Guardian Family Advantage PPO Benefits
In-Network Out-of-Network
Deductibles
What you pay out-of-pocket before the plan pays benefits
You Pay
Individual $50 $50
Waived for Preventive Care Yes Yes
Out of Pocket Maximum – Applies to members under 19 only
Once this amount is reached, Guardian will pay 100% of your child’s dental charges for the rest of the year
Individual (One Child) $350 n/a
Family (2+ Children) $700 n/a
Plan Maximum
The maximum amount that you can be reimbursed for services received
Annual Maximum
Applies to members 19 and over*
$1,500 $1,500
Co-Insurance
The amount Guardian pays toward the cost of a covered charge.
Guardian Pays
Preventive Services
Most routine dental services, including: oral exams, cleanings, x-rays
100% 80%
Basic Services
Moderately complex dental services, including fillings, and simple extractions
80% 60%
Major Services
More complex dental services including: crowns, complex extractions, oral
surgery, periodontal and endodontic services
50% 40%
Medically Necessary Orthodontia
Applies to members under age 19 only
50% 30%
Waiting Periods
The initial time period following enrollment for which no benefits would be paid
Major Services
Applies to member 19 and older
12 months 12 months
Medically Necessary Orthodontia None None
Maximum Rollover – Applies to members 19 and over
This allows you to rollover a part of your annual maximum for future use
Threshold: Maximum dollar amount of claims that can be paid for you to
be eligible
Rollover Amount: Amount you can rollover this year
In-Network only Rollover: : Rollover more if you see a network dentist
Account Limit
$700
$350
$500
$1,250
*Annual maximums may apply to children under 19 for services that are not included in the pediatric essential
health benefit
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Find a dentist at
www.GuardianAnytime.com
Guardian’s Family Advantage Dental PPO Plan
With Guardian's PPO option, you can see any dentist you want but save more when you visit a dentist that participates in Guardian’s
DentalGuard Preferred network. As one of the largest nationwide networks on and off the health insurance marketplace, chances are your
dentist is already a participant. Charges for services provided by participating dentists are based on negotiated, discounted fee schedules,
and are reimbursed directly from Guardian. If you choose to see a dentist outside of the network, you'll be reimbursed by 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 any amounts over the maximum allowable charge as well as any co-insurance.
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered
service marks of The Guardian Life Insurance Company of America and are used with express permission.
GuardianAnytime.com
GUARDIAN DENTAL COVERAGE
ON THE HEALTH INSURANCE EXCHANGE FOR RHODE ISLAND
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The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered
service marks of The Guardian Life Insurance Company of America and are used with express permission.
GuardianAnytime.com
GUARDIAN DENTAL COVERAGE
ON THE HEALTH INSURANCE EXCHANGE FOR RHODE ISLAND
Find a dentist at
www.GuardianAnytime.com
Get the “Maximum” from your PPO dental benefits
A solution to reducing costs and allowing employees to get more out of their dental funds.
Guardian will roll over a portion of your unused annual dental maximum into a personal Maximum Rollover Account,
which can be used in future years if you reach your plan’s annual maximum. As an added advantage, more money is
rolled over if in-network dentists are used exclusively during the benefit year.
How Maximum Rollover Works
Depending on the plan’s annual maximum, if claims dollars for the year don’t exceed a certain threshold, the set
Maximum Rollover Amount (pre-determined based on the annual maximum) can be rolled over.
Plan Annual
Maximum*
Threshold
Maximum
Rollover Amount
In-Network Only
Rollover Amount
Maximum
Rollover Account
Limit
$1,500 $700 $350 $500 $1,250
Maximum Claims
Reimbursement
Claims amount that
determines rollover
eligibility
Additional dollars
added to Plan
Annual Maximum
for future years
Additional dollars
added to Plan
Annual Maximum
for future years if
only in-network
providers were used
during the benefit
year
Maximum Rollover
Account cannot
exceed $1,250
$1,500 $1,500 $1,500 $1,500
$350 $700
$100
+ $350
+ $350
- $600
Annual Max
Rollover Balance
Here’s how the benefits work (Sample Plan)
YEAR ONE: Jane starts with a $1,500 Plan Annual Maximum.
She submits $150 in dental claims. Since she did not exceed
the $700 Threshold, she receives a $350 rollover that will be
applied to Year Two.
YEAR TWO: Jane now has an increased Plan Annual
Maximum of $1,850. This year, she submits $500 in claims and
receives an additional $350 rollover added to her Plan Annual
Maximum.
YEAR THREE: Jane now has an increased Plan Annual
Maximum of $2,200. This year, she submits $2,100 in claims. All
claims are paid due to the Maximum Rollover Amount
accumulated.
YEAR FOUR: Jane’s Plan Annual Maximum is $1,600
($1,500 Plan Annual Maximum + $100 remaining Maximum
Rollover Amount accumulated)
Limitations and Exclusions for Guardian PPO Plans
Coverage is limited to charges that are necessary to prevent, diagnose or treat dental disease, defect or injury.
Depending on plan type, deductibles, waiting periods, per service frequency limitations, and payment limits may apply.
The list of dental services illustrated and limitations and exclusions listed below are not exhaustive. Please refer to a
certificate of coverage for full plan description and the list of covered dental services.
• This plan does not pay for:
• Any restoration procedure, appliance or dental prosthesis used solely to: a) alter vertical dimension; b) restore or
maintain occlusion, except to the extent that this plan covers orthodontic treatment; c) splint or stabilize teeth for
periodontal reasons; or d) treat a condition caused by abrasion or attrition.
• Cosmetic or experimental treatments, unless specifically listed in your benefit details, are not covered.
• Replacing a lost, stolen or missing appliance or prosthetic device; or making a spare appliance or device.
• Treatment needed due to: a) an on-the-job or job-related injury; or b) a condition for which benefits are payable
by Workers' Compensation or similar laws.
• Replacing an appliance or prosthetic device with a like appliance or device, unless: a) it is damaged while in the
covered person's mouth in an injury suffered while insured, and can't be fixed; or b) can't be made usable and
meets the replacement age criteria selected by the employer.
• Treatment of congenital or developmental malformations, or the replacement of congenitally missing teeth.
• Evaluations and consultations for non-covered services; detailed and extensive oral evaluations.
• Any procedure performed in conjunction with, as part of, or related to a non-covered procedure.
Guardian Dental is underwritten by The Guardian Life Insurance Company of America, New York, NY.
Policy limitations and exclusions apply. Plan documents are the final arbiter of coverage. Dental policy form #GP-1-DG2000 et
al.
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered
service marks of The Guardian Life Insurance Company of America and are used with express permission.
GuardianAnytime.com
Page 3 of 3
File # 2014-11287 Exp 9/16
GUARDIAN DENTAL COVERAGE
ON THE HEALTH INSURANCE EXCHANGE FOR RHODE ISLAND
Find a dentist at
www.GuardianAnytime.com
