Page 41 - Complete Hi-Res 7-product Kit

[Major Services] In-Network Out-of-Network
[Simple extractions]
[Surgical extractions]
[Oral surgery]

[General anesthesia and I.V. sedation]
[Prosthetic repair and recementation services]
[Endodontics (including root canal treatment)] [50%] [50%]

[Non-surgical periodontal therapy]
[Periodontal surgery]
[Bridges]
[Full and partial dentures]
[Denture reline and rebase services]

[Crowns, inlays, onlays, and related services]

[Orthodontics] In-Network Out-of-Network
[Orthodontic exams]
[X-rays]

[Extractions] [50%] [50%]
[Study models]
[Appliances]

In-Network/Out-of-Network Providers
• This plan lets you choose any dentist you wish. However, your out-of-pocket costs are likely to be
lower when you choose a network dentist. For example:
— If you need a crown and see a network dentist, you pay a deductible (if applicable), then [50%] of
the remaining discounted fee for PPO members. This is known as a PPO negotiated fee.
— If you go to an out-of-network dentist, you pay a deductible (if applicable), then [50%] of the
remaining amount typically charged for a crown by dentists in your area. This is known as the
usual and customary fee.

• There is a nationwide network of dentists. To find a network dentist near you, visit
LincolnFinancial.com and select Find a Dentist.

Deductibles and Maximums
• There is [an annual] deductible of [$50 for individuals/$150 for families].
— [The deductible is waived for all preventive services.]
• There is a [$1,000] maximum for all [preventive, basic, and major] services performed each year.
— [With MaxRewards®, a portion of unused benefits can be rolled from one year into the next. See the
plan policy for details.]
— [With SmileRewards , costs for preventive services do not count toward this annual maximum.]
SM
• [There is a [$1,000] lifetime maximum for orthodontics.]

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