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Dental Insurance | PPO Plan Summary of Benefits

Prepared for: [Sample Company Employees]
Enrollment Deadline: [Month XX, 2017]

Group rates for [Sample employees] make dental insurance
more affordable than ever. The Lincoln DentalConnect® PPO
plan covers most [preventive, basic, and major] services[,
along with orthodontics]. The specific treatments covered
and the coverage amounts for each — along with additional
plan benefits and services — are outlined on the following
pages.

[To take advantage of this coverage, simply complete and
return your Enrollment Form by Month XX, 2017. Your
premium comes out of your paycheck, so no money is due
now.]

Coverage Levels

Preventive Services In-Network Out-of-Network

[Routine oral exams]
[Bitewing X-rays]
[Full-mouth or panoramic X-rays]

[Routine cleanings]
[Fluoride treatments ] [100%] [100%]
[Space maintainers]

[Sealants]
[Consultations]
[Harmful habit appliances]

Basic Services In-Network Out-of-Network
[Other dental X-rays (including periapical films)]

[Problem focused exams]
[Palliative treatment (including emergency relief of dental pain)]
[Injections of antibiotics and other therapeutic medications]
[Fillings] [80%] [80%]

[Prefabricated stainless steel and resin crowns]
[Biopsy and examination of oral tissue (including brush biopsy)]
[Periodontal maintenance procedures]
[Occlusal guard and adjustments]

[Form Filing Number] Dental Insurance | PPO Plan Summary of Benefits