lD
en
tal
De
nta
lC
ove
rag
e
PL
AN
HIG
HL
IGH
TS
:
key*
00317159
0001
EV6.0
Th
erm
alM
anag
emen
tS
olu
tio
ns,
LL
CD
BA
San
tier
Her
eis
you
rn
ewco
vera
ge.M
ake
sure
you
are
awar
eo
fth
ed
ead
lin
ed
ate
for
you
rco
vera
geel
ecti
on
s.
Ifyo
um
iss
the
dea
dli
ne,
the
cove
rage
may
be
del
ayed
or
you
may
no
tb
eel
igib
lefo
ren
roll
men
tth
isye
ar.
You
rG
ua
rdia
np
lan
nu
mb
er:
31
71
59
Lea
rnm
ore
ab
out
Gu
ard
ian
at
ww
w.g
uar
dia
nli
fe.c
om
.
We’r
e r
eady
to g
et
work
ing f
or
you
If y
ou’r
e lik
e m
ost
em
plo
yees
, fin
din
g e
nough t
ime
in t
he
day
to a
ccom
plis
h y
our
length
y
to-d
o li
st c
an o
ften
be
no e
asy
task
.
As
your
Guar
dia
n c
ove
rage
beg
ins,
we
wan
t yo
u t
o k
now
that
we’
re h
ere
for
you e
very
ste
p
of
the
way
and a
re c
om
mitte
d t
o p
rovi
din
g y
ou w
ith t
he
reso
urc
es t
o o
bta
in f
ast,
acc
ura
te
answ
ers
to y
our
ben
efits-
rela
ted q
ues
tions.
One
way
in w
hic
h w
e do t
his
is t
hro
ugh o
ur
onlin
e m
ember
res
ourc
e, G
uar
dia
n A
nyt
imes
m,
whic
h a
llow
s yo
u t
o m
anag
e yo
ur
ben
efits
when
it w
ork
s bes
t fo
r yo
u —
day
or
nig
ht.
Plu
s,
it o
ffer
s hel
pfu
l res
ourc
es t
o e
nsu
re y
ou g
et a
cces
s to
the
qual
ity
care
you n
eed.
We
enco
ura
ge
you t
o t
ake
a co
uple
min
ute
s to
chec
k out
and r
egis
ter
for
Guar
dia
n
Anyt
imes
mat
ww
w.G
uar
dia
nA
nyt
ime.
com
. W
e pro
mis
e it w
ill b
e tim
e w
ell s
pen
t.
Wel
com
e to
Guar
dia
n!
Pla
nD
eta
ils
Th
isb
oo
klet
exp
lain
syo
ur
bas
icp
lan
op
tio
ns.
Yo
ur
det
aile
dce
rtif
icat
eo
fco
vera
ge
will
be
pro
vid
edto
you
afte
ryo
uen
roll.
Fin
da
ne
two
rkd
en
tist
inm
inu
tes
Use
ou
rP
rovi
der
On
line
Sea
rch
atw
ww
.Gu
ard
ian
An
ytim
e.co
m
Un
de
rsta
nd
you
rb
en
efi
tsP
leas
efi
nd
ag
loss
ary
for
insu
ran
cete
rms
incl
ud
ed.
UN
DE
RS
TA
ND
YO
UR
CO
VE
RA
GE
:
nR
evie
wyo
ur
ben
efit
s
nC
om
ple
teyo
ur
enro
llm
ent
form
,if
app
lica
ble
nS
ign
and
retu
rnfo
rmto
you
rp
lan
adm
inis
trat
or
Dea
rT
her
mal
Man
agem
ent
So
luti
on
s,L
LC
DB
AS
anti
erE
mp
loy
ee,
We
rep
leas
edto
tell
you
that
Gu
ard
ian
wil
lb
eo
ur
den
tal
cove
rage
pro
vid
erth
isye
ar.
We
hav
ech
ose
nG
uar
dia
nb
ecau
seo
fit
sco
mp
etit
ive
rate
s,ex
cell
ent
serv
ice
rep
uta
tio
n,
and
reli
able
den
tal
clai
ms
pay
men
t.
As
you
may
kn
ow
,th
eco
sto
fd
enta
lco
vera
geh
asri
sen
dra
mat
ical
lyo
ver
the
pas
tte
nye
ars.
