Page 9 - 2020-21 Sample Benefits Guide

[Company Name] Benefits Enrollment Guide

Vision Finding In-Network Providers

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

In-Network Out-of-Network
Copay
Exam
Materials
Lenses
Single
Bifocal
Trifocal
Lenticular
Frames

Contacts

Frequency
Exam
Lenses
Contacts (in lieu of
glasses)
Frames

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] Vision Contributions

Employee Only $
Employee and Spouse $
Employee and Child(ren) $
Family $

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