GUARDIAN_Enrollment_Kit_for_Pickens_County_Board_of

Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/31/2017

Group Number: 00542688

About Your Benefits:

Taking care of your teeth can be expensive. That’s why the right dental insurance is so important — it not only pays for preventive

care that can keep you and your family healthy, but it also helps pay for more extensive, costly and often unexpected expenses —

such as fillings, crowns and root canals. Plus, you save money and have the assurance that you are getting the right care when you use

one of our contracted dentists. Guardian been providing outstanding dental plans to millions of Americans for more than 50 years.

When you enroll with Guardian, you have access to one of the nation’s largest dental networks offering significant discounts so you

know there’s always high-quality, affordable dental care close by. From preventive checkups and cleanings, to comprehensive oral

care treatments, we have you covered.

With your Guardian Choice plan, employees select either a Network Access Plan (NAP) or a Value Plan and can change their

election annually. Premium rates are the same for both plans. The Value Plan offers members who choose to see a Guardian

participating dentist the most savings and Out-of-Network benefits are limited to our PPO fee schedule.

Pickens County Board of Education All Eligible Employees Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

Dental Benefit Summary

Pickens County Board of Education

Your Dental Plan PPO

Your Network is

DentalGuard Preferred

Calendar year deductible

Value Plan NAP Plan

In / Out-Net In / Out-Net

Individual $50 $50

Family limit 3 per family

Waived for Preventive Preventive

Charges covered for you (co-insurance)

Value Plan NAP Plan

In / Out-Net In / Out-Net

Preventive Care 100% 100%

Basic Care 100% 80%

Major Care 60% 50%

Orthodontia 50% 50%

Annual Maximum Benefit

$1000

Maximum Rollover

Yes

Rollover Threshold $500

Rollover Amount $250

Rollover Account Limit $1000

Lifetime Orthodontia Maximum

$1000

Dependent Age Limits

A Sample of Services Covered by Your Plan:

Pickens County Board of Education All Eligible Employees Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

PPO

Plan pays (on average)

Value Plan NAP Plan

In / Out-Net In / Out-Net

Preventive Care Cleaning (prophylaxis) 100% 100%

Frequency:

Once Every 6 Months

Fluoride Treatments 100% 100%

Limits: Under Age 14

Oral Exams 100% 100%

X-rays 100% 100%

Basic Care Anesthesia* 100% 80%

Fillings

‡ 100% 80%

Periodontal Maintenance 100% 80%

Frequency: Once Every 6 Months

(Standard)

Scaling & Root Planing (per quadrant) 100% 80%

Simple Extractions 100% 80%

Major Care Bridges and Dentures 60% 50%

Dental Implants 60% 50%

Inlays, Onlays, Veneers** 60% 50%

Perio Surgery 60% 50%

Repair & Maintenance of

Crowns, Bridges & Dentures

60% 50%

Root Canal 60% 50%

Single Crowns 60% 50%

Surgical Extractions 60% 50%

Orthodontia Orthodontia 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. 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.

Need Assistance?

Call the Guardian Helpline (888) 600-1600, weekdays,

8:00 AM to 8:30 PM, EST. Refer to your member ID (social

security number) and your plan number: 00542688

Please call the Guardian Helpline if you need to use

your benefits within 30 days of plan effective date.

Please note, self-serve options over the phone or

online at Guardian Anytime are not available until the

case is fully implemented, please wait to speak to a

live agent when calling the Guardian Helpline.

Pickens County Board of Education All Eligible Employees Benefit Summary

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

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

Guardian Choice – Additional Details

You have the flexibility to choose the plan that can best meet your needs.

Both plans can meet your needs; the difference is how out-of-network benefits are reimbursed. If you visit a dentist

in the Guardian network, you will receive the most savings through the Value Plan. If there is a possibility of using

an out-of-network dentist then the Network Access Plan offers the highest out-of-network reimbursement.

