Page 13 - Jones and Frank Benefits Enrollments Guide

Dental Benefits

Jones & Frank will continue to offer our dental plan through Guardian Life Insurance
Company of America. The dental plan provides you with access to In-Network providers or,
the option to seek treatment from a dentist that is not part of the Guardian Life Dental Network. For the
2018 plan year, you will have the option of adding Orthodontia benefits for children (under age 19). The
following chart provides a summary of the benefits.

Low Plan High Plan

In Network Out of Network In Network Out of Network

Diagnostic &
100% of UCR Covered 100% of UCR Covered 100% of UCR Covered 100% of UCR Covered
Preventative
Deductible is waived Deductible is waived Deductible is waived Deductible is waived
Services
Basic 90% of UCR Covered, 80% of UCR Covered, 90% of UCR Covered, 80% of UCR Covered,

Services after Deductible. after Deductible. after Deductible. after Deductible.

Major 60% of UCR Covered, 50% of UCR Covered, 60% of UCR Covered, 50% of UCR Covered,

Services after Deductible. after Deductible. after Deductible. after Deductible.
Annual $25 per person. $25 per person. $25 per person. $25 per person.
Individual Waived for Waived for Waived for Waived for
Deductible Preventive/Diagnostic Preventive/Diagnostic Preventive/Diagnostic Preventive/Diagnostic
Annual $75 Family Cap. $75 Family Cap. $75 Family Cap. $75 Family Cap.
Family Waived for Waived for Waived for Waived for
Deductible Preventive/Diagnostic Preventive/Diagnostic Preventive/Diagnostic Preventive/Diagnostic
Annual
$1500 per Insured $1500 per Insured $1500 per Insured $1500 per Insured
Benefit
Maximum (With Rollover) (With Rollover) (With Rollover) (With Rollover)

Covered as Basic Covered as Basic Covered as Basic Covered as Basic
Endodontics
Service Service Service Service

Covered as Basic Covered as Basic Covered as Basic Covered as Basic
Periodontics
Service Service Service Service

Orthodontia 50% up to a Lifetime 50% up to a Lifetime
Not Covered Not Covered
(Children) Maximum of $1000 Maximum of $1000

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