Page 8 - Benefit Guide
P. 8
2019 Benefits Enrollment
DENTAL
Remember to visit in-network
dentists to receive the deepest We partner with [Carrier] to offer you and your family members dental
level of discount on your services.
insurance. Visit www.[Carrier].com to ind in-network providers and
To ind a participating in- access a variety of online tools and programs.
network dentist in your area
go to [website.com] or call Plan 1 Plan 2
[555.555.5555]. Calendar Year Deductible
Individual $25 $75
Orthodontia Family $50 $225
Services Note Calendar Year Maximum
The lifetime maximum illustrated $1,500 $1,500
is different from the calendar Coinsurance
year maximum. For orthodontia Preventive 100% no deductible 100% no deductible
services, this limit does not
reset each year, this is the most Basic 80% after deductible 80% after deductible
your plan will cover for your Major 50% after deductible 50% after deductible
services for the lifetime of your Orthodontia
participation in this program.
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $1,000 $1,000
Examples of Beneit Applies to Adults and children Adults and children
Services
z Preventive—exams, This is a high level summary of your beneit coverage. Full coverage details are available in your
cleanings, luoride, x-rays, summary plan description (SPD). In the event there is a discrepancy between what is relected in
and sealants this guide and what is communicated in your SPD, the terms of your SPD will prevail.
z Basic—illings, extractions,
periodontics, repairs, and
oral surgery Employee Dental Contributions
z Major—crowns, inlays, Plan 1 Plan 2
dentures, and dental impacts Employee Only $ $
Employee and Spouse $ $
Employee and Child(ren) $ $
Family $ $
8
DENTAL
Remember to visit in-network
dentists to receive the deepest We partner with [Carrier] to offer you and your family members dental
level of discount on your services.
insurance. Visit www.[Carrier].com to ind in-network providers and
To ind a participating in- access a variety of online tools and programs.
network dentist in your area
go to [website.com] or call Plan 1 Plan 2
[555.555.5555]. Calendar Year Deductible
Individual $25 $75
Orthodontia Family $50 $225
Services Note Calendar Year Maximum
The lifetime maximum illustrated $1,500 $1,500
is different from the calendar Coinsurance
year maximum. For orthodontia Preventive 100% no deductible 100% no deductible
services, this limit does not
reset each year, this is the most Basic 80% after deductible 80% after deductible
your plan will cover for your Major 50% after deductible 50% after deductible
services for the lifetime of your Orthodontia
participation in this program.
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $1,000 $1,000
Examples of Beneit Applies to Adults and children Adults and children
Services
z Preventive—exams, This is a high level summary of your beneit coverage. Full coverage details are available in your
cleanings, luoride, x-rays, summary plan description (SPD). In the event there is a discrepancy between what is relected in
and sealants this guide and what is communicated in your SPD, the terms of your SPD will prevail.
z Basic—illings, extractions,
periodontics, repairs, and
oral surgery Employee Dental Contributions
z Major—crowns, inlays, Plan 1 Plan 2
dentures, and dental impacts Employee Only $ $
Employee and Spouse $ $
Employee and Child(ren) $ $
Family $ $
8
