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2018 Benefits Enrollment Guide Annual Enrollment INSERT DATES INSERT COMPANY LOGO
2018 Benefits Enrollment Guide Annual Enrollment  INSERT DATES   INSERT COMPANY LOGO

What s Inside INSERT COMPANY NAME provides employees and their eligible dependents a vital program of benefits designed to keep you healthy protect your financial security and help you balance your life at work and home Open enrollment is the time for you to review your current coverage and elect the benefits that will best meet the needs of you and your family during the coming year This guide highlights your benefits Official plan and insurance documents govern your rights and benefits under each plan For more details about your benefits including covered expenses exclusions and limitations please refer to the individual Summary Plan Description SPD plan document or certificate of coverage for each plan which can be found in our company s designated office If any discrepancy exists between this guide and the official documents the official documents will prevail X X X X X X X X X X X X X X X X X X X X X What s Changing for 2018 Getting Ready to Enroll Healthcare Definitions Who s Eligible to Enroll Changing Your Benefits Your Health Plan Options Health Reimbursement Account HRA and Health Savings Account HSA Your Dental Plan Your Vision Plan Flexible Spending Accounts Your Income Protection Options Voluntary Income Protection Costs Employee Assistance Program 401 k Savings Plan Wellness Program Supplemental Voluntary Plans Legal Plan Other Benefits Health Program Costs for 2018 Resources and Contact Information Required Notices IMPORTANT Insert page numbers after editing and delete this text box What s Changing for 2018 To insert company name in the gray bar go to View Master Slide Master and add the name to pages 1 5 7 and 9 INSERT COMPANY NAME 2018 Benefits Enrollment 3 New INSERT PLAN NAME Features Other Changes Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam New INSERT PLAN NAME Features Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam
What   s Inside  INSERT COMPANY NAME  provides employees and their eligible dependents a vital program of benefits designe...
What s Inside INSERT COMPANY NAME provides employees and their eligible dependents a vital program of benefits designed to keep you healthy protect your financial security and help you balance your life at work and home Open enrollment is the time for you to review your current coverage and elect the benefits that will best meet the needs of you and your family during the coming year This guide highlights your benefits Official plan and insurance documents govern your rights and benefits under each plan For more details about your benefits including covered expenses exclusions and limitations please refer to the individual Summary Plan Description SPD plan document or certificate of coverage for each plan which can be found in our company s designated office If any discrepancy exists between this guide and the official documents the official documents will prevail X X X X X X X X X X X X X X X X X X X X X What s Changing for 2018 Getting Ready to Enroll Healthcare Definitions Who s Eligible to Enroll Changing Your Benefits Your Health Plan Options Health Reimbursement Account HRA and Health Savings Account HSA Your Dental Plan Your Vision Plan Flexible Spending Accounts Your Income Protection Options Voluntary Income Protection Costs Employee Assistance Program 401 k Savings Plan Wellness Program Supplemental Voluntary Plans Legal Plan Other Benefits Health Program Costs for 2018 Resources and Contact Information Required Notices IMPORTANT Insert page numbers after editing and delete this text box What s Changing for 2018 To insert company name in the gray bar go to View Master Slide Master and add the name to pages 1 5 7 and 9 INSERT COMPANY NAME 2018 Benefits Enrollment 3 New INSERT PLAN NAME Features Other Changes Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam New INSERT PLAN NAME Features Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam Non et lat aperovitati volore iunt ullat Sum in cus re nemporeped que mil illandae nos dolore mi volupta quidesci blaut mo doluptur Eliciur autas ipiteni moloreiciunt videllecusam apicipitibus perferferias doluptatum estiam
What   s Inside  INSERT COMPANY NAME  provides employees and their eligible dependents a vital program of benefits designe...