Fo
rco
mp
anie
sli
ke
ou
rs,
cost
sh
ave
mo
reth
antr
iple
dsi
nce
19
97
.E
ven
so,
Th
erm
alM
anag
emen
tS
olu
tio
ns,
LL
CD
BA
San
tier
wil
lp
aya
gen
ero
us
per
cen
tage
of
the
cost
of
you
rd
enta
lin
sura
nce
inth
eco
min
gye
ar.
Ifap
pli
cab
le,
you
rco
ntr
ibu
tio
nis
pai
dth
rou
ghp
ayro
lld
edu
ctio
n.
Sh
elly
Val
dez
Pla
nC
oord
ina
tor
Th
erm
alM
anag
emen
tS
olu
tio
ns,
LL
CD
BA
San
tier
Pre
par
edfo
rT
he
rma
lM
an
ag
em
en
tS
olu
tio
ns,
LL
CD
BA
Sa
nti
er
Gu
ard
ian
Gro
up
Pla
nN
um
ber
31
71
59
ww
w.g
ua
rdia
nli
fe.c
omE
nro
llm
ent
Kit
31
71
59
,0
00
1,E
N
We
lco
me
1
Note
s:
2
Why
Den
talI
nsur
ance
?
Goo
dor
alhy
gien
eis
impo
rtan
t,no
ton
lyfo
rlo
oks,
but
for
gene
ralh
ealth
asw
ell.
Aro
utin
ede
ntal
exam
inat
ion
can
dete
ctsy
mpt
oms
ofm
ore
than
125
dise
ases
,in
clud
ing
hear
tdi
seas
e,di
abet
es,
anem
ia,
stom
ach
ulce
rs,
oste
opor
osis
and
kidn
eydi
seas
e.R
egul
arch
eck
ups
and
clea
ning
sca
nsa
veyo
uth
epa
inan
dex
pens
eof
futu
repr
oble
ms.
Den
tali
nsur
ance
will
keep
thes
evi
sits
affo
rdab
lean
dis
aco
st-e
ffec
tive
way
tom
inim
ize
heal
thca
reco
sts
for
you
and
your
fam
ily.
The
Am
eric
anD
enta
lHyg
ieni
sts
Ass
ocia
tion
estim
ates
that
for
ever
y$1
spen
ton
prev
entio
nor
oral
heal
thca
re,
asm
uch
as$8
to$5
0is
save
don
futu
reem
erge
ncy
and
rest
orat
ive
proc
edur
es.
Usi
ngyo
urde
ntal
insu
ranc
efo
rre
gula
rde
ntal
chec
kup
sca
nim
prov
eyo
urhe
alth
byhe
lpin
gyo
u:
1)
Pre
ven
tO
ral
Ca
nce
r:A
ccor
ding
toTh
eO
ralC
ance
rFo
unda
tion,
som
eone
dies
from
oral
canc
erev
ery
hour
ofev
ery
day
inth
eU
nite
dS
tate
sal
one.
Whe
nyo
uha
veyo
urde
ntal
clea
ning
,yo
urde
ntis
tis
also
scre
enin
gyo
ufo
ror
alca
ncer
,w
hich
ishi
ghly
cura
ble
ifdi
agno
sed
earl
y.
2)
Pre
ven
tG
um
Dis
ea
se:
Gum
dise
ase
isan
infe
ctio
nin
the
gum
tissu
esan
dbo
neth
atke
epyo
urte
eth
inpl
ace
and
ison
eof
the
lead
ing
caus
esof
adul
tto
oth
loss
.If
diag
nose
dea
rly,
itca
nbe
trea
ted
and
reve
rsed
.If
trea
tmen
tis
not
rece
ived
,a
mor
ese
riou
san
dad
vanc
edst
age
ofgu
mdi
seas
em
ayfo
llow
.R
egul
arde
ntal
clea
ning
san
dch
eck
ups,
floss
ing
daily
and
brus
hing
twic
ea
day
are
key
fact
ors
inpr
even
ting
gum
dise
ase.
