Page 20 - Busey 2020 Benefits
P. 20
DENTAL
We partner with Guardian to offer you comprehensive dental coverage.
To Find a Dental Our dental plan makes dental care more affordable for associates and
Provider
1 . Go to their families. Keep in mind, the information in the chart provided is a
www.guardiananytime.com summary only. Please refer to your Certiicate of Coverage (COC) for
2 . Hover over MyAccount/Login complete details OTL.
3 . Select “Find a Provider” (top,
center) Visit www.guardiananytime.com.
4 . Select “Search Providers” In-Network Out-of-Network
(center, left) Calendar Year Deductible
$50
$50
5 . Select “Find a Dentist” Individual $150 $150
Family
6 . Select “PPO” as plan type and Coinsurance
enter ZIP Code, then press Preventive 100% 100%
“Search” Basic 80% 80%
Major 50% 50%
Calendar Year Maximum
Guardian ofers a maximum rollover $1,250 $1,250
feature. Here’s how it works: Orthodontia
Coinsurance 50% 50%
If you incur $600 or less of dental Lifetime maximum $1,500 $1,500
claims during the plan year, you Beneit applies to Children under age 20 Children under age 20
are allowed a maximum rollover Visits and Exams Once every 6 months Once every 6 months
Visit for oral examination
amount of $300 to be added to your
For provider search information, Prophylaxis, including scaling and Once every 6 months Once every 6 months
plan maximum for future years. As
see page 7. polishing
an added bonus, if you saw only
Once every 6 months
Once every 6 months
in-network providers during the plan Fluoride Children under age 19 Children under age 19
year, you will receive an additional Sealants Once every 6 months Once every 6 months
$150 towards your annual maximum Children under age 19 Children under age 19
amount . X-Rays
Bitewing x-rays 2 per beneit year 2 per beneit year
Benefit Compensation Full mouth x-rays Once every 60 months Once every 60 months
Endodontics
Bi-Weekly Pulpotomy Covered at 80% Covered at 80%
Rates < $100,000 ≥ $100,000 Apicoectomy Covered at 80% Covered at 80%
Associate $9 .90 $11 .42 Minor Restorations
only Amalgam (silver) illings Covered at 80% Covered at 80%
Associate + $22 .84 $25 .88 Composite illings (anterior teeth Covered at 80% Covered at 80%
spouse only)
Associate + $28 .39 $32 .17 Stainless steel crowns Covered at 80% Covered at 80%
child(ren) Uncomplicated extractions Covered at 80% Covered at 80%
Family $46 .41 $52 .60 Surgical removal of erupted tooth Covered at 80% Covered at 80%
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and partial dentures Covered at 50% Covered at 50%
Denture repairs Covered at 50% Covered at 50%
20 2020 Benefits Guide
We partner with Guardian to offer you comprehensive dental coverage.
To Find a Dental Our dental plan makes dental care more affordable for associates and
Provider
1 . Go to their families. Keep in mind, the information in the chart provided is a
www.guardiananytime.com summary only. Please refer to your Certiicate of Coverage (COC) for
2 . Hover over MyAccount/Login complete details OTL.
3 . Select “Find a Provider” (top,
center) Visit www.guardiananytime.com.
4 . Select “Search Providers” In-Network Out-of-Network
(center, left) Calendar Year Deductible
$50
$50
5 . Select “Find a Dentist” Individual $150 $150
Family
6 . Select “PPO” as plan type and Coinsurance
enter ZIP Code, then press Preventive 100% 100%
“Search” Basic 80% 80%
Major 50% 50%
Calendar Year Maximum
Guardian ofers a maximum rollover $1,250 $1,250
feature. Here’s how it works: Orthodontia
Coinsurance 50% 50%
If you incur $600 or less of dental Lifetime maximum $1,500 $1,500
claims during the plan year, you Beneit applies to Children under age 20 Children under age 20
are allowed a maximum rollover Visits and Exams Once every 6 months Once every 6 months
Visit for oral examination
amount of $300 to be added to your
For provider search information, Prophylaxis, including scaling and Once every 6 months Once every 6 months
plan maximum for future years. As
see page 7. polishing
an added bonus, if you saw only
Once every 6 months
Once every 6 months
in-network providers during the plan Fluoride Children under age 19 Children under age 19
year, you will receive an additional Sealants Once every 6 months Once every 6 months
$150 towards your annual maximum Children under age 19 Children under age 19
amount . X-Rays
Bitewing x-rays 2 per beneit year 2 per beneit year
Benefit Compensation Full mouth x-rays Once every 60 months Once every 60 months
Endodontics
Bi-Weekly Pulpotomy Covered at 80% Covered at 80%
Rates < $100,000 ≥ $100,000 Apicoectomy Covered at 80% Covered at 80%
Associate $9 .90 $11 .42 Minor Restorations
only Amalgam (silver) illings Covered at 80% Covered at 80%
Associate + $22 .84 $25 .88 Composite illings (anterior teeth Covered at 80% Covered at 80%
spouse only)
Associate + $28 .39 $32 .17 Stainless steel crowns Covered at 80% Covered at 80%
child(ren) Uncomplicated extractions Covered at 80% Covered at 80%
Family $46 .41 $52 .60 Surgical removal of erupted tooth Covered at 80% Covered at 80%
Inlays Covered at 50% Covered at 50%
Onlays Covered at 50% Covered at 50%
Crowns Covered at 50% Covered at 50%
Full and partial dentures Covered at 50% Covered at 50%
Denture repairs Covered at 50% Covered at 50%
20 2020 Benefits Guide
