Page 9 - Research Affiliates EE Guide 1-19

Benefits

Dental Insurance

Guardian | PPO Dental Plans
With the Guardian Preferred Provider Organization (PPO) dental plans, you may visit a network dentist and benefit from the
negotiated rate or visit a non‐network dentist. When you utilize a network dentist, your out-of-pocket expenses will be less. You
may also obtain services using a non-network dentist; however, you will be responsible for the difference between the covered
amount and the actual charges and you may be responsible for filing claims. With the Value plan, non-network benefits are limited
to Guardian’s less rich PPO fee schedule. The PPO plan is especially useful if you are using a non-network provider, as you will not
pay more than what 90% of the providers in the area are charging.

Guardian Guardian
Plan Name Value PPO PPO

Network Name PPO Non-Network PPO Non-Network
Dental Benefits
Calendar Year Maximum $2,500 with Maximum Rollover $2,500 with Maximum Rollover

Deductible (Annual)
- Individual $50 $50 $50 $50
- Family $150 $150 $150 $150
Preventive No Charge No Charge No Charge No Charge
Exams, X-Rays, Cleanings (Fee Schedule) (UCR 90th)

Basic Services Deductible, Deductible, Deductible, 20% Deductible, 20%
Fillings, Oral Surgery, then No Charge then No Charge (UCR 90th)
Endodontics, Periodontics (Fee Schedule)
Major Services Deductible, 40% Deductible, 40% Deductible, 50% Deductible, 50%
Crowns, Prosthetics (Fee Schedule) (UCR 90th)
Orthodontia
- Covered Members Children & Adults Children & Adults
- Coinsurance 50% 50%
- Lifetime Benefit Maximum $1,500 $1,500

Guardian’s Maximum Rollover
With Maximum Rollover, Guardian will roll-over a portion of your unused annual maximum into your personal Maximum Rollover
Account (MRA). If you have a paid claim and do not exceeded the paid claims threshold of $700 during the benefit year, you will be
credited $350 to your MRA. As an added advantage, more money will be rolled over if in-network dentists are use.

Finding a Dental Provider
Go to www.guardiananytime.com or call (800) 541-7846. Refer to the “PPO” network when prompted.

Website Instructions: Click “Find a Provider” from Guardian’s website. You may search by location and
dentist’s name or location and office practice name. When choosing the dental network, please choose the
option that states “Dental Plan, PPO”.

Note
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300. Predetermination
enables you and your dentist to know in advance what the payment will be for any service that may be in question.

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