Guardian Dental
Customer Service: 800-541-7846
Guardian DentalGuard
Plan Number: G-00473089
Benefit Year - January 1 through December 31
http://www.guardiananytime.com/
Benefit Summary
Certificate of Plan Benefits
Summary of Dental Plan Benefits
With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Out-of-network benefits are limited to our PPO fee schedule.
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Delta Guard Preferred PPO Dentist
|
Non-PPO Dentist |
| Covered Services |
Plan Pays |
You Pay |
Plan Pays |
You Pay |
| Preventative |
|
|
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| Cleaning (prophylaxis) 2 in 12 months, Oral Exams, Xrays |
100% |
0% |
100% |
0% |
| Fluoride Treatments (Under age 19), Sealants (per tooth) |
100% |
0% |
100% |
0% |
| Radiographs - X-rays |
100% |
0% |
100% |
0% |
| Basic Care |
|
|
|
|
| Anesthesia* |
80% |
20% |
50% |
50% |
| Filings** |
80% |
20% |
50% |
50% |
| Perio Surgery |
80% |
20% |
50% |
50% |
| Perio Maintenance Frequency (Once every 3 months) enhanced |
80% |
20% |
50% |
50% |
| Repair & Maintenance of Crowns, Bridges & Dentures, Root Canal |
80% |
20% |
50% |
50% |
| Scaling & Root Planing, Simple Extractions, Surgical Extractions |
80% |
20% |
50% |
50% |
| Major Care |
|
|
|
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| Bridges, Dentures, Dental Implants, Inlays, Onlays, Single Crowns, Veneers*** |
60% |
40% |
50% |
50% |
| Orthodontia |
|
|
|
|
| Orthodontic Services (to age 19) - Used to correct malposed teeth (for example, braces) |
50% |
50% |
50% |
50% |
- This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. ***Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury and only when the tooth cannot be restored with amalgam or composite filling material. The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia - restrictions apply. **Fillings - restrictions may apply to composite fillings.
Maximum Payment - $1,000 per person total per benefit year.
Deductible - None.
Waiting Period - Employees who are eligible for dental benefits are covered on the first day of employment.