Page 13 - Moonwell Studios Benefit Guide
P. 13

Dental Plan








         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 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.

                                                                                  Guardian
         Plan Name                                                              PPO NAP Plan
         Network Name                                             PPO Network                  Non-Network
         Dental Benefits
         Calendar Year Maximum Benefit                                              $2,000
         Annual Deductible
          - Individual                                                               $50
          - Family                                                                   $150
         Preventive Services                                        No Charge                    No Charge*

         Basic Services                                          Deductible, 20%              Deductible, 20%*
         Major Services                                          Deductible, 50%              Deductible, 50%*
         Orthodontia (12 month waiting period)
          - Child                                                    50% / $2,000 Lifetime Benefit Maximum
          - Adult                                                    50% / $2,000 Lifetime Benefit Maximum
         *Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference between what
         Guardian pays them and what the dentist usually charges. Based on 90th UCR.





         Note:
         We strongly recommend you ask your
         dentist for a predetermination if total
         charges are expected to exceed $300.                  Finding a Dental Provider
         Predetermination enables you and your                 Go to www.guardiananytime.com/fpapp/FPWeb/
         dentist to know in advance what the                   Refer to the PPO Network under Find a Dentist
         payment will be for any service that may
         be in question.





         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 $800 during
         the benefit year, you will be credited $400—$600 to your MRA. As an added advantage, more money will be rolled
         over if you visit an in-network dentist.






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