Page 17 - AES Flipbook

Group PPO Dental Proposal for
AES

Premium Summary Value Plan 3 Fee Schedule

Situs Zip (State) Lives
20707 (MD) 13

Monthly Monthly Rates
Employee +Spouse +Child(ren) Family Total
Employee $34.82 $71.03 $84.14 $124.04
Employer $0.00 $0.00 $0.00 $0.00
Total $34.82 $71.03 $84.14 $124.04
Bi­Weekly Bi­Weekly Rates
Employee +Spouse +Child(ren) Family Total
Employee $16.07 $32.78 $38.83 $57.25
Employer $0.00 $0.00 $0.00 $0.00
Total $16.07 $32.78 $38.83 $57.25
Lives 13

Important Notes:
» Quote Date: 3/22/2019. Rates are valid from 1/1/2019 through 6/30/2019.
» Rates assume Voluntary coverage (20% or less employer contribution).
» A minimum of 5 enrolled employees is required.
» Dependent Children are covered up to age 26.
» A 2 year rate guarantee is included provided the employee participation requirement is met and and enrollment does
not change by more than +/‐ 25%
» Industry Category ‐ SIC: Engineering and Management Services ‐ 87xx
» OON reimbursement based on the fee schedule, the dentist can bill the patient for the difference between the fee schedule
and the actual charge.

» Major Services: There is a 12 month waiting period for Major services.

DentalGuard Dental Insurance Plan General Limitations and Exclusions:
This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental
disease, defect or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under Preventive Services),
orthodontic (unless expressly provided for), cosmetic or experimental treatments, any to the extent benefits are payable by any other
payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The
plan limits benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic and prosthodontic services. The
services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are
the final arbiter of coverage. GP‐1‐DG2000 et al.

The DentalGuard® policy is underwritten by The Guardian Life Insurance Company of America and offered through Allstate Benefits.
DentalGuard® is a registered servicemark of The Guardian Life Insurance Company of America (''Guardian''), used with permission.
Guardian is not responsible for the statements in this material. Allstate Benefits is authorized to offer certain DentalGuard® policies
underwritten by Guardian, but Allstate Benefits is not an affiliate or related entity of Guardian.
Home Office Use: 6.2019 / 5.1.2019 / 20707 / 87xx / 0.1 / 0 / 13

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The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004