Getting Ready to Enroll Healthcare Definitions INSERT COMPANY NAME 2018 Benefits Enrollment 4 Open enrollment is from INSERT ENROLLMENT DATES Benefits you select now will go into effect on INSERT DATE and will remain in effect for the calendar year unless you experience a Qualified Life Event QLE Don t wait until the last minute to enroll Enrollment is Easy Check and Update any personal information that has changed in the past year Clarify your current benefits coverage and plan for your needs in the coming year Remember that any Flexible Spending Account FSA balances will be forfeited if not used before the end of the calendar year Re enroll in the FSA if you plan to use it Ask questions of the benefit plan providers or check the Summary Plan Descriptions SPDs located in the company s designated office Confirm your enrollment decisions before submitting your selections Keep a copy for your records Have Questions or Need More Info You can find Summary Plan Descriptions SPDs and other benefits program information in the company s designated office INSERT COMPANY NAME 2018 Benefits Enrollment 5 In Network vs Out of Network Our plans are designed to give you the freedom to use the healthcare provider of your choice However when you use an in network provider the percentage you pay out of pocket will be based on a set fee which is usually lower than the actual charge If you use a provider who is out of network you may be responsible for paying the difference between the reasonable and customary R C charges and what the provider charges R C is the amount that is generally considered reasonable based on the average that most providers charge for a particular service in a geographic region Preventive Care Services These are services that are generally linked to routine wellness exams and screenings Non preventive services are those that are considered treatment or diagnosis for an illness injury or other medical condition Preventive care is covered at 100 in network Copayments and Coinsurance A copayment or copay is the fixed dollar amount you pay for certain in network services In some cases you may be responsible for coinsurance after the copay is made Coinsurance is the percentage of covered expenses shared by you and the plan In some cases coinsurance is paid after you meet a deductible For example if the plan pays 80 of an in network covered charge you pay the remaining 20 Annual Deductible The amount of money you must first pay out of pocket before your plan begins paying for services covered by coinsurance is your annual deductible After you meet your deductible the plan pays for a percentage of eligible expenses coinsurance until you meet your out of pocket maximum If you receive services from an out ofnetwork provider the plan has a higher deductible and pays a lower percentage of coinsurance
Getting Ready to Enroll  Healthcare Definitions  INSERT COMPANY NAME    2018 Benefits Enrollment   4  Open enrollment is f...
Getting Ready to Enroll Healthcare Definitions INSERT COMPANY NAME 2018 Benefits Enrollment 4 Open enrollment is from INSERT ENROLLMENT DATES Benefits you select now will go into effect on INSERT DATE and will remain in effect for the calendar year unless you experience a Qualified Life Event QLE Don t wait until the last minute to enroll Enrollment is Easy Check and Update any personal information that has changed in the past year Clarify your current benefits coverage and plan for your needs in the coming year Remember that any Flexible Spending Account FSA balances will be forfeited if not used before the end of the calendar year Re enroll in the FSA if you plan to use it Ask questions of the benefit plan providers or check the Summary Plan Descriptions SPDs located in the company s designated office Confirm your enrollment decisions before submitting your selections Keep a copy for your records Have Questions or Need More Info You can find Summary Plan Descriptions SPDs and other benefits program information in the company s designated office INSERT COMPANY NAME 2018 Benefits Enrollment 5 In Network vs Out of Network Our plans are designed to give you the freedom to use the healthcare provider of your choice However when you use an in network provider the percentage you pay out of pocket will be based on a set fee which is usually lower than the actual charge If you use a provider who is out of network you may be responsible for paying the difference between the reasonable and customary R C charges and what the provider charges R C is the amount that is generally considered reasonable based on the average that most providers charge for a particular service in a geographic region Preventive Care Services These are services that are generally linked to routine wellness exams and screenings Non preventive services are those that are considered treatment or diagnosis for an illness injury or other medical condition Preventive care is covered at 100 in network Copayments and Coinsurance A copayment or copay is the fixed dollar amount you pay for certain in network services In some cases you may be responsible for coinsurance after the copay is made Coinsurance is the percentage of covered expenses shared by you and the plan In some cases coinsurance is paid after you meet a deductible For example if the plan pays 80 of an in network covered charge you pay the remaining 20 Annual Deductible The amount of money you must first pay out of pocket before your plan begins paying for services covered by coinsurance is your annual deductible After you meet your deductible the plan pays for a percentage of eligible expenses coinsurance until you meet your out of pocket maximum If you receive services from an out ofnetwork provider the plan has a higher deductible and pays a lower percentage of coinsurance
Getting Ready to Enroll  Healthcare Definitions  INSERT COMPANY NAME    2018 Benefits Enrollment   4  Open enrollment is f...
