Page 12 - My FlipBook
P. 12
Beneit Resource
Guide
Dental
Dental Dental coverage is offered through Guardian. Please review the plan
Coverage summary below. Keep in mind, the information in the chart provided is
a summary only.
Plan 1 Plan 2
(Buy-up Option)
Deductible/Maximum
Individual deductible $50 $50
Family deductible Max $150 (or Max $150 (or $50
$50 per person) per person)
Calendar year maximum $750 $750
Maximum rollover $150 $150
Coinsurance
Preventive services 80% 100%
(exams, x-rays, cleanings)
Basic Services 80% 100%
(illings, root canals, oral surgery)
Major Services 50% 50%
(bridges, crowns, dentures)
Orthodontia 50% up to $750 50% up to $750
(dependents up to age 19)
Rate per Pay Period
Plan 2
Plan 1 (Buy-up Option)
Employee only $10.50 $11.75
Family $27.50 $30.50
12
Guide
Dental
Dental Dental coverage is offered through Guardian. Please review the plan
Coverage summary below. Keep in mind, the information in the chart provided is
a summary only.
Plan 1 Plan 2
(Buy-up Option)
Deductible/Maximum
Individual deductible $50 $50
Family deductible Max $150 (or Max $150 (or $50
$50 per person) per person)
Calendar year maximum $750 $750
Maximum rollover $150 $150
Coinsurance
Preventive services 80% 100%
(exams, x-rays, cleanings)
Basic Services 80% 100%
(illings, root canals, oral surgery)
Major Services 50% 50%
(bridges, crowns, dentures)
Orthodontia 50% up to $750 50% up to $750
(dependents up to age 19)
Rate per Pay Period
Plan 2
Plan 1 (Buy-up Option)
Employee only $10.50 $11.75
Family $27.50 $30.50
12
