Page 16 - SC Fuels EE Guide 2020 National

DENTAL PLAN

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).

Guardian
PPO
Network Name PPO Network Non-Network
Dental Benefits
Team Member Rate Per Paycheck
• Team Member Only $9.00
• Team Member + Spouse $29.00
• Team Member + Child(ren) $26.10
• Team Member + Family $54.25
Calendar Year Maximum Benefit $1,500 with Maximum Rollover
Annual Deductible
• Individual $50
• Family $150
Preventive Services (You Pay) No Charge 20% UCR*
• X-Rays, Exams, Cleanings
Basic Services (You Pay) Deductible, 10% Deductible, 20% UCR*
• Restorative/Oral Surgery
• Endodontics/Periodontics
• Composite Fillings
Major Services (You Pay) Deductible, 50% Deductible, 50% UCR*
• Crowns, Bridges, Implants
Orthodontia (Children & Adults) 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:
Go to www.guardiananytime.com - click “Find a We strongly recommend you ask your
dentist for a predetermination if total
Provider” and select the “PPO Dental Plan” charges are expected to exceed $300.

16 | TEAM MEMBER BENEFITS