Page 14 - SC Fuels Benefit Guide 2018 TEXAS

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. 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 23 for Guardian
Resources and Contacts).

Guardian
PPO
Network Name PPO Network Non-Network
DENTAL BENEFITS
Calendar Year Maximum Benefit $1,500
Calendar Year Deductible Deductible Waived for Preventive Services
• Individual $50
• Family $150
Preventive Services
• X-Rays/Exams/Cleanings No Charge No Charge UCR
Basic Services
• Restorative/Oral Surgery Ded, 20% Ded, 20% UCR
• Endodontics/Periodontics Ded, 20% Ded, 20% UCR
• Composite Fillings (Posterior) Ded, 20% Ded, 20% UCR
Major Services
• Crowns/Bridges/Implants Ded, 50% Ded, 50% UCR
Orthodontia
• Children / Adults 50% with $1,500 Lifetime Maximum Benefit
Employee Rate Per Paycheck
• Employee Only $9.00
• Employee + 1 $29.00
• Employee + 2 or More $54.25

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.

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.

FINDING A DENTAL PROVIDER:
• Visit www.guardiananytime.com. Click Find a Provider and select the PPO Dental Plan.

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