Benefits for 2023
Dental Coverage
SUMMARY OF COVERAGE
Guardian
Plan Option
PPO
DHMO
Plan Provisions
InNetwork
Out of Network
InNetwork
Deductible Individual / Family
$50 / $150
n/a
Deductible period
Calendar year
Calendar Year Maximum $1,000
$1,000
Unlimited
Orthodontia Lifetime Maximum
n/a
$1,500 - $2,800
Orthodontia Age Limit
n/a
Adult & Child
Reimbursement Basis
Unit 1 - Preventive Care
100%
100%
Fee Schedule
Unit 2 - Basic Services
80%
80%
Fee Schedule
Unit 3 - Major Services
50%
50%
Fee Schedule
Unit 4 - Orthodontia
n/a
n/a
Fee Schedule
Available for employees working 20+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
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