Page 10 - MMCS Benefit Guide 2019 FINAL

Dental Benefits

Guardian | DHMO Dental Plan - CA Only
With the Dental Health Maintenance Organization (DHMO) plan through Guardian, you are required to select a general
dentist to provide your dental care. You will contact your general dentist for all of your dental needs, such as routine check‐
ups and emergency situations. If specialty care is needed, you do need a referral. For covered procedures, you'll pay the pre‐
set copay or coinsurance fee described in your DHMO plan booklet. Please keep a copy of your booklet to refer to when
utilizing your dental care. This will show the applicable copays that apply to all of the dental services that are covered under
this plan.

Guardian | PPO Dental Plan - All States
With the Guardian Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the
negotiated rate or visit an out-of-network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less.
You may also obtain services using an out-of-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.

Guardian Guardian
Plan Features
DHMO Plan PPO Plan
MetLife Dental
Network Network Out-of-Network
Network
Dental Benefits
Calendar Year Maximum Unlimited $2,000
Office Visit Copay $5 Copay None

Deductible (Annual) Waived for Preventive Services
- Individual $0 None $50
- Family $0 Max 3 per Family

Preventive (Plan Pays) See Copay Schedule 100% 100%
Exams, X-Rays, Cleanings

Basic Services (Plan Pays) See Copay Schedule 90% 80%
Fillings, Oral Surgery,
Endodontics, Periodontics
Major Services (Plan Pays) See Copay Schedule 60% 50%
Crowns, Prosthetics
Orthodontia
- Covered Members Children & Adults Children & Adults
- Copay $1,975 Child / $2,175 Adult N/A
- Coinsurance N/A 50%
- Lifetime Benefit Max N/A $2,000
- Dependent Age Up to 26 Up to 26
*The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limita-
tions and exclusions.

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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