Forms & Documents

Summary of Benefits (SOB)

Chiro/Acu: Landmark

	Acupuncture Schedule of Benefits $10 20 Plan Highlights
	Acupuncture Schedule of Benefits $10 20 Plan Highlights
	Acupuncture Schedule of Benefits $10 30 Plan Highlights
	Acupuncture Schedule of Benefits $10 30 Plan Highlights
	Acupuncture Schedule of Benefits $15 20 Plan Highlights
	Acupuncture Schedule of Benefits $15 20 Plan Highlights
	Acupuncture Schedule of Benefits $15 30 Plan Highlights
	Acupuncture Schedule of Benefits $15 30 Plan Highlights
	Acupuncture Schedule of Benefits $20 20 Plan Highlights
	Acupuncture Schedule of Benefits $20 20 Plan Highlights
	Acupuncture Schedule of Benefits $20 30 Plan Highlights
	Acupuncture Schedule of Benefits $20 30 Plan Highlights
	Acupunture Schedule of Benefits $35 10 Plan Hightlights
	Acupunture Schedule of Benefits $35 15 Plan Hightlights
	Acupunture Schedule of Benefits $35 20 Plan Hightlights
	Chiropractic Schedule of Benefits $10 20 Plan Highlights
	Chiropractic Schedule of Benefits $10 20 Plan Highlights
	Chiropractic Schedule of Benefits $10 30 Plan Highlights
	Chiropractic Schedule of Benefits $10 30 Plan Highlights
	Chiropractic Schedule of Benefits $15 20 Plan Highlight
	Chiropractic Schedule of Benefits $15 20 Plan Highlights
	Chiropractic Schedule of Benefits $15 30 Plan Highlights
	Chiropractic Schedule of Benefits $15 30 Plan Highlights
	Chiropractic Schedule of Benefits $20 20 Plan Highlight
	Chiropractic Schedule of Benefits $20 20 Plan Highlights
	Chiropractic Schedule of Benefits $20 30 Plan Highlights
	Chiropractic Schedule of Benefits $20 30 Plan Highlights
	Chiropractic Schedule of Benefits $25 10 Plan Highlights
	Chiropractic Schedule of Benefits $25 15 Plan Highlights
	Chiropractic Schedule of Benefits $25 20 Plan Highlights
	Combined Schedule of Benefits $10 20 Plan Highlights
	Combined Schedule of Benefits $10 20 Plan Highlights
	Combined Schedule of Benefits $10 30 Plan Highlights
	Combined Schedule of Benefits $10 30 Plan Highlights
	Combined Schedule of Benefits $15 20 Plan Highlights
	Combined Schedule of Benefits $15 20 Plan Highlights
	Combined Schedule of Benefits $15 30 Plan Highlights
	Combined Schedule of Benefits $15 30 Plan Highlights
	Combined Schedule of Benefits $20 20 Plan Highlights
	Combined Schedule of Benefits $20 20 Plan Highlights
	Combined Schedule of Benefits $20 30 Plan Highlights
	Combined Schedule of Benefits $20 30 Plan Highlights
	Landmark Chiropractic Only Expanded Evidence of Coverage
	Landmark Chiropractic Only Standard Evidence of Coverage
	Landmark Combined Expanded Evidence of Coverage
	Landmark Combined Standard Evidence of Coverage

Dental PPO: Delta Dental

	Choice PPO $1,500 without Ortho Plan Highlights
	Choice Premier $1,000 without Ortho Evidence of Coverage
	Choice Premier $1,000 without Ortho Evidence of Coverage
	Choice Premier $1,000 without Ortho Plan Highlights
	Choice Premier $1,500 without Ortho Evidence of Coverage
	Choice Premier $1,500 without Ortho Evidence of Coverage
	Choice Premier $1,500 without Ortho Plan Highlights
	Choice Premier $2,000 without Ortho Evidence of Coverage
	Choice Premier $2,000 without Ortho Evidence of Coverage
	Choice Premier $2,000 without Ortho Plan Highlights
	PPO Advantage 400 | $1000 Max | D&P Max Waiver SOB
	PPO Advantage 400 | $1000 Max SOB
	PPO Advantage 400 | $1500 Max | D&P Max Waiver SOB
	PPO Advantage 400 | $1500 Max SOB
	PPO Advantage 400 | $2000 Max | D&P Max Waiver SOB
	PPO Advantage 400 | $2000 Max SOB
	PPO Advantage 400 | $2500 Max | D&P Max Waiver SOB
	PPO Advantage 400 | $2500 Max SOB
	PPO Advantage 400 Voluntary | $1000 Max SOB
	PPO Advantage 400 Voluntary | $1500 Max SOB
	PPO Advantage 400 Voluntary | $2000 Max SOB
	PPO Advantage 400 Voluntary | $2500 Max SOB
	PPO Core 100 | $1000 Max SOB
	PPO Core 100 | $1500 Max SOB
	PPO Core 100 Voluntary | $1000 Max SOB
	PPO Core 100 Voluntary | $1500 Max SOB
	PPO Core 200 | $1000 Max SOB
	PPO Core 200 Voluntary | $1000 Max SOB
	PPO Deluxe 300 | $1500 Max | D&P Max Waiver SOB
	PPO Deluxe 300 | $1500 Max SOB
	PPO Deluxe 300 | $1500 Max SOB
	PPO Deluxe 300 | $2000 Max | D&P Max Waiver SOB
	PPO Deluxe 300 | $2000 Max SOB
	PPO Deluxe 300 | $2500 Max | D&P Max Waiver SOB
	PPO Deluxe 300 | $2500 Max SOB
	PPO Deluxe 300 | $3000 Max | D&P Max Waiver SOB
	PPO Deluxe 300 | $3000 Max SOB
	PPO Deluxe 300 Voluntary | $1500 Max SOB
	PPO Deluxe 300 Voluntary | $2000 Max SOB
	PPO Deluxe 300 Voluntary | $2500 Max SOB
	PPO Deluxe 300 Voluntary | $3000 Max SOB
	PPO Dual Choice 2 | $1500 Max | D&P Max Waiver SOB
	PPO Dual Choice 2 | $1500 Max SOB
	PPO Dual Choice 2 | $2000 Max | D&P Max Waiver SOB
	PPO Dual Choice 2 | $2000 Max SOB
	PPO Dual Choice 2 Voluntary | $1500 Max SOB
	PPO Dual Choice 2 Voluntary | $2000 Max SOB
	PPO Dual Choice Buy-up | $1500 Max SOB
	PPO Dual Choice Buy-up | $2000 Max SOB
	PPO Dual Choice Core | $1000 Max SOB
	PPO Plus Premier Advantage 100 | $1000 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 100 | $1000 Max SOB
	PPO Plus Premier Advantage 100 | $1500 Max | D&P Max Waiver SOB

Sales Guides & Flyers

Brochures/Flyers: Broker/Employer

CoPower SELECT Landmark Summary of Benefits and Rate Guide