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Any service furnished solely for cosmetic reasons. You would be responsible for the deductible and any amounts over the UCR as well as any co-insurance, Most routine dental services, including oral exams, cleanings, x-rays, Moderately complex dental services, including fillings and simple extractions, More complex dental services including crowns, complex extractions, oral surgery, periodontal, and endodontic services, Benefit maximum payout increases every year for the 1st 3 years; one preventive visit required for each member each year. Any service, Appliance, Dental Prosthesis, modality or surgical service intended to treat or diagnose disturbances of the temporomandibular joint (TMJ) that are incidental to, or result from, a medical condition unless required due to state law. Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis. Any restoration, service, Appliance or Dental Prosthesis used solely to: (1) alter vertical dimension; (2) restore or maintain occlusion; (3) treat a condition necessitated by attrition or abrasion; or (4) splint or stabilize teeth for periodontal reasons. Guardian Dental Select Silver Coverage Summary (see your policy for further details) Choose any Dentist In-Network Dentist Guardian’s negotiated rates save you up to 35% at In-Network Dentists Out-of-Network Dentist Charges for services provided by participating dentists are based on • You can see any dentist you want, but save up to 35% when you visit a dentist that participates in Guardian’s network. Treatment for which no charge is made. Any service performed in conjunction with, as part of, or related to a service which is not covered by this Policy. Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis. Guardian’s negotiated rates save you up to 35% at In-Network Dentists, Reimbursement is based on the lower of your dentist’s fees or the amount that would be paid to dentists who have agreed to be reimbursed according to Guardian’s negotiated fee schedule, Most routine dental services, including oral exams, cleanings, x-rays, Moderately complex dental services, including fillings and simple extractions, More complex dental services including crowns, complex extractions, oral surgery, periodontal, and endodontic services, Benefit maximum payout increases every year for the 1st 3 years; one preventive visit required for each member each year. Please refer to your plan documents for a complete list of limitations and exclusions. Charges for services provided by participating dentists are based on negotiated, discounted fee schedules, and are reimbursed directly from Guardian. Treatment of congenital or developmental malformations or the replacement of congenitally missing teeth. Duplication of radiograph images, the completion of claim forms, OSHA or other infection control charges. Reimbursement is based on the lower of your dentist’s fees or the amount that would be paid to dentists who have agreed to be reimbursed according to Guardian’s negotiated fee schedule. This usually means treatment furnished by: (1) the covered person's employer, labor union or similar group, in its dental or medical department or clinic; (2) a facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for or sponsored by any governmental body.. If you choose to see a dentist outside of the Network, you'll be reimbursed based on Usual and Customary (UCR) charges. ,n-Network Dentist Guardian’s negotiated rates save you up to 35% at In-Network Dentists Out-of-Network Dentist Reimbursement is based on the lower of your dentist’s fees or the amount that would be paid to dentists who have agreed to be reimbursed according to Guardian’s negotiated fee schedule Your Plan Benefits Guardian Pays Any service or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature. Non-renewal will not affect any otherwise valid claim that starts while this Policy is in force. Application of desensitizing medicaments and desensitizing resins for cervical and/or root surface. With This Plan: • You have access to over 114,000 dentists. A fixed bridge replacing the extracted portion of a hemisected tooth or the placement of more than one unit of a crown and/or bridge, per tooth. Treatment of congenital or developmental malformations or the replacement of congenitally missing teeth. Pulp vitality tests or caries susceptibility tests. After one continuous year of coverage and acceptance of premium for any portion of the second or subsequent year sufficient notice shall be a number of full months most nearly equivalent to one fourth the number of months of continuous coverage from the inception date of the Policy, to the date of mailing of the notice. Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the settling of a fracture or dislocation that is incidental to or results form a medical condition. Guardian’s negotiated rates save you up to 35% at In-Network Dentists, Charges for services provided by participating dentists are based on negotiated, discounted fee schedules, and are reimbursed directly from Guardian. Policy limitations and exclusions apply. We reserve the right to change rates on this Policy issued to persons of the same class in Your state following the initial twelve month period. The actual limitations and exclusions that apply to your Dental Plan are governed by the policy forms approved for use in your state. Bite registration, bite analysis or occlusion analysis - mounted case. Overdentures and related services including root canal therapy on teeth supporting an overdenture. Educational services, including, but not limited to: (1) oral hygiene instruction; (2) tobacco counseling; or (3) nutritional counseling. Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation that is incidental to or results from a medical condition. However, no period of required notice shall exceed two years. Reimbursement is based on the lower of your dentist’s fees or the amount that would be paid to dentists who have agreed to be reimbursed according to Guardian’s negotiated fee schedule. This usually means treatment furnished by: (1) the covered person’s employer, labor union or similar group, in its dental or medical department or clinic; (2) a facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for or sponsored by any governmental body. Those shown above are illustrative only. This policy provides DENTAL insurance only. Treatment needed due to: (1) an on-the-job or job-related injury; or (2) a condition for which benefits are payable by Worker's Compensation or similar laws. Guardian Advantage PPO Silver With This Plan: • You have access to over 114,000 dentists. Dental insurance is underwritten by The Guardian Life Insurance Company of America, New York, NY. Duplication of radiograph images, the completion of claim forms, OSHA or other infection control charges. Treatment for which no charge is made. The actual limitations and exclusions that apply to your Dental Plan are governed by the policy forms approved for use in your state. Pulp vitality tests or caries susceptibility tests. Plan documents are the final arbiter of coverage. Guardian Dental is underwritten by The Guardian Life Insurance Company of America, New York, NY. • Get most services, including: oral exams cleanings and x-rays covered at 80%. Duplication of radiograph images, the completion of claim forms. Any service performed on a tooth or teeth with a guarded, questionable or poor prognosis. Save up to 35% off standard dental rates with an in-network dentist Large Network of Dentists. The actual limitations and exclusions that apply to your Dental Plan are governed by the policy forms approved for use in your state. Bite registration, bite analysis or occlusion analysis – mounted case. If We do raise Your premium due to a change in rates, then at least 60 days prior to Your renewal date, We will send written notice to You at Your last known address shown on record. The replacement of extracted or missing third molars (wisdom teeth). Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis. Find an eye doctor Opens in an external window. Temporary or provisional Dental Prosthesis or Appliances except interim partial dentures (stayplates) to replace Anterior Teeth extracted while covered under this Policy. The localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue. If You are eligible for Medicare, review the Guide to Health Insurance for People with Medicare, which is available from the Company. Any service furnished solely for cosmetic reasons. Orthodontic treatment, unless the Policy provides specific benefits for orthodontic treatment. This includes, but is not limited to: (1) characterization and personalization of a Dental Prosthesis; (2) bleaching of discolored teeth; and (3) odontoplasty. Policy limitations and exclusions apply. Guardian Advantage PPO Silver. Guardian Dental Advantage Silver. Please refer to your plan documents for a compete list of limitations and exclusions. Application of desensitizing medicaments and desensitizing resins for cervical and/or root surface. Please refer to your plan documents for a complete list of limitations and exclusions. Temporary or provisional Dental Prosthesis or Appliances except interim partial dentures (stayplates) to replace Anterior Teeth extracted while covered under this Policy. Those shown above are illustrative only. Products are not available in all states. Any service or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature. Any service, Appliance, Dental Prosthesis, modality or surgical service intended to treat or diagnose disturbances of the temporomandibular joint (TMJ) that are incidental to, or result from, a medical condition unless required due to state law. Tooth re-implantation or tooth transplantation. Policy limitations and exclusions apply. If you choose to see a dentist outside of the Network, you'll be reimbursed based on Usual and Customary (UCR) charges. Plan documents are the final arbiter of coverage. Any service furnished solely for cosmetic reasons. This includes, but is not limited to: (1) characterization and personalization of a Dental Prosthesis; (2) bleaching of discolored teeth; and (3) odontoplasty. OSHA or other infection control charges. A fixed bridge replacing the extracted portion of a hemisected tooth or the placement of more than one unit of a crown and/or bridge, per tooth.

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