Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/12/2016
Group Number: 00460054
About Your Benefits:
A visit to your dentist can help you keep a great smile and prevent many health issues. But dental care can be costly and you can be
faced with unforeseen expenses. Did you know, a crown can cost as much as $1,400
1
? Guardian dental insurance will help you pay
for it. With access to one of the largest network of dental providers in the country, who agreed to charge negotiated fees for their
services of up to 30% less than average charges in the same community, you will benefit from lower out-of-pocket costs, quality care
from screened and reviewed dentist, no claim forms to file, and excellent customer service. Enroll today and smile next time you see
your dentist!
1
http://health.costhelper.com/dental-crown.html.
With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist.
LIGON INDUSTRIES LLC Benefit Summary
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
Dental Benefit Summary
LIGON INDUSTRIES LLC
Your Dental Plan PPO
Your Network is
DentalGuard Preferred
Your Monthly premium
$27.32
You and spouse/domestic partner $54.78
You and child(ren) $71.19
You, spouse/domestic partner and child(ren) $98.64
Calendar year deductible
In-Network Out-of-Network
Individual $50 $50
Family limit 3 per family
Waived for Preventive None
Charges covered for you (co-insurance)
In-Network Out-of-Network
Preventive Care 100% 100%
Basic Care 90% 80%
Major Care 60% 50%
Orthodontia 50% 50%
Annual Maximum Benefit
$1500 $1500
Maximum Rollover
Yes
Rollover Threshold $700
Rollover Amount $350
Rollover In-network Amount $500
Rollover Account Limit $1250
Lifetime Orthodontia Maximum
$1000
Dependent Age Limits
26
3
A Sample of Services Covered by Your Plan:
LIGON INDUSTRIES LLC Benefit Summary
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
PPO
Plan pays (on average)
In-network Out-of-network
Preventive Care Cleaning (prophylaxis) 100% 100%
Frequency:
Once Every 6 Months
Fluoride Treatments 100% 100%
Limits: Under Age 19
Oral Exams 100% 100%
Sealants (per tooth) 100% 100%
X-rays 100% 100%
Basic Care Anesthesia* 90% 80%
Fillings
‡ 90% 80%
Perio Surgery 90% 80%
Periodontal Maintenance 90% 80%
Frequency: Once Every 6 Months
(Standard)
Repair & Maintenance of
Crowns, Bridges & Dentures
90% 80%
Root Canal 90% 80%
Scaling & Root Planing (per quadrant) 90% 80%
Simple Extractions 90% 80%
Surgical Extractions 90% 80%
Major Care Bridges and Dentures 60% 50%
Inlays, Onlays, Veneers** 60% 50%
Single Crowns 60% 50%
Orthodontia Orthodontia 50% 50%
Limits: 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. The total number of cleanings and
periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia – restrictions apply. ‡For PPO and or
Indemnity members, Fillings – restrictions may apply to composite fillings.
This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist,
your paycheck stub prevails.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure information
about your Guardian benefits including access to an image of your
ID Card. Your on-line account will be set up within 30 days after
your plan effective date..
Find A Dentist:
Visit www.GuardianAnytime.com
Click on “Find A Provider”; You will need to know your plan,
which can be found on the first page of your dental benefit
summary.
EXCLUSIONS AND LIMITATIONS
n Important Information about Guardian’s DentalGuard Indemnity and
DentalGuard Preferred Network PPO plans: 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 (unless they are expressly provided for), 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-DG2000 et al.
n PPO and or Indemnity 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-DG2000
4
About Your Benefits:
Eye care is a vital component of a healthy lifestyle. With vision insurance, having regular exams and purchasing contacts or glasses is
simple and affordable. The coverage is inexpensive, yet the benefits can be significant! Guardian provides rich, flexible plans that
allow you to safeguard your health while saving you money. Review your plan options and see why vision insurance may be a great
benefit for you.
