Page 15 - Guide
P. 15
Dental Coverage
Dental Weekly Contribution Rates
Base
Our dental plan makes dental care more affordable for employees and Employee $5.35 Premier
$6.12
their families. Research suggests the health of your mouth mirrors the Employee + $11.24 $12.85
overall health of your body. Which is why we offer dental coverage spouse $9.63 $14.08
Employee +
through our insurance partner Guardian. With this coverage you will child(ren)
have broad access to in-network providers. With an expansive selection Family $17.13 $19.89
of in-network providers you have a better chance of avoiding additional
out-of-pocket exposure or “balance billing”. Balance billing is the practice Special benefit: if a
of non-network providers billing the patient for amounts exceeding the member submits at
reimbursement amount under your Guardian dental plan. When this least 1 claim and stays
happens, you are responsible for the additional amounts charged. Make under $500 a part of the
sure your dentist is in Guardian’s Network at www.guardianlife.com. Stay unused maximum will
be rolled over for use in
in-network and ensure your savings! future years
Dental Base Plan In-network Out-of-network
Annual Deductible
Individual $50
Family limit 3 per family 3 per family
Waived for Preventive Preventive
Charges Covered for You (Coinsurance)
Preventative care (e.g., cleanings) 100% 100%
Basic care (e.g., illings) 80% 80%
Major care (e.g., crowns, dentures) 50% 50%
Orthodontia Not covered Not covered
Annual maximum beneits $1,000
Dependent age limits To age 26 To age 26
We are excited to announce we are offering a second dental plan option.
The new plan features higher plan maximums and orthodontia coverage.
The following chart is a summary of the new dental plan option.
Dental Premier Plan In-network Out-of-network
Annual Deductible
Individual $50
Family limit 3 per family 3 per family
Waived for Preventive Preventive
Charges Covered for You (Coinsurance)
Preventative care (e.g., cleanings) 100% 100%
Basic care (e.g., illings) 80% 80%
Major care (e.g., crowns, dentures) 50% 50%
Orthodontia (children to age 26) 50% up to $2,000 lifetime maximum
Annual maximum beneits $2,000
Dependent age limits To age 26 To age 26
This summary of beneits is intended to be a brief outline of coverage. The entire provisions of
beneits and exclusions are contained in the Summary Plan Description (SPD). In the event of a 15
conlict between the SPD and this description, the terms of the SPD will prevail.
Dental Weekly Contribution Rates
Base
Our dental plan makes dental care more affordable for employees and Employee $5.35 Premier
$6.12
their families. Research suggests the health of your mouth mirrors the Employee + $11.24 $12.85
overall health of your body. Which is why we offer dental coverage spouse $9.63 $14.08
Employee +
through our insurance partner Guardian. With this coverage you will child(ren)
have broad access to in-network providers. With an expansive selection Family $17.13 $19.89
of in-network providers you have a better chance of avoiding additional
out-of-pocket exposure or “balance billing”. Balance billing is the practice Special benefit: if a
of non-network providers billing the patient for amounts exceeding the member submits at
reimbursement amount under your Guardian dental plan. When this least 1 claim and stays
happens, you are responsible for the additional amounts charged. Make under $500 a part of the
sure your dentist is in Guardian’s Network at www.guardianlife.com. Stay unused maximum will
be rolled over for use in
in-network and ensure your savings! future years
Dental Base Plan In-network Out-of-network
Annual Deductible
Individual $50
Family limit 3 per family 3 per family
Waived for Preventive Preventive
Charges Covered for You (Coinsurance)
Preventative care (e.g., cleanings) 100% 100%
Basic care (e.g., illings) 80% 80%
Major care (e.g., crowns, dentures) 50% 50%
Orthodontia Not covered Not covered
Annual maximum beneits $1,000
Dependent age limits To age 26 To age 26
We are excited to announce we are offering a second dental plan option.
The new plan features higher plan maximums and orthodontia coverage.
The following chart is a summary of the new dental plan option.
Dental Premier Plan In-network Out-of-network
Annual Deductible
Individual $50
Family limit 3 per family 3 per family
Waived for Preventive Preventive
Charges Covered for You (Coinsurance)
Preventative care (e.g., cleanings) 100% 100%
Basic care (e.g., illings) 80% 80%
Major care (e.g., crowns, dentures) 50% 50%
Orthodontia (children to age 26) 50% up to $2,000 lifetime maximum
Annual maximum beneits $2,000
Dependent age limits To age 26 To age 26
This summary of beneits is intended to be a brief outline of coverage. The entire provisions of
beneits and exclusions are contained in the Summary Plan Description (SPD). In the event of a 15
conlict between the SPD and this description, the terms of the SPD will prevail.
