DENTAL INSURANCE
JL Marine Systems offers dental coverage through Guardian. The Dental PPO Plan allows you to use in- network or out-of-network benefits. If out-of-network dentists are used, you will be responsible to pay the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The charts below provides a brief overview of the plan.
DENTAL PPO Option 1
DENTAL PPO Option 2
In-Network
Out-of Network*
In-Network
Out-of Network*
CALENDAR YEAR DEDUCTIBLE Individual
$50
$50
$50
$100 $150
Family
$150
$150
$150
ANNUAL MAXMIUM
$1,000
$1,000
$1,500
$1,500
Diagnostic & Preventive
Exams Cleanings Fluoride X-Rays Sealants
Covered in full
Covered in full
Covered in full
Covered in full
Regular Restorative Services
Amalgam Fillings Extractions - Single Tooth Endodontics (Root Canal) Periodontics (Gum Disease) MAJOR SERVICES Crowns
Covered 80% after deductible
Covered 80% after deductible
Covered 80% after deductible
Covered 80% after deductible
Covered 50% after deductible Covered 25% after deductible
Covered 50% after deductible Covered 25% after deductible
Covered 50% after deductible Covered 50% after deductible
Covered 50% after deductible Covered 50% after deductible
Bridges Dentures
Orthodontia (child only)
Orthodontia Lifetime Maximum
$500
$1,500
Subject to balance billing. Please refer to your plan document for specific details.
DENTAL PPO Option 1
EMPLOYEE COST WEEKLY
EMPLOYEE COST BI-WEEKLY
Employee Only
$ 5.50 $12.75 $15.76 $23.06
$11.01 $25.51 $31.52 $46.12
Employee + Spouse
Employee + Child(ren)
Family
DENTAL PPO Option 2
EMPLOYEE COST WEEKLY
EMPLOYEE COST BI-WEEKLY
Employee Only
$ 5.91 $13.71 $18.51 $26.35
$11.83 $27.41 $37.02 $52.70
Employee + Spouse
Employee + Child(ren)
Family
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