Guardian’s Family Essentials Dental PPO Plan

With Guardian’s PPO option, you can see any dentist you want but save more when you visit a dentist that participates in Guardian’s DentalGuard Preferred network. As one of the largest nationwide networks on and off the health insurance marketplace, chances are your dentist is already a participant. Charges for services provided by participating dentists are based on negotiated, discounted fee schedules, and are reimbursed directly from Guardian. If you choose to see a dentist outside of the network, you’ll be reimbursed based on the lower of your dentist’s fees, or the maximum allowable charge, which is the amount that would be paid to dentists who have agreed to be reimbursed according to a negotiated fee schedule . You would be responsible for any amounts over the maximum allowable charge as well as any co-insurance.

Guardian Family Essentials PPO Benefits – 2016 Plan Year
In-Network Out-of-Network
Deductibles
What you pay out-of-pocket before the plan pays benefits
You Pay
Individual $75 $150
Waived for Preventive Care No No
Out of Pocket Maximum – Applies to members under 19 only
Once this amount is reached, Guardian will pay 100% of your child’s dental charges for the rest of the year
Individual (One Child) $350 n/a
Family (2+ Children) $700 n/a
Plan Maximum
The maximum amount that you can be reimbursed for services received
Annual Maximum
Applies to members 19 and over*
$1,000 $1,000
Co-Insurance
The amount Guardian pays toward the cost of a covered charge
Guardian Pays
Preventive Services
Most routine dental services, including:
oral exams, cleanings, x-rays
100% 100%
Basic Services
Moderately complex dental services,
including fillings, and simple extractions
50% 50%
Major Services
More complex dental services including:
crowns, complex extractions, oral surgery,
periodontal and endodontic services
50% 50%
Medically Necessary Orthodontia
Applies to members under age 19 only
50% 50%
Waiting Periods
The initial time period following enrollment for which no benefits would be paid
Basic Services
Applies to member 19 and older
6 months 6 months
Major Services
Applies to member 19 and older
12 months 12 months
Medically Necessary Orthodontia 24 month 24 month
*Annual maximums may apply to children under 19 for services that are not included in the pediatric essential health benefit

Limitations and Exclusions for Guardian PPO Plans

Coverage is limited to charges that are necessary to prevent, diagnose or treat dental disease, defect or injury. Depending on plan type, deductibles, waiting periods, per service frequency limitations, and payment limits may apply.

The list of dental services illustrated are not exhaustive. Please refer to a certificate of coverage for full plan description, the list of covered dental services and plan exclusions and limitations (noted below).

This plan does not pay for:

  • Treatment for which no charge is made. This usually means treatment furnished by: (1) the Covered Person’s employer, labor union or similar group, in its dental or medical department or clinic; (2) a facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for or sponsored by any governmental body.
  • Treatment needed due to: (1) an on-the-job or job-related Injury; or (2) a condition for which benefits are payable by Worker’s Compensation or similar laws.
  • Any procedure or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature.
  • Any procedure performed in conjunction with, as part of, or related to a procedure which is not covered by this Plan.
  • Any service furnished solely for cosmetic reasons, unless this Plan provides benefits for a specific cosmetic services. Excluded cosmetic services include but are not limited to: (1) characterization and personalization of a Dental Prosthesis; and (2) odontoplasty.
  • Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation; that is incidental to or results from a medical condition.
  • Replacing an existing Appliance or Dental Prosthesis with a like or unlike Appliance or Dental Prosthesis unless: (1) it is at least 60 months old and is no longer usable; or (2) it is damaged while in the Covered Person’s mouth in an Injury suffered while covered, and cannot be made serviceable.
  • Any procedure, Appliance, Dental Prosthesis, modality or surgical procedure intended to treat or diagnose disturbances of the temporomandibular joint (TMJ) that are incidental to or result from a medical condition.
  • Educational services, including, but not limited to: (1) oral hygiene instruction; (2) plaque control; (3) tobacco counseling; or (4) diet instruction.
  • Duplication of radiographs, the completion of claim forms, OSHA or other infection control charges.
  • Any restoration, procedure, Appliance or prosthetic device used solely to: (1) alter vertical dimension; (2) restore or maintain occlusion; (3) treat a condition necessitated by attrition or abrasion; or (4) splint or stabilize teeth for periodontal reasons.
  • Bite registration or bite analysis.
  • Precision attachments and the replacement of part of a: (1) precision attachment; or (2) magnetic retention or overdenture attachment.
  • Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis.
  • The replacement of extracted or missing third molars/wisdom teeth.
  • Overdentures and related services, including root canal therapy on teeth supporting an overdenture.

Limitations and Exclusions for Guardian PPO Plans

  • A fixed bridge replacing the extracted portion of a hemisected tooth or the placement of more than one unit of crown and/or bridge per tooth.
  • Any endodontic, periodontal, crown or bridge abutment procedure or Appliance performed for a tooth or teeth with a guarded, questionable or poor prognosis.
  • Temporary or provisional Dental Prosthesis or Appliances except interim partial dentures/stayplates to replace Anterior Teeth extracted while covered under this Plan.
  • The use of local anesthetic.
  • Cephalometric radiographs, oral/facial images, including traditional photographs and images obtained by intraoral camera
  • Orthodontic Treatment, unless the benefit provision provides specific benefits for Orthodontic Treatment.
  • Prescription medication.
  • Desensitizing medicaments and desensitizing resins for cervical and/or root surface.
  • Pulp vitality tests or caries susceptibility tests.
  • The localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue.
  • Tooth transplants.
  • Evaluations and consultations for non-covered services, or detailed and extensive oral evaluations.
  • Any service or procedure associated with the placement, prosthodontic restoration or maintenance of a dental implant and any incremental charges to other covered services as a result of the presence of a dental implant.
  • Treatment of congenital or developmental malformations, or the replacement of congenitally missing teeth.

Guardian Dental is underwritten by The Guardian Life Insurance Company of America, New York, NY.

Policy limitations and exclusions apply. Plan documents are the final arbiter of coverage.

Plans are not available in the following counties: Allegany, Broome, Cayuga, Chautauqua, Chenango, Clinton, Cortland, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Ontario, Orleans, Oswego, Otsego, Saint Lawrence, Schoharie, Schuyler, Seneca, Steuben, Tioga, Tompkins, Washington, Wayne, Wyoming, Yates

Learn More About Guardian

Guardian has been a trusted name in insurance for over 155 years. Today, we have one of the largest dental insurance networks in the country and our dentists can help you with significant savings on the dental care you need* Learn More About Guardian

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