Page 10 - Casting Network Benefits Guide 2020

Dental Vision

PPO Plan Guardian VSP Vision Plan
This plan offers you the freedom and flexibility to use the dentist of your You can see a VSP Choice in-network provider or an out-of-network
choice. However, you will maximize your benefits and reduce your provider, however, your costs will be lower if you visit an in-network
out-of-pocket costs if you choose a dentist who participates in the PPO provider. If you visit an in-network provider you will be responsible for a
network. When you utilize a PPO dentist, your out-of-pocket expenses copayment at the time of your service. If you receive services from an
will be less. If you obtain services using a non-network dentist, you will out-of-network provider, you’ll pay all costs at the time of service and
be responsible for the difference between the covered amount and submit a claim for reimbursement.
the actual charges and you may be responsible for filing claims. The
chart below provides a high-level overview of your dental plan. LASIK is not covered, however you may receive additional discounts.

PLAN NAME GUARDIAN PPO PLAN NAME GUARDIAN PPO (VSP NETWORK)
NETWORK NAME PPO NON-NETWORK NETWORK NAME VSP CHOICE NETWORK NON-NETWORK

Deductible (per calendar year) Exam

Individual / Family $50 / $150 Once Every 12 Months $10 Copay Up to $39
Benefit Maximum (per calendar year; Preventive, Basic Lenses
and Major Services combined) Once every 12 months
Per Individual $2,000 Single Vision $25 Copay Up to $23

Covered Services Bifocal $25 Copay Up to $37
100% Trifocal $25 Copay Up to $49
Preventive Services 100%
Deductible Waived
Frames
Basic Services 90% 80%
Once every 12 months $150 Allowance Up to $46
Major Services 60% 50%
Contact Lenses (in lieu of glasses)
Orthodontia 50%
(Child/Adult) $1,500 Once every 12 months $150 Allowance Up to $100

FINDING A DENTAL PROVIDER FINDING A VISION PROVIDER
www.guardiananytime.com Network Name: DentalGuard Preferred www.vsp.com Network Name: VSP Choice

10 Dental & Vision Plans