DENTAL INSURANCE
Palmetto Prime offers two dental plans 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 for pay the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.
High Dental PPO Plan (Option 1)
Low Dental PPO Plan (Option 2)
Out-of Network 1
Out-of Network 1
In-Network
In-Network
Calendar Year Deductible Individual
$50
$50
$50
$100
Family
$150
$150
$150
$300
Annual Maximum
$1,500
$1,000
Diagnostic & Preventive Exams
Cleanings Fluoride X-Rays Sealants Regular Restorative
Covered in full
Covered in full
Covered in full
Covered in full
Services Fillings
Covered 80% after deductible
Covered 50% after deductible
Covered 80% after deductible
Covered 50% after deductible
Extractions - Single Tooth
Major Services Crowns
Bridges Dentures Endodontics (Root Canal) Periodontics (Gum Disease) Orthodontia Child Only
Covered 50% after deductible
Covered 25% after deductible
Covered 50% after deductible
Covered 25% after deductible
Not Available
Not Available
Not Available
Not Available
1 Subject to balance billing. Please refer to your plan document for specific details.
High PPO Dental Plan (Option 1)
Low PPO Dental Plan (Option 2)
Employee Contributions (Weekly)
Employee Only
$ 6.60
$ 4.21
Employee + Spouse
$15.17 $16.50 $24.30
$9.68
Employee + Child(ren)
$10.48 $15.31
Family
5
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