Page 12 - Surfline Benefits Guide 2017

Dental

Guardian | PPO Dental Plan
With the Guardian Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the negotiated rate or
visit a non-network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may also obtain services using a
non-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
PPO Plan
Network Name DentalGuard Preferred Non-Network*
DENTAL BENEFITS
Calendar Year Maximum Benefit $1,500
Annual Deductible
• Individual $50
• Family 3x Individual
Preventive Services (You Pay) No Charge No Charge
Basic Services (You Pay) Deductible, 10% Deductible, 20%
Major Services (You Pay) Deductible, 40% Deductible, 50%
Orthodontia
• Covered Family Members Adult & Children
• Coinsurance (You Pay) 50%
• Lifetime Maximum Benefit $1,500

*If you choose to see a non-network dentist, you’ll be reimbursed based on Usual and Customary (UCR) charges at the 90th percentile. You
would be responsible for any amounts over the UCR as well as any coinsurance.

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 $350 to your
MRA. As an added advantage, up to $500 additional dollars will be added to your account for future years if only in-network providers are used
during the benefit year. Your MRA limit is $1,250.

Finding a Dental Provider

Call (800) 541-7846 or go to www.guardiananytime.com. From the Guardian website, select “Employees”, “Dental
Insurance” and “Find a Dentist or Vision Provider.” Next, select “Find a Dentist” then “PPO” under the “Select Your
Dental Plan” drop-down menu. Refer to the “DentalGuard Preferred” network when prompted.

Take advantage of the tools and resources available on www.guardiananytime.com. Once you register you will have
access to, manage your claims, find providers, and more.

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