Page 18 - Levelland 2024 Benefit Guide
P. 18

Dental Option:

        Guardian



         Semi Monthly 24 Pay Periods   Option 1     Option 2
                                                                         Dependent Information

         Employee Only                  $20.40       $22.40   SkyBlue Healthcare offers our employees the  opportunity to cover
                                                              their spouse or dependent  children. Children can join or remain on
         Employee + Spouse              $40.38       $45.13   a parent’s vision plan until age 26. When a child turns 26, they will
                                                              lose vision coverage on the last day of their birth month. This is an
         Employee + Child(ren)          $53.55       $59.85   automated process.

         Employee + Family              $78.48       $88.83
                                                               DentalGuard Preferred (DGP) Network

                                               Option 1 (Standard)                 Option 2 (Standard Plus)
         Type of Service                 Non-Network  Dentists  Reimbursed at          Non-Network Dentists
                                          90% Usual & Customary  (U&C ) Fees    90% Usual & Customary  (U&C ) Fees
         Preventive Services                Covered at 100%; CYD Waived           Covered at 100%; CYD Waived

         Basic Services                       Covered at 80% after CYD               Covered at 80% after CYD

         Major Services                       Covered at 50% after CYD               Covered at 50% after CYD
         Annual Maximum                                 $1,000                                $1,500

         Maximum Rollover Benefit  Limit                $1,000                                $1,250

            Rollover Amount                             $250                                   $350
            Claims Threshold                            $500                                   $700

         Annual Deductible (CYD)             $50 Individual  / $150 Family         $50 Individual  / $150 Family

         Orthodontics Lifetime Max                   Not Covered                              $1,000

         Type of Service                                         Benefit Description


                                        Routine cleanings, oral exams, bitewing   Routine cleanings, oral exams, bitewing
         Preventive Services            and full mouth x-rays, fluoride, sealants,   and full mouth x-rays, fluoride, sealants,
                                        space maintainers.                    space maintainers.
                                        Fillings, simple extractions, oral surgery,   Fillings, simple extractions, oral surgery,
         Basic Services                 endodontics (root canals), periodontics,   endodontics (root canals), periodontics,
                                        complex extractions and anesthesia.   complex extractions and anesthesia.

                                        Crowns, bridges, dentures, inlays,    Crowns, bridges, dentures, inlays,
                                        onlays,  labial veneers, dentures crown/  onlays,  labial veneers, dentures crown/
         Major Services
                                        bridges repair and implants           bridges repair and implants


         Orthodontia Services                       Not Available                   Included (Adult & Children)


                       NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.

                   Website: https://www.guardianlife.com/contact-us  or Customer Service: 1-800-541-7846 Mon-Fri: 5am - 5:30pm PST
                                                             18
   13   14   15   16   17   18   19   20   21   22   23