GUARDIAN® is a registered trademark of The Guardian Life Insurance Company of America
UNIVERSITY OFVIRGINIA PHYSICIANSGROUP
ALL ELIGIBLE EMPLOYEES
Group
number:
00035294
Your dental coverage
Option 1 or 2: CORE PLAN or BUYUP PLAN plan, you can visit any dentist; but you pay less out-of-pocket when you choose
a PPO dentist. Out-of-network benefits are based on a percentile of the prevailing fee data for the dentist's zip code.
Your Dental Plan Option 1: CORE PLAN Option 2: BUYUP PLAN
Your Network is
DentalGuard Preferred DentalGuard Preferred
Your Bi-weekly premium
$13.34 $19.87
You and Spouse $24.15 $35.96
You and Child(ren) $26.62 $39.65
You, Spouse and Child(ren) $40.63 $60.53
Calendar year deductible
In-Network Out-of-Network In-Network Out-of-Network
Individual $25 $50 $25 $50
Family limit 3 per family 3 per family
Waived for Preventive Preventive Preventive Preventive
Charges covered for you (co-insurance)
In-Network Out-of-Network In-Network Out-of-Network
Preventive Care 100% 100% 100% 100%
Basic Care 100% 80% 100% 80%
Major Care 0% 0% 60% 50%
Orthodontia Not Covered (applies to all levels) 50% 50%
Annual Maximum Benefit
$1000 $1500
Maximum Rollover
No Yes
Rollover Threshold $700
Rollover Amount $350
Rollover In-network Amount $500
Rollover Account Limit $1250
Lifetime Orthodontia Maximum
Not Applicable $1000
Dependent Age Limits
26 26
A Sample of Services Covered by Your Plan:
Your dental coverage
GUARDIAN® is a registered trademark of The Guardian Life Insurance Company of America
UNIVERSITY OFVIRGINIA PHYSICIANS GROUP
ALL ELIGIBLE EMPLOYEES
Group
number:
00035294
Option 1: CORE PLAN Option 2: BUYUP PLAN
Plan pays (on average) Plan pays (on average)
In-network Out-of-network In-network Out-of-network
Preventive Care Cleaning (prophylaxis) 100% 100% 100% 100%
Frequency:
Once Every 6 Months
Once Every 6 Months
Fluoride Treatments 100% 100% 100% 100%
Limits: No Age Limits Under Age 19
Oral Exams 100% 100% 100% 100%
Sealants (per tooth) 100% 100% 100% 100%
X-rays 100% 100% 100% 100%
Basic Care Anesthesia* 100% 80% 100% 80%
Fillings
‡ 100% 80% 100% 80%
Perio Surgery 100% 80% 100% 80%
Periodontal Maintenance 100% 80% 100% 80%
Frequency: Once Every 6 Months Once Every 6 Months
Repair & Maintenance of
Crowns, Bridges & Dentures
100% 80% 100% 80%
Root Canal 100% 80% 100% 80%
Scaling & Root Planing (per quadrant) 100% 80% 100% 80%
Simple Extractions 100% 80% 100% 80%
Surgical Extractions 100% 80% 100% 80%
Major Care Bridges and Dentures 0% 0% 60% 50%
Dental Implants Not Covered Not Covered 60% 50%
Inlays, Onlays, Veneers** 0% 0% 60% 50%
Single Crowns 0% 0% 60% 50%
Orthodontia Orthodontia Not Covered 50% 50%
Limits: Adults & Child(ren)
This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnity
members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the tooth
cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must
be placed prior to the age limit set by your plan; If full-time status is required by your plan in order to remain insured after a certain age; then
orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this
limitation does not apply. *General Anesthesia – restrictions apply. ‡For PPO and or Indemnity members, Fillings – restrictions may apply to
composite fillings.
