plan when they are no longer eligible. MUST I USE A PARTICIPATING DOCTOR? Yes. There are many participating dentists located throughout the area. In addition, there are many specialists, such as oral surgeons, orthodontists, endodontists and periodontists who will provide care for you and your family under this plan . Call our office to find out who participates and how your present dentist can participate. MONEY BACK GUARANTEE. If you are not completely satisfied with the plan , the plan will refund your subscriber fee if your written notice, subscriber agreement and ID card are returned during the first 30 days of coverage.

4 However, you will have to pay the dentist his or her usual fees for any services rendered. The application fee is not refundable. Once coverage has been in force for more than 30 days, no fees are refundable. WHAT IF I CANCEL BEFORE I'VE COMPLETED A FULL YEAR OF COVERAGE? Enrollment in the DENTAL plan is for at least one year. If you decide to drop the plan before completing a full year of coverage, you need only pay the balance of one year's monthly fees, or pay the dentist his or her usual fees for any services rendered, whichever is less. ARE THERE ANY LIMITS TO THE NUMBER OF VISITS I CAN MAKE? There are NO LIMITS to the number of DENTAL appointments you or your covered dependents can make. ARE THERE ANY OTHER LIMITS? As with other plans, there are services which this plan does not provide, such as services which are covered under Workers'.

5 Compensation or Employers' Liability Laws. For a complete list of exclusions, please check your certificate of coverage. For more information, write or call: Employee Security, Inc. 10400 Little Patuxent Parkway, Suite 260. Columbia, MD 21044. 1-800-638-1134. Note: This is a discount plan -- NOT an insurance product. It is NOT subject to the rate and form review process of the Massachusetts Insurance Department. This program is NOT covered by any Life and Health Guaranty Corporation. Fees are subject to change without notice. Not all dentists and hygienists perform all DENTAL procedures. You must contact our office BEFORE a procedure is performed if you wish to question the fee being charged by a participating dentist. Sample fees in any brochure or website are extremely limited as there are hundreds of DENTAL procedure codes and their discount fees may be out-of-date by the time you have a procedure performed.

6 We recommend obtaining a pre-treatment estimate of costs before having any work performed by your participating PROVIDER . Should you discover any discrepancy between the fees listed on the Schedule of Benefits and Surcharges' and the fee listed on your pre-treatment estimate, please contact Employee Security, Inc. prior to having any work performed. MTA PREFERRED PROVIDER DENTAL plan . SCHEDULE OF BENEFITS & SURCHARGES - EFFECTIVE JULY 15, 2015. THIS SCHEDULE APPLIES ONLY TO PARTICIPATING DENTISTS. PROCEDURE DESCRIPTION SUBSCRIBER'S CHARGE. DIAGNOSTIC/PREVENTIVE. MISC. CONSULTATION NO CHARGE. MISC. ORAL CANCER EXAMINATION NO CHARGE. D0120 PERIODIC ORAL EXAMINATION, ONCE EVERY SIX MONTHS NO CHARGE. D0140 LIMITED ORAL EVALUATION PROBLEM FOCUSED $61. D0145 ORAL EVALUATION FOR CHILD UNDER THREE YEARS OF AGE $53. D0150 COMPREHENSIVE ORAL EVALUATION NEW OR ESTABLISHED PATIENT NO CHARGE.

7 D0160 DETAILED AND EXTENSIVE ORAL EVALUATION PROBLEM FOCUSED, BY REPORT $129. D0170 RE-EVALUATION-LIMITED PROBLEM FOCUSED NO CHARGE. D0210 INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) NO CHARGE. D0220-D0240 INTRAORAL FILMS NO CHARGE. D0250-D0260 EXTRAORAL FILMS NO CHARGE. D0270-D0277 BITEWINGS NO CHARGE. D0330 PANORAMIC FILM $80. D0340 CEPHALOMETRIC FILM $90. D0460 PULP VITALITY TESTS $35. D0470 DIAGNOSTIC CASTS $80. D1110-D1120 PROPHYLAXIS, ONCE EVERY SIX MONTHS NO CHARGE. D1110 ADDITIONAL ADULT PROPHYLAXIS, (OVER 19 YEARS OF AGE) $80. D1120 ADDITIONAL CHILD PROPHYLAXIS, (19 AND UNDER) $65. D1203-D1204 TOPICAL APPLICATION OF FLUORIDE (ANNUALLY) $32. D1351 SEALANT-PER TOOTH $30. MISC. OFFICE VISIT CO-PAY $10. SPACE MAINTAINERS. D1510 SPACE MAINTAINER-FIXED-UNILATERAL $200. D1515 SPACE MAINTAINER-FIXED-BILATERAL $245. D1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $220.

