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Benefit
and Cost Summary
for
Dental (Network Access Plan) has been prepared for the employees of :
SAMPLE
COMPANY
Deductible- $50 individual
Percentage
Paid
Services
Preventive
Services*
100%
Emergency
Palliative Treatment
Oral Examination - every six months
X-Rays - four bitewings every twelve months full mouth series every five years
Teeth Cleaning - every six months
Fluoride Treatments for Children - every six months under age 14
Space Maintainers for Children - under age 16
Topical Sealants for unrestored molar teeth
-one treatment for child(ren) under
16 in a three (3) year period
Basic Services
80%
Laboratory
Test
Diagnostic Consultation - one per year
Fillings & Crowns: Amalgam, Silicate & Acrylic
Root Canal Therapy
Periodontal Services
Oral Surgery - extractions
Repairs of dentures, bridgework, crowns, etc.
General Anesthesia - surgical procedures only
Major Services
50%
Fillings & Crowns: Gold and Porcelain
Bridges Installation - fixed and removable
Dentures - Full and Partial
Inlays
Onlays
Crowns and Posts
Orthodontic
Services
50%
$1,000 Lifetime Maximum for child(ren) under age 19
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There is an $1,000 annual maximum for all Preventive, Basic
and Major services combined.
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Deductible is waived for Preventive services. |
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3 individual deductibles per family.
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· Children are covered up to age 20 or 26 if a full time
student. |
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There are no waiting periods for any services (unless
Employee/Dependents are a Late Entrant1). |
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· All out of network services are based on usual, reasonable,
and customary rates for given area |
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Access to a network access plan - a listing of dentists
contracted with Guardian to provide additional discounts off services and
procedures to Guardian dental plan members. Locate these dentists on the web
at www.glic.com. |
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Dental Claims - P. O. Box 2459, Spokane, WA 99210-2459, ph:
1-800-695-4542, fax: 509-468-4590. |
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Pre-determination Review - Guardian will gladly assist you and
your dentist by determining what benefits could be payable for services and
procedures over $300. Have your
dentist fax your treatment plan to Guardian, note that it is a
pre-determination review and we will let your dentist know what benefits
would be payable. (This
includes orthodontic treatment if your plan includes it) |
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Special Limitation: Teeth
lost or missing before a covered person becomes insured by this plan.
A covered person may have one or more congenitally missing teeth or
have lost one or more teeth before he became insured by this plan.
We won’t pay for a prosthetic device which replaces such teeth
unless the device also replaces one or more natural teeth lost or extracted
after the covered person became insured by this plan.
R3 - DG4
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DentalGuard General Limitations and Exclusions: This policy provides
dental insurance only. Coverage is
limited to those charges that are necessary to prevent, diagnose or treat dental
disease, defect , or injury. Deductibles apply. The
plan does not pay for: oral hygiene services (except as covered under preventive
services), orthodontia (unless expressly provided for), cosmetic or experimental
treatments, any treatments to the extent benefits are payable by any other payor
or for which no charge is made, prosthetic devices unless certain conditions are
met, and services ancillary to surgical treatment,
The plan limits benefits for diagnostic consultations and for preventive,
restorative, endodontic, periodontic, and prosthodontic services.
The services, exclusions and limitations listed above do not constitute a
contract and are a summary only. The
Guardian plan documents are the final arbiter of coverage.
Contract #
GP-1-DNTL-90-1 et al.
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