3)
He
lpM
ain
tain
Go
od
Ph
ysic
al
He
alt
h:
Rec
ent
stud
ies
have
linke
dhe
art
atta
cks
and
stro
kes
togu
mdi
seas
e,re
sulti
ngfr
ompo
oror
alhy
gien
e.A
dent
alcl
eani
ngev
ery
six
mon
ths
help
sto
keep
your
teet
han
dgu
ms
heal
thy
and
coul
dpo
ssib
lyre
duce
your
risk
ofhe
art
dise
ase
and
stro
kes,
asw
ella
sm
any
othe
rse
riou
sco
nditi
ons.
4)
Ke
ep
Yo
ur
Te
eth
:S
ince
gum
dise
ase
ison
eof
the
lead
ing
caus
esof
toot
hlo
ssin
adul
ts,
regu
lar
dent
alch
eck
ups
and
clea
ning
s,br
ushi
ngan
dflo
ssin
gar
evi
talt
oke
epin
gas
man
yte
eth
asyo
uca
n.K
eepi
ngyo
urte
eth
mea
nsbe
tter
chew
ing
func
tion
and
ultim
atel
y,be
tter
heal
th.
5)
Pre
ven
tth
eN
ee
dfo
rA
dva
nce
dT
rea
tme
nt:
You
rde
ntis
tan
dhy
gien
ist
will
beab
leto
dete
ctan
yea
rly
sign
sof
prob
lem
sw
ithyo
urte
eth
orgu
ms
that
can
beea
sily
trea
tabl
e.If
thes
epr
oble
ms
goun
trea
ted,
root
cana
ls,
gum
surg
ery
and
rem
oval
ofte
eth
coul
dbe
com
eth
eon
lytr
eatm
ent
optio
nsav
aila
ble.
6)
Ha
vea
Bri
gh
ta
nd
Wh
ite
Sm
ile
:Y
our
dent
alhy
gien
ist
can
rem
ove
mos
tto
bacc
o,co
ffee
and
tea
stai
ns.
Dur
ing
your
clea
ning
,yo
urhy
gien
ist
will
also
polis
hyo
urte
eth
toa
beau
tiful
shin
e.
7)
Pro
tect
you
rch
ild
ren
sh
ea
lth
:To
oth
deca
yis
the
mos
tco
mm
onch
roni
cch
ildho
oddi
seas
e,fiv
etim
esm
ore
com
mon
than
asth
ma
and
resu
ltsin
alo
ssof
51m
illio
nsc
hool
hour
sea
chye
ar.
Reg
ular
chec
kup
sca
nhe
lppr
even
tto
oth
deca
yin
your
child
ren.
So
urc
es:w
ww
.ab
ou
t.co
m,A
mer
ican
Aca
dem
yo
fP
edia
tric
s
Pre
par
edfo
rT
he
rma
lM
an
ag
em
en
tS
olu
tio
ns,
LL
CD
BA
Sa
nti
er
Gu
ard
ian
Gro
up
Pla
nN
um
ber
31
71
59
ww
w.g
ua
rdia
nli
fe.c
omE
nro
llmen
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17
15
9,0
00
1,E
N3
Den
tal
Pla
ns
YO
UR
GU
AR
DIA
NP
LA
NO
FF
ER
S:
Nat
iona
lP
PO
netw
ork
ofm
ore
than
87,0
00de
ntis
tsat
over
200,
000
loca
tions
natio
nwid
e.
Rel
iabl
ecl
aim
spa
ymen
tfo
urda
yson
aver
age
Find
out
ifyo
urde
ntis
tis
inG
uard
ian
sne
twor
kat
ww
w.G
uard
ianA
nytim
e.co
m
Let
Gu
ard
ian
pu
tit
s3
0-p
lus
yea
rsof
den
tal
ben
efit
sex
per
ien
ceto
wor
kfo
ryo
ua
nd
you
rfa
mil
y.
CO
MP
AR
ET
HE
PL
AN
SO
pti
on
1:
Pre
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idO
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on
2:
PP
ON
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ork
Man
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Den
talC
are
Den
talG
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Pre
ferr
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len
da
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du
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wo
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rk
Indi
vidu
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ible
$50
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Fam
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it3
per
fam
ilyW
aive
dfo
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reve
ntiv
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reve
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wo
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Pre
vent
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Car
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copa
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ch10
0%10
0%
Bas
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are
(e.g
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vere
dpr
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ure.
