Page 8 - Sample Guide
P. 8
Lockton collateral, not for leave behind or distribution.
Finding In-Network DENTAL
Providers We partner with [Carrier] to offer you and your family members dental
Remember to visit in-network insurance. Visit www.[Carrier].com to ind in-network providers and
dentists to receive the deepest access a variety of online tools and programs.
level of discount on your services.
Plan 1 Plan 2
To ind a participating in- Calendar Year Deductible
network dentist in your area
go to [website.com] or call Individual $25 $75
[555 .555 .5555] . Family $50 $225
Calendar Year Maximum
Orthodontia $1,500 $1,500
Services Note Coinsurance
The lifetime maximum illustrated Preventive 100% no deductible 100% no deductible
is diferent from the calendar Basic 80% after deductible 80% after deductible
year maximum. For orthodontia Major 50% after deductible 50% after deductible
services, this limit does not reset Orthodontia
each year, this is the most your
plan will cover for your services for Coinsurance 50% after deductible 50% after deductible
the lifetime of your participation in Lifetime Maximum $1,000 $1,000
this program. Beneit Applies to Adults and children Adults and children
Examples of This is a high level summary of your beneit coverage. Full coverage details are available in your
Services summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Preventive—exams, cleanings,
luoride, x-rays, and sealants
Basic—illings, extractions, Employee [Monthly/Weekly/Bi-Weekly] Dental
periodontics, repairs, and oral Contributions
surgery
Major—crowns, inlays, Plan 1 Plan 2
dentures, and dental impacts Employee Only $ $
Employee and Spouse $ $
Employee and Child(ren) $ $
Family $ $
8
Finding In-Network DENTAL
Providers We partner with [Carrier] to offer you and your family members dental
Remember to visit in-network insurance. Visit www.[Carrier].com to ind in-network providers and
dentists to receive the deepest access a variety of online tools and programs.
level of discount on your services.
Plan 1 Plan 2
To ind a participating in- Calendar Year Deductible
network dentist in your area
go to [website.com] or call Individual $25 $75
[555 .555 .5555] . Family $50 $225
Calendar Year Maximum
Orthodontia $1,500 $1,500
Services Note Coinsurance
The lifetime maximum illustrated Preventive 100% no deductible 100% no deductible
is diferent from the calendar Basic 80% after deductible 80% after deductible
year maximum. For orthodontia Major 50% after deductible 50% after deductible
services, this limit does not reset Orthodontia
each year, this is the most your
plan will cover for your services for Coinsurance 50% after deductible 50% after deductible
the lifetime of your participation in Lifetime Maximum $1,000 $1,000
this program. Beneit Applies to Adults and children Adults and children
Examples of This is a high level summary of your beneit coverage. Full coverage details are available in your
Services summary plan description (SPD). In the event there is a discrepancy between what is relected in
this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Preventive—exams, cleanings,
luoride, x-rays, and sealants
Basic—illings, extractions, Employee [Monthly/Weekly/Bi-Weekly] Dental
periodontics, repairs, and oral Contributions
surgery
Major—crowns, inlays, Plan 1 Plan 2
dentures, and dental impacts Employee Only $ $
Employee and Spouse $ $
Employee and Child(ren) $ $
Family $ $
8
