Page 12 - Ria Benefits Guide 2020 FINAL Texas

Guardian Dental Plan Choices

Guardian
Plan Name DHMO
Network Name In-Network
Dental Benefits
Calendar Year Maximum Benefit Unlimited
Annual Deductible
- Individual $0
- Family $0
Office Visit Copay $0
Preventive Services $0
Cleaning (prophylaxis) & Oral Exams $0
Basic Services $10-$155
Major Services $40-140
Orthodontia $2,500-$2,800

Employee contribution per pay date DHMO
- Employee $7.51
- Employee + spouse $14.71
- Employee + child(ren) $14.99
- Employee + family $22.20

Guardian Guardian
Plan Name DPPO - TX Low Option DPPO - High Option
Network Name In-Network Non-Network In-Network Non-Network
Dental Benefits
Calendar Year Max. Benefit $1,000 $1,000
Annual Deductible
- Individual $50 $100 $50 $50
- Family $150 $300 $150 $150
Office Copay $0 $0 $0 $0
Preventive Services $0 $0 $0 $0

Cleaning (prophylaxis) & Oral $0 $0 $0 $0
Exams
Basic Services Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 20%
(member pays) (member pays) (member pays) (member pays)
Major Services Deductible, 50% Deductible, 75% Deductible, 50% Deductible, 50%
(member pays) (member pays) (member pays) (member pays)
Orthodontia
- Child 50% / $1,000 Lifetime Benefit Maximum 50% / $1000 Lifetime Benefit Maximum
- Adult 50% / $1,000 Lifetime Benefit Maximum 50% / $1,000 Lifetime Benefit Maximum

Employee contribution per
pay date DPPO—TX Low Option DPPO—High Option
- Employee $14.17 $21.96
- Employee + spouse $28.76 $42.86
- Employee + child(ren) $27.92 $41.99
- Employee + family $51.94 $70.33
12 RIA EMPLOYEE BENEFITS 2020