See
100%
80%
Maj
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are
(e.g
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ture
s)P
lan
Det
ails
,fo
r60
%50
%
Ort
hodo
ntia
mor
ein
form
atio
n.N
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over
ed
An
nu
al
Ma
xim
um
Be
ne
fit
Unl
imite
d$1
500
$150
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Lif
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me
Ort
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do
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De
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2626
Op
tio
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:W
ithyo
urP
re-P
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plan
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uen
joy
nego
tiate
ddi
scou
nts
from
our
netw
ork
dent
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oupa
ya
fixed
copa
yfo
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dse
rvic
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ut-o
f-ne
twor
kvi
sits
are
not
cove
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Op
tio
n2
:W
ithyo
urP
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plan
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uca
nvi
sit
any
dent
ist;
but
you
pay
less
out-
of-p
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tw
hen
you
choo
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PP
Ode
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CA
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PL
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Net
wo
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nly
In-n
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Freq
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mon
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$010
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Lim
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Und
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$010
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Sea
lant
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$510
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X-r
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$010
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sthe
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100%
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Filli
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Per
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Per
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ntal
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$15
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ever
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mon
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$45-
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Maj
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Den
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s$1
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$70-
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$160
60%
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hodo
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Ort
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$1,9
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Cov
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Lim
its:
Adu
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Chi
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This
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lya
part
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ofde
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serv
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.You
rce
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sw
illsh
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wha
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cove
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and
excl
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orP
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don
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need
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caus
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deca
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inju
ryor
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thol
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whe
nth
eto
oth
cann
otbe
rest
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with
amal
gam
orco
mpo
site
filin
gm
ater
ial.
Whe
nO
rtho
dont
iaco
vera
geis
for
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ld(r
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only
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orth
odon
ticap
plia
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mus
tbe
plac
edpr
ior
toth
eag
elim
itse
tby
your
plan
;If
full-
time
stat
usis
requ
ired
byyo
urin
orde
rto
rem
ain
insu
red
afte
ra
cert
ain
age;
then
orth
odon
ticm
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cem
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ntin
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aine
d.If
Ort
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cove
rage
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dults
and
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this
limita
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appl
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eto
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ning
san
dpe
riod
onta
lmai
nten
ance
proc
edur
esar
eco
mbi
ned
ina
12m
onth
peri
od.*
Gen
eral
Ane
sthe
sia
-re
stri
ctio
nsap
ply.
For
PP
Oan
dor
Inde
mni
tym
embe
rs,F
illin
gs-
rest
rict
ions
may
appl
yto
com
posi
tefil
lings
.
Ple
ase
note
:The
plan
deta
ilslis
ted
here
are
som
eof
the
mos
tcom
mon
serv
ices
rela
ted
tode
ntal
cove
rage
.The
co-
insu
ranc
epe
rcen
tage
sfo
rth
eP
PO
plan
optio
nsco
rres
pond
toth
eco
vera
geca
tego
ries
ofP
reve
ntiv
e,B
asic
,Maj
oran
dO
rtho
dont
ialis
ted
inth
eta
ble
abov
e.
