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Select for Families and Individuals

PPO

Out of Network benefits are based on a covered fee schedule.
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Plan Summary Schedule of Benefits

Preventive Care

In Network
Guardian Pays
Out Of Network
Guardian Pays
Exams, cleaning, X-rays, topical fluoride
100%
70%

Restorative Services

6 month waiting period & deductible apply
In Network
Guardian Pays
Out Of Network
Guardian Pays
Fillings
Amalgam-One Surface; primary or permanent
60%
40%
Diagnostic Services
60%
40%

Major Services

12 month waiting period & deductible apply
In Network
Guardian Pays
Out Of Network
Guardian Pays
Crowns
50%
30%
Bridges
50%
30%
Dentures
50%
30%
The coinsurance/copayment amounts listed are examples and may be found on the Schedule of Benefits. This plan may not be available in all Counties. Please visit the See Plans and Prices section at www.healthcare.gov to confirm availability in your area.

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PPO

Basic for Families and Individuals

Plan Summary Schedule of Benefits

  • A family plan, including adults and children.

  • You are responsible for a percent of the total billed (coinsurance).

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$1500

Deductibles

FROM$50

View Details

PPO

Essentials for Families and Individuals

Plan Summary Schedule of Benefits

  • A comprehensive family plan, including adults and children.

  • You are responsible for a percent of the total billed (coinsurance).

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$1000

Deductibles

FROM$50

View Details

PPO

Preventive Plus for Families and Individuals

Plan Summary Schedule of Benefits

  • A PPO Plan for families that provides coverage for preventive and basic services.

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$1000

Deductibles

FROM$50

View Details

PPO

Preventive Plus for Families and Individuals

Plan Summary Schedule of Benefits

  • A PPO Plan for families that provides coverage for preventive and basic services.

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$1000

Deductibles

FROM$50

View Details

PPO

Essentials for Families and Individuals

Plan Summary Schedule of Benefits

  • A comprehensive family plan, including adults and children.

  • You are responsible for a percent of the total billed (coinsurance).

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$1000

Deductibles

FROM$50

View Details

PPO

Select for Families and Individuals

Plan Summary Schedule of Benefits

  • A comprehensive family plan, including adults and children.

  • You are responsible for a percent of the total billed (coinsurance).

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$800

Deductibles

FROM$50

View Details

PPO

Basic for Families and Individuals

Plan Summary Schedule of Benefits

  • A family plan, including adults and children.

  • You are responsible for a percent of the total billed (coinsurance).

  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

Annual Maximum

$1500

Deductibles

FROM$50

View Details

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