Page 8 - Benefits Guide
P. 8
2019 Benefits Guide
DENTAL
Finding In-Network
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 Individual $25 $75
go to [website.com] or call
[555.555.5555]. Family $50 $225
Calendar Year Maximum
Orthodontia $1,500 $1,500
Coinsurance
Services Note Preventive 100% no deductible 100% no deductible
The lifetime maximum illustrated Basic 80% after deductible 80% after deductible
is different from the calendar
year maximum. For orthodontia Major 50% after deductible 50% after deductible
services, this limit does not Orthodontia
reset each year, this is the most Coinsurance 50% after deductible 50% after deductible
your plan will cover for your
services for the lifetime of your Lifetime Maximum $1,000 $1,000
participation in 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.
z Preventive—exams,
cleanings, luoride, x-rays,
and sealants Employee [Monthly/Weekly/Bi-Weekly] Dental
z Basic—illings, extractions, Contributions
periodontics, repairs, and oral
surgery Plan 1 Plan 2
z Major—crowns, inlays, Employee Only $ $
dentures, and dental impacts Employee and Spouse $ $
Employee and Child(ren) $ $
Family $ $
8
DENTAL
Finding In-Network
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 Individual $25 $75
go to [website.com] or call
[555.555.5555]. Family $50 $225
Calendar Year Maximum
Orthodontia $1,500 $1,500
Coinsurance
Services Note Preventive 100% no deductible 100% no deductible
The lifetime maximum illustrated Basic 80% after deductible 80% after deductible
is different from the calendar
year maximum. For orthodontia Major 50% after deductible 50% after deductible
services, this limit does not Orthodontia
reset each year, this is the most Coinsurance 50% after deductible 50% after deductible
your plan will cover for your
services for the lifetime of your Lifetime Maximum $1,000 $1,000
participation in 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.
z Preventive—exams,
cleanings, luoride, x-rays,
and sealants Employee [Monthly/Weekly/Bi-Weekly] Dental
z Basic—illings, extractions, Contributions
periodontics, repairs, and oral
surgery Plan 1 Plan 2
z Major—crowns, inlays, Employee Only $ $
dentures, and dental impacts Employee and Spouse $ $
Employee and Child(ren) $ $
Family $ $
8