EX
CL
US
ION
SA
ND
LIM
ITA
TIO
NS
nIm
port
ant
Info
rmat
ion
abou
tG
uard
ian
sD
enta
lGua
rdIn
dem
nity
and
Den
talG
uard
Pre
ferr
edP
PO
plan
s:Th
ispo
licy
prov
ides
dent
alin
sura
nce
only
.Cov
erag
eis
limite
dto
thos
ech
arge
sth
atar
ene
cess
ary
topr
even
t,di
agno
seor
trea
tde
ntal
dise
ase,
defe
ct,o
rin
jury
.Ded
uctib
les
appl
y.Th
epl
ando
esno
tpa
yfo
r:or
alhy
gien
ese
rvic
es(e
xcep
tas
cove
red
unde
rpr
even
tive
serv
ices
),or
thod
ontia
(unl
ess
expr
essl
ypr
ovid
edfo
r),c
osm
etic
orex
peri
men
tal
trea
tmen
ts(u
nles
sth
eyar
eex
pres
sly
prov
ided
for)
,any
trea
tmen
tsto
the
exte
ntbe
nefit
sar
epa
yabl
eby
any
othe
rpa
yor
orfo
rw
hich
noch
arge
ism
ade,
pros
thet
icde
vice
sun
less
cert
ain
cond
ition
sar
em
et,a
ndse
rvic
esan
cilla
ryto
surg
ical
trea
tmen
t.Th
epl
anlim
itsbe
nefit
sfo
rdi
agno
stic
cons
ulta
tions
and
for
prev
entiv
e,re
stor
ativ
e,en
dodo
ntic
,per
iodo
ntic
,and
pros
thod
ontic
serv
ices
.The
serv
ices
,exc
lusi
ons
and
limita
tions
liste
dab
ove
dono
tco
nstit
ute
aco
ntra
ctan
dar
ea
sum
mar
yon
ly.T
heG
uard
ian
plan
docu
men
tsar
eth
efin
alar
bite
rof
cove
rage
.C
ontr
act
#G
P-1
-DG
2000
etal
.n
Impo
rtan
tinf
orm
atio
nab
outG
uard
ian
sM
anag
edD
enta
lGua
rdPr
e-Pa
id(F
lorid
a,N
ewYo
rk)P
lan,
Gua
rdia
ns
Man
aged
Den
talG
uard
(Col
orad
o)Pl
an,M
anag
edD
enta
lGua
rdIn
c.s
(Ohi
o)Pl
an,M
anag
edD
enta
lCar
es
DH
MO
(Cal
iforn
ia)P
lan,
Man
aged
Den
talG
uard
,Inc
.sM
anag
edD
enta
lGua
rd(N
ewJe
rsey
)Pla
n,M
anag
edD
enta
lGua
rd,I
nc.s
Man
aged
Den
talG
uard
DH
MO
(Tex
as)P
lan
and
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aged
Den
talG
uard
-LIB
ERTY
Den
talP
lan
ofN
evad
a,In
c.(N
evad
a):T
his
plan
prov
ides
pre-
paid
dent
albe
nefit
sth
roug
ha
netw
ork
ofpa
rtic
ipat
ing
gene
rald
entis
tsan
dsp
ecia
ltyca
rede
ntis
ts.A
llco
vere
dse
rvic
esm
ustb
e
prov
ided
byth
em
embe
rsPr
imar
yCa
reD
entis
t.Sp
ecia
ltyca
rese
rvic
esar
eco
vere
don
lyw
hen
refe
rred
byth
em
embe
rsPr
imar
yCa
reD
entis
tand
appr
oved
inad
vanc
eby
Man
aged
Den
talG
uard
.Onl
yth
ose
serv
ices
liste
din
the
plan
are
cove
red.
Cert
ain
serv
ices
are
subj
ectt
oan
nual
orot
herp
erio
dic
limita
tions
.Whe
reor
thod
ontic
bene
fits
are
spec
ifica
llyin
clud
ed,t
hepl
anpr
ovid
esfo
rone
cour
seof
com
preh
ensi
vetr
eatm
entp
erlif
etim
e,pe
rmem
ber.
Unl
ess
spec
ifica
llyin
clud
ed,t
heM
anag
edD
enta
lGua
rdpl
ando
esno
tpro
vide
orth
odon
ticbe
nefit
sif
com
preh
ensi
veor
thod
ontic
trea
tmen
torr
eten
tion
isin
prog
ress
asof
the
mem
bers
effe
ctiv
eda
teun
dert
heM
anag
edD
enta
lGua
rdpl
an.T
hese
rvic
es,e
xclu
sion
san
dlim
itatio
nslis
ted
here
dono
tcon
stitu
tea
cont
ract
and
are
asu
mm
ary
only
.Th
eM
anag
edD
enta
lGua
rdpl
ando
cum
ents
are
the
final
arbi
tero
fcov
erag
e.G
P-1-
MD
G1,
etal
.orG
P-1-
MD
G-F
L-1-
08,e
tal.