Healthcare Definitions continued If HSA HRA plans are not offered delete text Who s Eligible to Enroll INSERT COMPANY NAME 2018 Benefits Enrollment 6 Out of Pocket Maximum The amount of coinsurance you will be required to pay for eligible health care expenses is limited Once you reach the maximum amount the plan begins to pay 100 of eligible expenses Please note that there may be separate in network and out of network annual out of pocket maximums Summary Plan Description SPD The SPD is an important document that tells participants what the plan provides and how it operates including when an employee can begin to participate in the plan how service and benefits are calculated when benefits become vested and how to file a claim for benefits Employers are legally obligated by The Employee Retirement Income Security Act ERISA to provide employees SPDs for each benefit plan offered by the employer Health Savings Account HSA An HSA is a savings account used in conjunction with a high deductible health plan HDHP that allows users to save money tax free for IRS qualified medical expenses An HSA allows the employer to make contributions to the account and the account balance rolls over from year to year For a complete list of IRS qualified medical expenses consult IRS Pub 502 https www irs gov pub irspdf p502 pdf Health Reimbursement Arrangement HRA An HRA is an IRS approved tax advantaged employer funded health benefit plan used in conjunction with a high deductible health plan HDHP that reimburses employees for out ofpocket medical expenses and individual health insurance premiums INSERT COMPANY NAME 2018 Benefits Enrollment 7 You are eligible to enroll for the benefits described in this guide if you are an active fulltime employee scheduled to work at least XX hours per week Benefits unless explained otherwise will be available to you on the first of the month following XX days of service You must enroll for benefits within XX days of your hire date This does not include the health plan that is available after XX days of continuous service Only the employer can make contributions to an employee s account and provide reimbursement for eligible expenses An HRA account balance may or may not roll over from year to year depending on the plan design For certain health plans pediatric dental and vision coverage for children ends at age 19 or up to age 21 in certain states Eligible dependents include your Legally married spouse Same or opposite sex domestic partner Children up to age 26 health plan with integral dental and or vision Children under the age of 20 or to age 26 if a fulltime student stand alone dental or standalone vision life and AD D
Healthcare Definitions continued  If HSA HRA plans are not offered, delete text.  Who   s Eligible to Enroll   INSERT COMP...
Healthcare Definitions continued If HSA HRA plans are not offered delete text Who s Eligible to Enroll INSERT COMPANY NAME 2018 Benefits Enrollment 6 Out of Pocket Maximum The amount of coinsurance you will be required to pay for eligible health care expenses is limited Once you reach the maximum amount the plan begins to pay 100 of eligible expenses Please note that there may be separate in network and out of network annual out of pocket maximums Summary Plan Description SPD The SPD is an important document that tells participants what the plan provides and how it operates including when an employee can begin to participate in the plan how service and benefits are calculated when benefits become vested and how to file a claim for benefits Employers are legally obligated by The Employee Retirement Income Security Act ERISA to provide employees SPDs for each benefit plan offered by the employer Health Savings Account HSA An HSA is a savings account used in conjunction with a high deductible health plan HDHP that allows users to save money tax free for IRS qualified medical expenses An HSA allows the employer to make contributions to the account and the account balance rolls over from year to year For a complete list of IRS qualified medical expenses consult IRS Pub 502 https www irs gov pub irspdf p502 pdf Health Reimbursement Arrangement HRA An HRA is an IRS approved tax advantaged employer funded health benefit plan used in conjunction with a high deductible health plan HDHP that reimburses employees for out ofpocket medical expenses and individual health insurance premiums INSERT COMPANY NAME 2018 Benefits Enrollment 7 You are eligible to enroll for the benefits described in this guide if you are an active fulltime employee scheduled to work at least XX hours per week Benefits unless explained otherwise will be available to you on the first of the month following XX days of service You must enroll for benefits within XX days of your hire date This does not include the health plan that is available after XX days of continuous service Only the employer can make contributions to an employee s account and provide reimbursement for eligible expenses An HRA account balance may or may not roll over from year to year depending on the plan design For certain health plans pediatric dental and vision coverage for children ends at age 19 or up to age 21 in certain states Eligible dependents include your Legally married spouse Same or opposite sex domestic partner Children up to age 26 health plan with integral dental and or vision Children under the age of 20 or to age 26 if a fulltime student stand alone dental or standalone vision life and AD D
Healthcare Definitions continued  If HSA HRA plans are not offered, delete text.  Who   s Eligible to Enroll   INSERT COMP...
