Page 16 - SC Fuels EE Guide 2020 Imperial & SD

DENTAL PLAN CHOICES

SIMNSA | DHMO Plan
The SIMNSA DHMO option is available to San Diego or Mexico residents who would like to access dental care
services in Mexico. This plan allows you to visit a select network of qualified Spanish-speaking dentists, in
Tijuana, Mexicali, Rosarito or Tecate. Please note that dental services in the United States are not covered.

Guardian | PPO Plan
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your
benefits and reduce your out-of-pocket costs if you choose a dentist who participates in the PPO network. When
you utilize a network dentist, your out-of-pocket expenses will be less. You may access your plan by using your
ID card, provided by Guardian, or by providing your dentist with your social security number (your dependents
will need to provide your social security number). You may order additional ID cards by calling Guardian Member
Services, or registering on the Guardian website (see page 24 for Guardian Resources and Contacts).

SIMNSA Guardian
DHMO PPO
Network Name SIMNSA PPO Network Non-Network
Dental Benefits
Team Member Rate Per Paycheck
• Team Member Only $2.27 $9.00
• Team Member + Spouse $8.57 $29.00
• Team Member + Child(ren) $13.82 $26.10
• Team Member + Family $15.00 $54.25
Calendar Year Maximum Benefit Unlimited $1,500 with Maximum Rollover
Annual Deductible
• Individual $0 $50
• Family $0 $150
Preventive Services (You Pay) Copays Apply No Charge 20% UCR*
Basic Services (You Pay) Copays Apply Deductible, 10% Deductible, 20% UCR*
Major Services (You Pay) Copays Apply Deductible, 50% Deductible, 50% UCR*
Orthodontia (Children & Adults) $50 per Visit 50% with $1,500 Lifetime Maximum Benefit
*Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference charged.

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 exceed the paid claims threshold of $700
during the benefit year, you will be credited up to $350 to your MRA. As an added advantage, more money will
be rolled over if in-network dentists are used.

FINDING A DENTAL PROVIDER Note:
• DHMO: Go to www.simnsa.com We strongly recommend you ask your
• PPO: Go to www.guardiananytime.com - click dentist for a predetermination if total
“Find a Provider” and select the “PPO Dental charges are expected to exceed $300.
Plan”

16 | TEAM MEMBER BENEFITS