(Flo
rida)
,GP-
1-M
DG
-NY1
,eta
l.or
GP-
1-M
DG
-NY-
1-08
,et
al.(
New
York
),G
P-1-
MD
G-C
O-1
,eta
l.(C
olor
ado)
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1MD
C1,e
tal.
orG
P-1-
MD
C-CA
-1-0
8,et
al.(
Calif
orni
a),
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1-M
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-1-N
J,et
al.o
rGP-
1-M
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1-08
,eta
l.(N
ewJe
rsey
),G
P-1-
MD
G-T
X1,e
tal.
orG
P-1-
MD
G-T
X-1-
08,e
tal.
(Tex
as),
GP-
1-M
DG
-OH
-1,e
tal.
(Ohi
o),N
V110
717,
etal
(Nev
ada)
.n
For
PP
Oan
dor
Inde
mni
tyS
peci
alLi
mit
atio
n:Te
eth
lost
orm
issi
ngbe
fore
aco
vere
dpe
rson
beco
mes
insu
red
byth
ispl
an.
Aco
vere
dpe
rson
may
have
one
orm
ore
cong
enita
llym
issi
ngte
eth
orha
velo
ston
eor
mor
ete
eth
befo
rehe
beca
me
insu
red
byth
ispl
an.
We
won
tpa
yfo
rapr
osth
etic
devi
cew
hich
repl
aces
such
teet
hun
less
the
devi
ceal
sore
plac
eson
eor
mor
ena
tura
ltee
thlo
stor
extr
acte
daf
tert
heco
vere
dpe
rson
beca
me
insu
red
byth
ispl
an.R
3
DG
2000
5
UN
DE
RS
TA
ND
ING
YO
UR
BE
NE
FIT
S
DE
NT
AL
Ba
sic
care
Mod
erat
ely
com
plex
dent
alse
rvic
es.
Mos
tpl
ans
cons
ider
fillin
gsan
dex
trac
tions
tobe
basi
cca
re.
Co
-in
sura
nce
The
port
ion
ofth
eco
vere
dch
arge
paid
byG
uard
ian.
Co
pa
y(s
hort
for
cop
aym
en
t)A
fixed
fee
paid
toa
dent
ist
atth
etim
ea
dent
alse
rvic
eis
perf
orm
ed.
Som
esa
mpl
eco
pays
are
show
nin
this
book
let.
Aco
mpl
ete
list
issh
own
inyo
urce
rtifi
cate
book
let.
Cla
ims
Pa
yme
nt
Ba
sis
PP
O&
NA
P
The
usua
lcos
tfo
ra
spec
ific
dent
alse
rvic
ein
your
area
.A
mou
nts
over
the
spec
ified
Usu
alC
usto
mar
y&
Rea
sona
ble
perc
entil
e(8
0%)
are
usua
llyth
epa
tient
sre
spon
sibi
lity:
In-N
etw
ork
:B
enef
itsar
eba
sed
ona
nego
tiate
dco
ntra
cted
fee
sche
dule
,an
dno
bala
nce
billi
ng.
Ou
t-o
f-N
etw
ork
:B
enef
itsar
eba
sed
onus
ual,
reas
onab
le,
and
cust
omar
yra
tes
for
agi
ven
area
.
De
du
ctib
leTh
eam
ount
ofch
arge
syo
uan
dyo
urfa
mily
mus
tpa
yea
chpl
anye
arbe
fore
the
plan
pays
you
any
bene
fits.
De
nta
lo
ffic
en
um
be
rTh
eun
ique
iden
tific
atio
nnu
mbe
ras
sign
edto
ade
ntal
prov
ider
.Ea
chfa
mily
mem
ber
mus
tse
lect
apr
imar
yca
rede
ntis
tan
den
ter
his
orhe
rnu
mbe
ron
the
enro
llmen
tfo
rm.
Fa
mil
yli
mit
Max
imum
num
ber
ofde
duct
ible
syo
urfa
mily
mus
tpa
yin
each
plan
year
befo
reth
ispl
anst
arts
payi
ngbe
nefit
sfo
ral
lcov
ered
fam
ilym
embe
rsfo
rth
ere
stof
the
plan
year
.
In-n
etw
ork
cha
rge
sC
harg
esfo
rse
rvic
espr
ovid
edby
dent
ists
who
are
am
embe
rof
your
plan
'sne
twor
k.
Ma
jor
care
Mor
eco
mpl
exde
ntal
serv
ices
.M
ost
plan
sco
nsid
ercr
owns
and
dent
ures
tobe
maj
orca
re.
