Page 14 - Ria Benefits Guide 2020 FINAL Mid-Atlantic

Guardian Dental Plan Choices

Guardian Guardian
Plan Name DPPO - 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% / $1,000 Lifetime Benefit Maximum
- Adult 50% / $1,000 Lifetime Benefit Maximum 50% / $1,000 Lifetime Benefit Maximum

Employee contribution per
pay date DPPO—Low Option DPPO—High Option
- Employee $15.38 $21.96
- Employee + spouse $31.14 $42.86
- Employee + child(ren) $30.27 $41.99
- Employee + family $59.57 $70.33

14 RIA EMPLOYEE BENEFITS 2020