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Essentials for Families and Individuals

PPO

Out of Network benefits are based on a covered fee schedule.

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%

Major Services

12 month waiting period & deductible apply
In Network
Guardian Pays
Out Of Network
Guardian Pays
Crowns
50%
50%
Bridges
50%
50%
Dentures
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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  • Get most preventive services, such as oral exams, cleanings, and X-rays at 100% once the annual deductible has been reached.

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$1000

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  • 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.

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