Ou
t-o
f-n
etw
ork
cha
rge
sC
harg
esfo
rse
rvic
espr
ovid
edby
dent
ists
who
are
not
mem
bers
ofyo
urpl
an's
netw
ork.
Pla
nye
ar
The
12m
onth
peri
odus
edto
appl
yth
ispl
an's
dedu
ctib
lean
dan
nual
max
imum
.Y
our
plan
'spl
anye
aris
the
cale
ndar
year
.
PP
O(P
refe
rred
Pro
vide
rO
rgan
izat
ion)
Pla
nth
atle
tsyo
uvi
sit
any
dent
ist,
but
usua
llypr
ovid
esbe
tter
bene
fits
for
the
serv
ices
ofP
PO
netw
ork
dent
ists
.P
PO
dent
ists
have
agre
edto
acce
ptdi
scou
nted
fees
aspa
ymen
tin
full.
Pre
-de
term
ina
tio
nR
evi
ew
Gua
rdia
nw
illgl
adly
assi
styo
uan
dyo
urde
ntis
tby
dete
rmin
ing
wha
tbe
nefit
sco
uld
bepa
yabl
efo
rse
rvic
esan
dpr
oced
ures
over
$300
.H
ave
your
dent
ist
fax
your
trea
tmen
tpl
anto
Gua
rdia
n,no
teth
atit
isa
pre-
dete
rmin
atio
nre
view
and
we
will
let
your
dent
ist
know
wha
tbe
nefit
sw
ould
bepa
yabl
e.Th
isin
clud
esor
thod
ontic
trea
tmen
tif
your
plan
incl
udes
it.P
re-d
eter
min
atio
nap
plie
sto
PP
Oan
dIn
dem
nity
plan
son
ly.
Pre
-Pa
idP
lan
Apl
anth
atre
quir
esyo
uto
visi
ta
netw
ork
dent
ist.
You
pay
afix
edco
pay
toth
ede
ntis
tfo
rea
chse
rvic
epe
rfor
med
.N
obe
nefit
sar
eav
aila
ble
for
serv
ices
ofde
ntis
tsw
hoar
eno
tin
the
netw
ork.
Pre
ven
tive
care
Mos
tro
utin
ede
ntal
serv
ices
.M
ost
plan
sco
nsid
erch
ecku
psan
dcl
eani
ngs
tobe
prev
entiv
eca
re.
6
AD
DIT
ION
AL M
AT
ER
IALS
7
8
Managed DentalGuard
Plan Schedule – 55M
V.19500 Page 1 of 2
MDG
Codes ++
Covered Services
Patient
Charges
0101* 0102 0120/0140/0150 0460 0470 9310 9430 9440
Appointments & Diagnostic Services Office visit - during regular hours -
participating general dentist only Broken appointment (without 24 hours
notice) Oral evaluation Pulp vitality tests Diagnostic casts Consultation (by dentist other than
practitioner providing treatment) Office visit for observation - regular hours -
no other service performed Emergency office visit - after regularly
scheduled office hours
$5.00
$25.00NO CHARGENO CHARGENO CHARGE
NO CHARGE
NO CHARGE
$50.00
0210 0220/0230/0240 0270/0272/0274 0330
Radiographs Intraoral - complete series (including
bitewings) Intraoral - periapical or occlusal - single
film Bitewings Panoramic film
NO CHARGE
NO CHARGENO CHARGENO CHARGE
1110/1120 1201/1203 1310 1330 1351 1510 1515 1550
Preventive & Space Maintenance Prophylaxis Topical application of fluoride (may include
prophylaxis) - child Nutritional counseling for control of dental
disease Oral hygiene instruction Sealant - per tooth Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral Recementation of space maintainer
NO CHARGE
NO CHARGE
NO CHARGENO CHARGE
$5.00$30.00$55.00$5.00
2110 2120 2130 2131 2140 2150 2160 2161 2210 2330 2331 2332 2335 2336 2380 2381 2382 2385 2386 2387
Restorative Amalgam - one surface - primary Amalgam - two surfaces - primary Amalgam - three surfaces - primary Amalgam - four or more surfaces - primary Amalgam - one surface - permanent Amalgam - two surfaces - permanent Amalgam - three surfaces - permanent Amalgam - four or more surfaces -
permanent Silicate cement - per restoration Resin/composite - one surface, anterior Resin/composite - two surfaces, anterior Resin/composite - three surfaces, anterior Resin/composite - four or more surfaces or
incisal angle, anterior Composite resin crown, anterior - primary Resin/composite - one surface, posterior -
