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Preventive Plus 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
Sumario Detalles del Plan

Preventive Care

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

Restorative Services

6 month waiting period & deductible apply
In Network
Guardian Pays
Out Of Network
Guardian Pays
Fillings
Amalgam-One Surface; primary or permanent
50%
50%
Diagnostic Services
50%
50%
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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