Page 8 - 2020-21 Sample Benefits Guide
P. 8
20XX






Finding In-Network Providers Dental

Remember to visit in-network dentists to receive the deepest We partner with [Carrier] to offer you and
level of discount on your services. your family members dental insurance. Visit
www.[Carrier].com to ind in-network providers and
To ind a participating in-network dentist in your area go to access a variety of online tools and programs.
[website.com] or call [555.555.5555].

Plan 1 Plan 2
Orthodontia Services Note Calendar Year Deductible

The lifetime maximum illustrated is diferent from the Individual $25 $75
calendar year maximum. For orthodontia services, this limit Family $50 $225
does not reset each year, this is the most your plan will Calendar Year
cover for your services for the lifetime of your participation Maximum
in this program. $1,500 $1,500
Coinsurance
Examples of Services Preventive 100% no 100% no

„ Preventive—exams, cleanings, luoride, x-rays, and deductible deductible
sealants Basic 80% after 80% after
deductible
deductible
„ Basic—illings, extractions, periodontics, repairs, and Major 50% after 50% after
oral surgery deductible deductible

„ Major—crowns, inlays, dentures, and dental impacts Orthodontia
Coinsurance 50% after 50% after
deductible deductible
Lifetime Maximum $1,000 $1,000
Beneit Applies to Adults and children Adults and
children

This is a high level summary of your beneit coverage. Full coverage
details are available in your 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.

Employee [Monthly/Weekly/Bi-
Weekly] Dental Contributions


Plan 1 Plan 2
Employee Only $ $
Employee and $ $
Spouse
Employee and $ $
Child(ren)
Family $ $






8
   3   4   5   6   7   8   9   10   11   12   13