Page 13 - Moonwell Studios Benefit Guide
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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.
Employee Benefits 13