Schedule of Covered Services and Copayments
With Guardian Advantage Gold PPO Plan:
- You have access to over 114,000 dentists.
- Get most services, including: oral exams cleanings and x-rays covered at 100%.
- You can see any dentist you want, but save up to 35% when you visit a dentist that participates in Guardian’s network.
- Can choose to see a dentist outside of the network, where 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 the deductible and any amounts over the maximum allowable charge as well as any co-insurance.
Dentists who are contracted in Guardian’s network have agreed to accept a discount for the Covered Services they perform. When You visit one of these Dentists, the discount will lower Your out-of-pocket costs. When You visit a Non-Contracted dentist, Your reimbursement will be based on Guardian’s fee schedule for Your specific Policy or on the 70th percentile of the prevailing fee data for the Dentist’s zip code.
The matrix below provides a very brief description of some important features of the Individual Plan and is intended to be used as a summary only. The Individual Plan/Policy or Contract should be consulted for a detailed and complete description of program benefits, limitations and exclusions. Please click here for complete benefit information.
Please click here for complete benefit information.
|PPO Plan Benefits|
|Out of Network
|Class I - Preventive (no waiting period)|
Most Routine dental services, including: oral exams, cleanings, x-rays, fluoride treatments for covered persons under 19, fillings and space maintainers to covered persons under 16.
|Class II - Basic (6 month waiting period, 30 day waiting period in Pennsylvania)|
Moderately complex dental services, including diagnostic services, fillings, and simple nonsurgical extractions.
|Class III - Major (12 month waiting period)|
|More complex dental services including: crowns, surgical extractions, oral surgery, periodontal, prosthodontic, endodontic services, and implant services.||50%||50%|
|Orthodontic Services (12 month waiting period)
For covered dependent children under age 19 years old when the active orthodontic appliance is first placed.
|Benefit Year Deductible per person
(Denductible is Waived for Preventive Services in Network Only)
|Benefit Year Maximum (Graded)
Note: Benefit Year Maximum increases every 12 months for 3 years, one preventive visit required per year per member.
|1st Year Max: $1,000
2nd Year Max: $1,250
3rd Year Max: $1,500
|Benefit Year Maximum for Orthodontics||$500|
|Lifetime Maximum for Orthodontics||$1,000|
|Lifetime Maximum for Implants||$1,000|