Page 15 - iFLY Benefit Guide 01-20

Dental Plan Choices

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 Guardian PPO network.
When you utilize a network dentist, your out-of-pocket expenses will be less, however, you will usually pay the
lowest amount for services when you visit a PPO dentist. If you obtain services using a non-network dentist, you will
be responsible for the difference between the covered amount and the actual charges and you may be responsible
for filing claims. The chart below provides a high-level overview of your dental plan.

If your dentist is in the Dental PPO Network, you will receive a higher level of
benefits if you enroll in the Value Plan. If your dentist is non-network, you

will receive a higher out-of-network reimbursement if you enroll in the NAP
plan.

Guardian Guardian
Plan Name Value Plan NAP Plan
Network Name PPO Non-Network PPO Non-Network

Dental Benefits
Calendar Year Maximum Benefit $1,500 $1,500
Maximum Rollover
- Rollover Threshold to Qualify $700 $700
- Rollover Amount $350 $350
- Rollover Account Limit $1,250 $1,250
Annual Deductible
- Individual $50 $50 $50
- Family $150 $150 $150
90th Percentile of
Reimbursement Base Fee Schedule Usual and
Customary
Preventive Services No Charge No Charge No Charge No Charge
Basic Services Deductible, 0% Deductible, 0% Deductible, 20% Deductible, 20%
Major Services Deductible, 40% Deductible, 40% Deductible, 50% Deductible, 50%
Orthodontia (Adult & Child) 50% / $1,500 Lifetime Benefit 50% / $1,500 Lifetime Benefit

Note
We strongly recommend you ask your
dentist for a predetermination if total Finding a Dental Provider
charges are expected to exceed $300.
Predetermination enables you and your Go to www.guardiananytime.com and select PPO as a
dentist to know in advance what the Plan Type.
payment will be for any service that may
be in question.

Team Member Benefits 15