Page 12 - Ria Benefits Guide 2020 FINAL National
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Guardian Dental Plan Choices


                                                                                         Guardian
         Plan Name                                                                        DHMO
         Network Name                                                                   In-Network
         Dental Benefits
         Calendar Year Maximum Benefit                                                   Unlimited
         Annual Deductible
          - Individual                                                                      $0
          - Family                                                                          $0
         Office Visit Copay                                                                 $0
         Preventive Services                                                                $0
         Cleaning (prophylaxis) & Oral Exams                                                $0
         Basic Services                                                                  $10-$155
         Major Services                                                                   $40-140
         Orthodontia                                                                   $2,500-$2,800

         Employee contribution per pay date                                               DHMO
          - Employee                                                                       $7.51
          - Employee + spouse                                                             $14.71
          - Employee + child(ren)                                                         $14.99
          - Employee + family                                                             $22.20


                                                    Guardian                                Guardian
         Plan Name                             DPPO - Low Option                       DPPO - High Option
         Network Name                     In-Network        Non-Network         In-Network         Non-Network
         Dental Benefits
         Calendar Year Max. Benefit                  $1,000                                   $1,000
         Annual Deductible
          - Individual                        $50               $100                $50                 $50
          - Family                           $150               $300               $150                $150
         Office Copay                         $0                 $0                 $0                  $0
         Preventive Services                  $0                 $0                 $0                  $0

         Cleaning (prophylaxis) & Oral        $0                 $0                 $0                  $0
         Exams
         Basic Services                  Deductible, 20%    Deductible, 50%      Deductible, 20%   Deductible, 20%
                                         (member pays)      (member pays)      (member pays)       (member pays)
         Major Services                  Deductible, 50%    Deductible, 75%     Deductible, 50%    Deductible, 50%
                                         (member pays)      (member pays)      (member pays)       (member pays)
         Orthodontia
          - Child                       50% / $1,000 Lifetime Benefit Maximum    50% / $1000 Lifetime Benefit Maximum
          - Adult                       50% / $1,000 Lifetime Benefit Maximum     50% / $1,000 Lifetime Benefit Maximum

         Employee contribution per
         pay date                              DPPO—Low Option                          DPPO—High Option
          - Employee                                 $15.38                                   $21.96
          - Employee + spouse                        $31.14                                   $42.86
          - Employee + child(ren)                    $30.27                                   $41.99
          - Employee + family                        $59.57                                   $70.33
    12  RIA EMPLOYEE BENEFITS 2020
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