Page 30 - 2022 Insurity OE Guide FINAL

Guardian – Dental Plan

Group #00491813 – PPO Network

Regular dental exams can help you and your dentist detect problems in the early stages when treatment is more basic and
costs are much lower. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and periodontal
disease and is an important part of maintaining your medical health. Insurity offers a PPO plan through the Guardian Dental
Guard Preferred Network. You can access a list of providers at www.guardiananytime.com.
Covered dependents may remain on your plan until the end of the calendar year in which they turn age 26.

Guardian Dental Summary

Preferred Network PPO Plan
IN-NETWORK OUT-OF-NETWORK
Calendar Deductible
Individual $0 $75
Family Limit Not Applicable 3 per family ($225 maximum)
Waived For Not Applicable Preventive
Preventive Services
Oral Exams
Cleaning/Prophylaxis (2 in 12 consecutive months)
Fluoride Treatments (under age 19) 100%
Sealants (per tooth)
X-rays
Basic Services
Anesthesia, Fillings, Periodontal Surgery, Periodontal Maintenance
Repair & Maintenance of Crowns, Bridges & Dentures
Root Canal 90% 80%
Scaling & Root Planing (per quadrant)
Simple Extractions
Surgical Extractions
Major Services
Bridges & Dentures, Dental Implants, Inlays, Onlays, Veneers, Single Crowns 60% 50%
Benefit Maximums
Dental Annual Maximum per Family Member $2,000 (not including orthodontia)
Orthodontia
Orthodontia 50% (child and adult); Lifetime Maximum $2,000

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