Plan Details
Plan Name Dental PPO
Description All Employees
Carrier Guardian
Effective Dates January 1, 2020 to January 1, 2021
In-Network Benefits Out-of-Network Benefits
General Plan Information
Annual Deductible/Individual $50 $50
Annual Deductible/Family $150 $150
Annual Plan Maximum $1,500 $1,500
Lifetime Orthodontia Plan Maximum $1,500 $1,500
Diagnostic and Preventive Services
Diagnostic and Preventive 100% 100%
Basic Services
Basic 80% after deductible 80% after deductible
Endodontic Treatment 80% after deductible 80% after deductible
Periodontic Treatment 80% after deductible 80% after deductible
Major Services
Major 50% after deductible 50% after deductible
Orthodontia Services
Orthodontia 50% 50%
Dependent Children Covered Covered
Adults (and Covered Full-Time Students, if Eligible) Covered Covered