Vision Benefit Summary
Visit any doctor with your Full Feature plan, but save by visiting any of the 50,000+ locations in the nation's largest vision
network.
Group Number: 00460054
LIGON INDUSTRIES LLC Benefit Summary
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
LIGON INDUSTRIES LLC
Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/12/2016
Your Vision Plan
Full Feature
Your Network is VSP Network Signature Plan
Your Monthly premium $ 10.72
You and spouse/domestic partner $ 18.04
You and child(ren) $ 18.40
You, spouse/domestic partner and child(ren) $ 29.12
Copay
Exams Copay $ 10
Materials Copay (waived for elective contact lenses) $ 25
Sample of Covered Services You pay (after copay if applicable):
In-network Out-of-network
Eye Exams $0 Amount over $46
Single Vision Lenses $0 Amount over $47
Lined Bifocal Lenses $0 Amount over $66
Lined Trifocal Lenses $0 Amount over $85
Lenticular Lenses $0 Amount over $125
Frames 80% of amount over $120¹ Amount over $47
Contact Lenses (Elective) Amount over $120 Amount over $120
Contact Lenses (Medically Necessary) $0 Amount over $210
Contact Lenses (Evaluation and fitting) 15% off UCR No discounts
Cosmetic Extras Avg. 30% off retail price No discounts
Glasses (Additional pair of frames and lenses) 20% off retail price^ No discounts
Laser Correction Surgery Discount Up to 15% off the usual charge or 5%
off promotional price
No discounts
Service Frequencies
Exams Every 12 months
Lenses (for glasses or contact lenses)‡‡ Every 12 months
Frames Every 24 months
Network discounts (cosmetic extras, glasses and contact lens
professional service)
Limitless within 12 months of exam.
Dependent Age Limits 26
Visit www.GuardianAnytime.com and click on “Find a Provider”
5
LIGON INDUSTRIES LLC Benefit Summary
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004
VSP
•
‡‡Benefit includes coverage for glasses or contact lenses, not both.
•
^ For the discount to apply your purchase must be made within 12 months of the eye exam. In addition Full-Feature plans offer 30% off additional prescription glasses and
nonprescription sunglasses, including lens options, if purchased on the same day as the eye exam from the same VSP doctor who provided the exam.
•
Charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use. The
only exception would be if a member purchases contact lenses from an out of network provider, members can use the balance towards additional contact lenses within
the same benefit period.
•
1
Extra $20 on select brands
This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheck
stub prevails.
Manage Your Benefits:
Go to www.GuardianAnytime.com to access secure
information about your Guardian benefits including access to
an image of your ID Card. Your on-line account will be set up
within 30 days after your plan effective date.
EXCLUSIONS AND LIMITATIONS
Important Information: This policy provides vision care limited benefits health
insurance only. It does not provide basic hospital, basic medical or major
medical insurance as defined by the New York State Insurance Department.
Coverage is limited to those charges that are necessary for a routine vision
examination. Co-pays apply. The plan does not pay for: orthoptics or vision
training and any associated supplemental testing; medical or surgical treatment
of the eye; and eye examination or corrective eyewear required by an
employer as a condition of employment; replacement of lenses and frames
that are furnished under this plan, which are lost or broken (except at normal
intervals when services are otherwise available or a warranty exists). The plan
limits benefits for blended lenses, oversized lenses, photochromic lenses,
tinted lenses, progressive multifocal lenses, coated or laminated lenses, a
frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and
optional cosmetic processes.
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-VSN-96-VIS et al.
Laser Correction Surgery:
On average, 15% off the usual charge or 5% off promotional price for vision
laser surgery. Members’ out-of-pocket costs are limited to $1,800 per eye for
LASIK and $1,500 per eye for PRK.
Laser surgery is not an insured benefit. The surgery is available at a discounted
fee. The covered person must pay the entire discounted fee. In addition, the
laser surgery discount may not be available in all states.
6
