Page 18 - Pampa 2024 Benefit Guide
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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
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