8 D1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $270. RESTORATIVE (FILLINGS INCLUDING CEMENT BASE). D2140 AMALGAM-ONE SURFACE $83. D2150 AMALGAM-TWO SURFACES $105. D2160 AMALGAM-THREE SURFACES $145. D2161 AMALGAM-FOUR OR MORE SURFACES $185. D2330 RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR $110. D2331 RESIN-BASED COMPOSITE TWO SURFACES, ANTERIOR $160. D2332 RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR $210. D2335 RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES OR. INVOLVING INCISAL ANGLE (ANTERIOR) $270. D2391 RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR $145. D2392 RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR $195. D2393 RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR $215. D2394 RESIN-BASED COMPOSITE- FOUR OR MORE SURFACES, POSTERIOR $275. D2510 INLAY-METALLIC-ONE SURFACE $475. D2520 INLAY-METALLIC-TWO SURFACES $500. D2530 INLAY-METALLIC-THREE OR MORE SURFACES $525.

9 D2542 ONLAY-METALLIC-TWO SURFACES $525. D2543 ONLAY-METALLIC-THREE SURFACES $550. D2544 ONLAY-METALLIC-FOUR OR MORE SURFACES $581. D2610 INLAY-PORCELAIN/CERAMIC-ONE SURFACE $515. D2620 INLAY-PORCELAIN/CERAMIC-TWO SURFACES $540. D2630 INLAY-PORCELAIN/CERAMIC-THREE OR MORE SURFACES $565. D2642 ONLAY-PORCELAIN/CERAMIC-TWO SURFACES $540. D2643 ONLAY-PORCELAIN/CERAMIC-THREE SURFACES $570. D2644 ONLAY-PORCELAIN/CERAMIC-FOUR OR MORE SURFACES $620. D2650 INLAY-RESIN-BASED COMPOSITE-ONE SURFACE $495. D2651 INLAY-RESIN-BASED COMPOSITE-TWO SURFACES $500. D2652 INLAY-RESIN-BASED COMPOSITE-THREE OR MORE SURFACES $520. D2662 ONLAY-RESIN-BASED COMPOSITE-TWO SURFACES $545. D2663 ONLAY-RESIN-BASED COMPOSITE-THREE SURFACES $565. D2664 ONLAY-RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES $585. DM 2011-STD-SCHED. PROCEDURE DESCRIPTION SUBSCRIBER'S CHARGE. CROWNS (CAPS) (AS SINGLE RESTORATIONS ONLY)*.

10 D2710 CROWN-RESIN (LABORATORY) $525. D2720 CROWN-RESIN WITH HIGH NOBLE METAL $560. D2721 CROWN-RESIN WITH PREDOMINATELY BASE METAL $530. D2722 CROWN-RESIN WITH NOBLE METAL $575. D2740 CROWN-PORCELAIN/CERAMIC SUBSTRATE $635. D2750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $680. D2751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $600. D2752 CROWN-PORCELAIN FUSED TO NOBLE METAL $650. D2780 CROWN-3/4 CAST HIGH NOBLE METAL $580. D2781 CROWN-3/4 CAST PREDOMINANTLY BASE METAL $550. D2782 CROWN-3/4 CAST NOBLE METAL $560. D2783 CROWN-3/4 PORCELAIN/CERAMIC $600. D2790 CROWN-FULL CAST HIGH NOBLE METAL $620. D2791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $555. D2792 CROWN-FULL CAST NOBLE METAL $600. D2794 CROWN-TITANIUM $655. D2799 PROVISIONAL CROWN $295. D2910-D2920 RECEMENT INLAY OR CROWN $70. D2930-D2931 PREFABRICATED STAINLESS STEEL CROWN $145.