Page 8 - 2020 Benefits Guide Sample
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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
Examples of $1,500 $1,500
Services Coinsurance
Preventive—exams, cleanings, Preventive 100% no deductible 100% no deductible
luoride, x-rays, and sealants Basic 80% after deductible 80% after deductible
Basic—illings, extractions, Major 50% after deductible 50% after deductible
periodontics, repairs, and oral Orthodontia
surgery Coinsurance 50% after deductible 50% after deductible
Major—crowns, inlays,
dentures, and dental impacts 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 $ $
Orthodontia Services Note
The lifetime maximum illustrated is different from the calendar year
maximum. For orthodontia services, this limit does not reset each year,
this is the most your plan will cover for your services for the lifetime of
your participation in this program.
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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
Examples of $1,500 $1,500
Services Coinsurance
Preventive—exams, cleanings, Preventive 100% no deductible 100% no deductible
luoride, x-rays, and sealants Basic 80% after deductible 80% after deductible
Basic—illings, extractions, Major 50% after deductible 50% after deductible
periodontics, repairs, and oral Orthodontia
surgery Coinsurance 50% after deductible 50% after deductible
Major—crowns, inlays,
dentures, and dental impacts 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 $ $
Orthodontia Services Note
The lifetime maximum illustrated is different from the calendar year
maximum. For orthodontia services, this limit does not reset each year,
this is the most your plan will cover for your services for the lifetime of
your participation in this program.
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