Changing Your Benefits Your Health Plan Options INSERT COMPANY NAME 2018 Benefits Enrollment 8 Certain Qualified Life Events QLEs may enable you to change your benefit elections at a time other than during open enrollment You can change your benefit elections during the year if you experience a qualified life event QLEs include Marriage Divorce annulment or legal separation Birth of your child Death of your spouse or dependent child Adoption of placement for adoption of your child Termination or commencement of your spouse s employment Change of employment status by you or your spouse or another dependent A significant change in your or your spouse s health coverage due to your spouse s employment Qualification by the Plan Administrator of a Medical Child Support Order Entitlement to Medicare or Medicaid Dependent satisfies or ceases to satisfy eligibility requirements Commencement of or return from an unpaid leave of absence A change in the place of residence of you your spouse or your dependent Your dependent satisfies or ceases to satisfy eligibility requirements The company s Health Program includes some of the latest and most cost efficient benefits whether for inpatient or outpatient care or for prescription drugs If you are offered more than one plan option compare the plans to see which one is best for you and your family IMPORTANT If you offer fewer than four plan options you can delete a column by right clicking and selecting Delete Delete Columns Benefit Plan Option 1 Plan Option 2 Plan Option 3 Plan Option 4 In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network Plan Year Deductible Individual Family 0 0 0 0 Plan Year Out of Pocket Maximum Individual Family 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Physician Services Office Visit Primary Specialist You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Well Child Care Immunizations Covered X You pay X Covered X You pay X Covered X You pay X Covered X You pay X Routine Physical Immunizations Covered X You pay X Covered X You pay X Covered X You pay X Covered X You pay X Routine Gynecological Care Mammograms Covered X You pay X Covered X You pay X Covered X You pay X Covered X You pay X Surgery Hospital Expenses You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Diagnostic Lab X ray You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Physician Surgeon Fees You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Hospital Services You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Emergency Room You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Pre natal Post natal You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Hospital Delivery You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Outpatient You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Inpatient You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Coinsurance INSERT 2018 Benefits Enrollment 9 0 0 COMPANY NAME 0 0 0 0 Outpatient Care Inpatient Care Urgent Care Maternity Care Mental Health Care Prescription Drugs Retail 30 day Generally your benefits election change must be consistent with the QLE If you experience a QLE you must generally notify INSERT COMPANY CONTACT within XX days of the change You may need to provide proof of the change If you do not make contact within XX days you will have to wait until the next annual open enrollment period to make changes unless you have another QLE Generic Formulary Non formulary Specialty Prescription Drugs Retail 90 day Generic Formulary Non formulary Specialty INSERT COMPANY NAME 2018 Benefits Enrollment 9
Changing Your Benefits  Your Health Plan Options  INSERT COMPANY NAME    2018 Benefits Enrollment   8  Certain Qualified L...
Changing Your Benefits Your Health Plan Options INSERT COMPANY NAME 2018 Benefits Enrollment 8 Certain Qualified Life Events QLEs may enable you to change your benefit elections at a time other than during open enrollment You can change your benefit elections during the year if you experience a qualified life event QLEs include Marriage Divorce annulment or legal separation Birth of your child Death of your spouse or dependent child Adoption of placement for adoption of your child Termination or commencement of your spouse s employment Change of employment status by you or your spouse or another dependent A significant change in your or your spouse s health coverage due to your spouse s employment Qualification by the Plan Administrator of a Medical Child Support Order Entitlement to Medicare or Medicaid Dependent satisfies or ceases to satisfy eligibility requirements Commencement of or return from an unpaid leave of absence A change in the place of residence of you your spouse or your dependent Your dependent satisfies or ceases to satisfy eligibility requirements The company s Health Program includes some of the latest and most cost efficient benefits whether for inpatient or outpatient care or for prescription drugs If you are offered more than one plan option compare the plans to see which one is best for you and your family IMPORTANT If you offer fewer than four plan options you can delete a column by right clicking and selecting Delete Delete Columns Benefit Plan Option 1 Plan Option 2 Plan Option 3 Plan Option 4 In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network Plan Year Deductible Individual Family 0 0 0 0 Plan Year Out of Pocket Maximum Individual Family 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Physician Services Office Visit Primary Specialist You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Well Child Care Immunizations Covered X You pay X Covered X You pay X Covered X You pay X Covered X You pay X Routine Physical Immunizations Covered X You pay X Covered X You pay X Covered X You pay X Covered X You pay X Routine Gynecological Care Mammograms Covered X You pay X Covered X You pay X Covered X You pay X Covered X You pay X Surgery Hospital Expenses You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Diagnostic Lab X ray You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Physician Surgeon Fees You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Hospital Services You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Emergency Room You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Pre natal Post natal You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Hospital Delivery You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Outpatient You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X Inpatient You pay X You pay X You pay X You pay X You pay X You pay X You pay X You pay X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Coinsurance INSERT 2018 Benefits Enrollment 9 0 0 COMPANY NAME 0 0 0 0 Outpatient Care Inpatient Care Urgent Care Maternity Care Mental Health Care Prescription Drugs Retail 30 day Generally your benefits election change must be consistent with the QLE If you experience a QLE you must generally notify INSERT COMPANY CONTACT within XX days of the change You may need to provide proof of the change If you do not make contact within XX days you will have to wait until the next annual open enrollment period to make changes unless you have another QLE Generic Formulary Non formulary Specialty Prescription Drugs Retail 90 day Generic Formulary Non formulary Specialty INSERT COMPANY NAME 2018 Benefits Enrollment 9
Changing Your Benefits  Your Health Plan Options  INSERT COMPANY NAME    2018 Benefits Enrollment   8  Certain Qualified L...
