Page 18 - Plainview 2024 Benefit Guide Final2

Dental Option:

Guardian

Semi Monthly
Option 1 Option 2
24 Pay Periods 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
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