Page 11 - Burke Hospital 2022 Benefits Summary
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Guardian DentalGuard PPO Paycheck Contributions
Pay Frequency
Single
Family
Bi-weekly
$3.30
$8.01
Semi-monthly
$3.58
$8.68
Annual Deductible*
Annual Benefit Maximum
Preventive Dental Services
Basic Dental Services
Major Dental Services Orthodontia Lifetime Maximum
Maximum Rollover Account**
Guardian DentalGuard PPO
In-Network
$50 individual / $150 family
$1,000
100%
90%
50% $1,000
Yes
Out-of-Network
$50 individual / $150 family
$1,000
100%
80%
50% $1,000
Yes
Orthodontia Services (Dependent children under age 19)
50% 50%
* Annual deductible is waived for all preventive services.
** All Burke members enrolled in the Guardian dental plan are eligible to earn additional dollars in their Maximum
Rollover Account. Please see your Guardian benefit summary for additional details.
2022 Benefits Summary Hospital 11