HSA and HRA Accounts If plan s are offered type over placeholder text if not delete page Your Dental Plan INSERT COMPANY NAME 2018 Benefits Enrollment 10 Health Savings Account HSA Health Reimbursement Account HRA INSERT COMPANY NAME will make a contribution to your account based upon your Health Plan coverage with 50 of the contribution paid in January 2018 and 50 of the contribution paid in April 2018 as long as you are employed with the company at the time that the contribution is made You also may contribute on a pretax basis by automatic payroll deductions or by depositing money from another bank account one time or on a recurring basis INSERT COMPANY NAME will contribute to your account each year to help you pay for healthcare expenses such as deductibles coinsurance or prescription drug copays You submit claims to the account administrator and receive reimbursement for these expenses You may not contribute to or withdraw funds from the HRA and unused balances roll over from year to year INSERT COMPANY NAME 2018 Benefits Enrollment 11 Good dental care is key to your overall health and wellness Reimbursement for dental services is based on your choice of in network or out of network provider and reasonable and customary charges R C in your local area The dental plan covers four main types of expenses i preventive and diagnostic services like routine exams and cleanings fluoride treatments sealants and X rays ii basic services such as simple fillings and extractions root canals oral surgery and gum disease treatment iii major services like crowns and dentures and iv orthodontia Benefit Annual Calendar Year Maximum In Network Out of Network 0 per person 0 per person Calendar Year Deductible 0 per person 0 per family Preventive Services no deductible X of provider fee X of R C fee Basic Services X of provider fee X of R C fee Major Services X of provider fee X of R C fee Orthodontia X of provider fee X of R C fee Orthodontia Lifetime Maximum 0 per dependent under age 20 0 per dependent under age 26
HSA and HRA Accounts  If plan s  are offered, type over placeholder text  if not, delete page.  Your Dental Plan   INSERT ...
HSA and HRA Accounts If plan s are offered type over placeholder text if not delete page Your Dental Plan INSERT COMPANY NAME 2018 Benefits Enrollment 10 Health Savings Account HSA Health Reimbursement Account HRA INSERT COMPANY NAME will make a contribution to your account based upon your Health Plan coverage with 50 of the contribution paid in January 2018 and 50 of the contribution paid in April 2018 as long as you are employed with the company at the time that the contribution is made You also may contribute on a pretax basis by automatic payroll deductions or by depositing money from another bank account one time or on a recurring basis INSERT COMPANY NAME will contribute to your account each year to help you pay for healthcare expenses such as deductibles coinsurance or prescription drug copays You submit claims to the account administrator and receive reimbursement for these expenses You may not contribute to or withdraw funds from the HRA and unused balances roll over from year to year INSERT COMPANY NAME 2018 Benefits Enrollment 11 Good dental care is key to your overall health and wellness Reimbursement for dental services is based on your choice of in network or out of network provider and reasonable and customary charges R C in your local area The dental plan covers four main types of expenses i preventive and diagnostic services like routine exams and cleanings fluoride treatments sealants and X rays ii basic services such as simple fillings and extractions root canals oral surgery and gum disease treatment iii major services like crowns and dentures and iv orthodontia Benefit Annual Calendar Year Maximum In Network Out of Network 0 per person 0 per person Calendar Year Deductible 0 per person 0 per family Preventive Services no deductible X of provider fee X of R C fee Basic Services X of provider fee X of R C fee Major Services X of provider fee X of R C fee Orthodontia X of provider fee X of R C fee Orthodontia Lifetime Maximum 0 per dependent under age 20 0 per dependent under age 26
HSA and HRA Accounts  If plan s  are offered, type over placeholder text  if not, delete page.  Your Dental Plan   INSERT ...