Here’s how this benefit works:

• Premiums are the same for either plan

• Option to switch plans each year at annual enrollment time

• Save an average of 30% over what dentists usually charge by using network providers

Value Plan Network Access Plan

Plan Description:

You receive a higher co-insurance level with this

plan than you would if you selected the NAP

plan – which means less out-of-pocket costs. All

benefits are paid based on a fee schedule.

Therefore, when using out-of-network care, the

dentist may charge the difference between the

fee schedule and their regular fee.

You will receive the same reimbursement for in and out-

of-network dentists. Co-insurance percentages for in-

network care are not as high as with the Value Plan. In-

network benefits are based on a negotiated PPO fee

schedule, out-of-network charges are based on local

UCR (usual, customary, reasonable) charges.

Out-of-network:

 Benefits are based on the discounted fee

schedules agreed upon by our network

dentists.

 Any amount that is charged over the fee

schedule is the responsibility of the patient.

 Benefits are based on usual, customary and

reasonable (UCR) charges that dentists in your area

charge for each procedure.

Co-insurance:

 Preventive services are covered 100%.

 Co-insurance for other services is higher than

the Network Access Plan.

 Preventive services are covered 100%.

 Co-insurance for other services is lower than the

Value Plan.

To find a dentist in your network, visit www.GuardianAnytime.com. You can also download our GuardianAnytime

mobile app to use our Find-a-Provider tool.

For Overview of your Dental Benefits, please see About Your Benefit Section of this Enrollment Booklet.

Guardian's Dental Insurance is underwritten and issued by The Guardian Life Insurance Company of America or its subsidiaries, New York, NY. Products are not available

in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage." Policy

Form #GP-1-DG2000, et al.

Dental Maximum Rollover



Save Your Unused Claims Dollars For When You Need Them Most

Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account

(MRA). If you reach your Plan Annual Maximum in future years, you can use money from your MRA. To qualify for an

MRA, you must have a paid claim (not just a visit) and must not have exceeded the paid claims threshold during the

benefit year. Your MRA may not exceed the MRA limit. You can view your annual MRA statement detailing your

account and those of your dependents on www.GuardianAnytime.com.

Please note that actual maximum limitations and thresholds vary by plan. Your plan may vary from the one used below

as an example to illustrate how the Maximum Rollover functions.

Plan Annual Maximum* Threshold Maximum Rollover Amount

Maximum Rollover Account

Limit

$1000 $500 $250 $1000

Maximum claims reimbursement

Claims amount that determines

rollover eligibility

Additional dollars added to Plan

Annual Maximum for future years

Plan Annual Maximum plus

Maximum Rollover cannot exceed

$2,000 in total

* If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines the Maximum

Rollover plan.

Here’s how the benefits work:

YEAR ONE: Jane starts with a $1,000 Plan Annual Maximum. She

submits $150 in dental claims. Since she did not reach the $500

Threshold, she receives a $250 rollover that will be applied to Year

Two.

YEAR TWO: Jane now has an increased Plan Annual Maximum of

$1,250. This year, she submits $50 in claims and receives an

additional $250 rollover added to her Plan Annual Maximum.

YEAR THREE: Jane now has an increased Plan Annual Maximum of

$1,500. This year, she submits $1,200 in claims. All claims are paid

due to the amount accumulated in her Maximum Rollover Account.

YEAR FOUR: Jane’s Plan Annual Maximum is $1,300 ($1,000 Plan

Annual Maximum + $300 remaining in her Maximum Rollover

Account).

For Overview of your Dental Benefits, please see About Your Benefit Section of this Enrollment Booklet.

NOTES:

You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit.

Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effective date in October, November

or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of 2013, the claim activity in 2014 will be used and

applied to MRAs for use in 2015.

Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefit year, will not begin until

the start of the next full benefit year. Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts

when coverage of Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year. (Actual eligibility timeframe may vary. See your

Plan Details for the most accurate information.)

Guardian's Dental Insurance is underwritten and issued by The Guardian Life Insurance Company of America or its subsidiaries, New York, NY. Products are not available in all

states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage.

Policy Form #GP-1-DG2000, et al.