Dental

You have the option to select between two dental plans.

For More Information
Call 1.800.541.7846 or visit www.guardianlife.com

You will have the ability to seek care from providers inside or outside the Dental Guard Preferred network.
Out-of-pocket costs are likely to be less when you choose an in-network dentist, as non-network providers can balance bill for their services
Coverage is available at 100% for Preventive and Basic Services, Major Services are covered at 60% and Orthodontia is covered at 50%
Orthodontia is now covered for children and adults
There is no waiting period in between preventive care services. You have the ability to obtain 2 cleanings in a calendar year without the six month wait in between care

	In-Network	Out-of-Network
Individual Deductible	$25	$50
Family Deductible	$75	$150
Deductible Waived for Preventitive	Yes	Yes
Annual Maximum Benefit	$1,500	$1,500
Orthodontia Lifetime Maximum	$1,500	$1,500
Type A: Preventive Care	100%	100%
Type B: Basic Care	100%	80%
Type C: Major Care	60%	50%
Orthodontia	50%	50%
Orthodontia Coverage	Adult and Children	Adult and Children

For those seeking a lower per pay contribution
You must seek care from a dentist in the DHMO network
Services within the plan have a set copay
There is no annual maximum on the number or types of services allowed
Services not covered when care received from an Out-of-network provider
Unavailable for employees in Columbus, Cincinnati, Toledo or Southern Ohio
Orthodontia is now covered for children and adults
There is no waiting period in between preventive care services. You have the ability to obtain 2 cleanings in a calendar year without the six month wait in between care

Service	In-Network
Clinical Oral Evaluation – Periodic oral evaluation	$0
Clinical Oral Evaluation – Comprehensive oral evaluation	$0
Prophylaxis – Adult/Child	$0
Topical Fluoride – Topical application (w/o prophy) – child	$0
Sealant Per Tooth Molars	$8
Amalgam Restorations – one surface, primary/permanent	$12
Amalgam Restorations – two surfaces, primary/permanent	$14
Amalgam Restorations – three surfaces, primary/ permanent	$17
Amalgam Restorations – four +surfaces, primary/permanent	$375
Crowns – Porcelain fused to predominantly base metal	$375
Crowns – Porcelain fused to noble metal	$120
Root Canal Therapy – Anterior (excluding final restoration)	$140
Root Canal Therapy – Bicuspid (excluding final restoration)	$180
Root Canal Therapy – Molar (excluding final restoration)	$240
Apicoectomy/Periradicular Surgery – Anterior	$125
Gingivectomy – 4+ Teeth/Quad	$50
Non-Surgical Periodontal – Scaling/root planing – four +	$27
Non-Surgical Periodontal – Periodontal maintenance	$452
Complete Dentures – Complete denture – upper	$452
Complete Dentures – Complete denture – lower	$500
Partial Dentures – Upper w/ metal base, resin saddles, etc.	$12
Extraction, coronal remnants – deciduous tooth	$15
Extractions – Erupted tooth or exposed root	$40
Surgical Extractions – extraction of tooth; erupted	$1,895 / $2,195
Orthodontia -Treatment (Child/Adult)	Orthodontia -Treatment (Child/Adult)