hana_guide

COMPANY LOGO

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK

Annual Deductible

Individual: $00 Family: $00

Individual: $00 Family: $00

Individual: $00 Family: $00

Benefit Maximum Annual Lifetime

$00 $00

$00 $00

00%

00%

00%

Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral Examinations; Topical Fluoride; X-rays; Bitewing; Sealants (up to age 14); Space Maintainers Basic Services Fillings; Extractions; Oral Surgery; Endodontics; Periodontics; Periodontal surgery; Anesthesia; Consultations; Repairs of dentures, crowns, inlays and onlays Major Services Bridge and Dentures; Crowns, Inlays, Onlays, Implants

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•

00%

00%

00%

•

•

00%

00%

00%

00%

00%

00%

Orthodontic Services (children only)

Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$000 $000 $000 $000

$000 $000 $000 $000

* after deductible

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