Spreadsheet: 1a54ecf9-3a29-4ab6-ba55-231b8fad3f5c
Sheet: Sheet1

([NAME]): (Dental Product Name) | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Coverage Period: Effective on or after (Date) | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12
Summary of Benefits and Coverage: What this Plan Covers & What it Costs |  |  |  |  |  |  |  | Coverage for: (Child only or Family) |  |  |  | Plan Type: (HMO) / (PPO)
 | This is only a summary. If you want more detail about your coverage and cost, you can get the complete terms in the policy or plan document (carrier website) or by calling (Carrier phone number)
DEDUCTIBLE and OUT OF POCKET MAXIMUM LEVEL |  |  |  |  |  | Your Share if you use a |  |  |  | DEDUCTIBLE and OUT OF POCKET MAXIMUM DESCRIPTION
 |  |  |  |  |  | Preferred Provider                         (In Network) |  | Non Preferred Provider (Out of Network)
Dental [NAME]: Individual Child Under 19 years old |  |  |  |  |  |  |  |  |  | You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st).
Dental [NAME]: Two or more Children Under 19 years old
Maximum Out of Pocket for Dental EHB: Individual                                    Child Under 19 years old |  |  |  |  |  |  |  |  |  | The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for Dental care expenses.
Maximum Out of Pocket for Dental EHB:                                                        Two or more Children Under 19 years old
Dental Deductible: Individual Adult |  |  |  |  |  |  |  |  |  | The Annual benefit maximum is the most the carrier would pay during a coverage period (usually one year) for their share of the cost of covered services.
Dental Deductible: Family (Adults and Dependents age 19 years old)
Annual Benefit Maximum for Dental: Individual Adult
DIAGNOSTIC and PREVENTIVE SERVICES
Services You May Need |  |  |  | Your Share if you use a |  |  |  | Limitations & Frequency
 |  |  |  | Preferred Provider                         (In Network) |  | Non Preferred Provider (Out of Network)
Oral Exams |  |  | Child
 |  |  | Adult
Bitewing X-Rays |  |  | Child
 |  |  | Adult
[NAME] |  |  | Child
 |  |  | Adult
Fluoride Treatments |  |  | Child
 |  |  | Adult
[NAME] |  |  | Child
 |  |  | Adult
Space Maintainer |  |  | Child
 |  |  | Adult
Sealants |  |  | Child
 |  |  | Adult
Palliative Treatment                          (for pain relief) |  |  | Child
 |  |  | Adult
BASIC and MAJOR SERVICE
Services You May Need |  |  |  | Your Share if you use a |  |  |  | Limitations & Frequency
 |  |  |  | Preferred Provider                         (In Network) |  | Non Preferred Provider (Out of Network)
[NAME] (White) Fillings |  |  | Child
 |  |  | Adult
Sedative Fillings |  |  | Child
 |  |  | Adult
Amalgam (Metal) Fillings |  |  | Child
 |  |  | Adult
Periodontics |  |  | Child
 |  |  | Adult
Oral Surgery |  |  | Child
 |  |  | Adult
Root canal therapy |  |  | Child
 |  |  | Adult
Medically Necessary Orthodontia |  |  | Child
 |  |  | Adult
Implants |  |  | Adult
[NAME] and [NAME] |  |  | Adult
Dentures Repair and Realignment |  |  | Adult
EXCLUDED SERVICES & OTHER COVERED SERVICES
Services Your Plan Does NOT (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Carriers can list additional non-covered benefits |  |  |  |  | Carriers can list additional non-covered benefits |  |  |  |  | Carriers can list additional non-covered benefits
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services)
Carriers can list additional covered benefits |  |  |  |  | Carriers can list additional covered benefits |  |  |  |  | Carriers can list additional covered benefits
Additional Comments  / Services