Company Name • 2024-2025 Benefits Guide
DENTAL GUARDIAN Although you can choose any dental provider, when you use an
www.guardianlife.com 800.555.1234
in-network dentist, you will generally pay less. If you choose an out-of-network provider, you may be billed the difference between what Guardian pays, and what your out-of-network provider charges for the services. To locate an in-network provider, please visit www.guardianlife.com .
Dental
Base Plan
Enhanced Plan
In-network
In-network
Annual deductible (Individual/Family)
$50 / $100
$50 / $100
Annual maximum (per person)
$1,500
$2,000
Diagnostic and preventive care - Includes cleanings, fluoride treatments, sealants and x-rays Basic services - Includes fillings, periodontics, scaling and root planning, and oral surgery Major services - Includes crowns, bridges and full and partial dentures
100%
100%
90%
90%
60%
Not Covered
Orthodontia
50%
Lifetime maximum
$1,000
Plan includes out-of-network benefits, see plan summary for additional details.
VISION GUARDIAN
www.guardianlife.com 800.555.1234
Our vision care benefits include coverage for eye exams, lenses and frames, contact lenses, and discounts for laser surgery. The vision plan is built around the Guardian providers, who have higher benefits at a lower cost to you. When you need services, consider using an in-network provider for the most bang for your buck! When you use an out-of-network provider, you will be reimbursed for services according to the grid below. To locate an in-network provider, visit www.guardianlife.com .
Vision
Base Plan
Enhanced Plan
In-network
In-network
Examination (every calendar year)
$10 copay
$0 copay
Material
$25 copay
$0 copay
Lenses (every calendar year) Single
$25 copay
$0 copay
Bifocal
$25 copay
$0 copay
Trifocal
$25 copay
$0 copay
Frames (every calendar year) New frames
$130 allowance
$150 allowance
Contact lenses (every calendar year) Elective
$130 allowance
$150 allowance
Medically necessary
$0 copay
$0 copay
Employees can elect dental and/or vision regardless of whether they are enrolled in medical.
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