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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.

 

                                                                 

Delta Guard Preferred PPO Dentist

Non-PPO Dentist                
Covered Services Plan Pays You Pay Plan Pays You Pay
Preventative
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
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.

 

 

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