primary Resin/composite - two surfaces, posterior -
primary Resin/composite - three or more surfaces,
posterior - primary Resin/composite - one surface, posterior -
permanent Resin/composite - two surfaces, posterior
- permanent Resin/composite - three or more surfaces,
posterior – permanent
NO CHARGE$5.00
$10.00$10.00$5.00$5.00
$10.00
$10.00$10.00$15.00$20.00$20.00
$25.00$20.00
$15.00
$20.00
$25.00
$15.00
$25.00
$30.00
MDG
Codes ++
Covered Services
Patient
Charges
2510 2520/6520 2530/6530 2543/6543 2544/6544 2702 2703 2740 2750 - 2752 2790 - 2792 2810/6780 6210 - 6212 6240 - 6242 6750 - 6752 6790 - 6792
Crown, Bridge & Other Cast Restorations
Inlay - metallic - one surface** Inlay - metallic - two surfaces** Inlay - metallic - three or more surfaces** Onlay - metallic - three surfaces** Onlay - metallic - four or more surfaces** Crown supporting existing partial denture,
in addition to crown Multiple crown and bridge unit treatment
plan - per unit Crown - porcelain/ceramic substrate Crown - porcelain fused to metal** Crown - full cast metal** Crown - 3/4 cast metallic** Pontic - cast metal** Pontic - porcelain fused to metal** Crown - abutment - porcelain fused to
metal** Crown - abutment - full cast metal**
$100.00$130.00$130.00$140.00$145.00
$125.00
$125.00$175.00$180.00$160.00$170.00$160.00$180.00
$180.00$150.00
2910/2920/6930 2930/2931 2932 2940 2950/6973 2951 2952/6970 2954/6972 2960
Other Restorative Services Recement inlay, crown, bridge Prefabricated stainless steel crown Prefabricated resin crown Sedative filling Core buildup, including any pins Pin retention - per tooth, in addition to
restoration Cast post & core Prefabricated post & core Labial veneer (laminate) – chairside
$5.00$15.00$40.00$5.00
$35.00
NO CHARGE$50.00$40.00$70.00
3110/3120 3220 3310 3320 3330 3346 3347 3348 3410 3421 3425 3426 3430
Endodontics Pulp cap Therapeutic pulpotomy Root canal – anterior Root canal – bicuspid Root canal – molar Root canal - retreatment – anterior Root canal - retreatment – bicuspid Root canal - retreatment - molar Apicoectomy/periradicular surgery -
anterior Apicoectomy/periradicular surgery -
bicuspid - first root Apicoectomy/periradicular surgery – molar - first root Apicoectomy/periradicular surgery – each additional root Retrograde filling - per root
$5.00$15.00$75.00$85.00
$150.00$90.00
$100.00$170.00
$100.00
$100.00
$110.00
$45.00$15.00
4210 4211 4240 4249 4260 4261
Periodontics Gingivectomy or gingivoplasty - per
quadrant Gingivectomy or gingivoplasty - per tooth Gingival flap procedure - including root
planing - per quadrant Clinical crown lengthening - hard tissue Osseous surgery - including flap entry,
closure - per quadrant - five to eight teeth
Osseous surgery - including flap entry, closure - per quadrant - one to four teeth
$75.00$25.00
$130.00$105.00
$195.00
$120.00
9
Managed DentalGuard
Plan Schedule – 55M
V.19500 Page 2 of 2
MDG
Codes ++
Covered Services
Patient
Charges
4270 4271 4341 4355 4910 4920 9951
Periodontics (cont.) Pedicle soft tissue graft procedure Free soft tissue graft procedure (including
donor site surgery) Periodontal scaling & root planing – per quadrant Full mouth debridement to enable
evaluation & diagnosis Periodontal maintenance procedures
(following active therapy) Unscheduled dressing change (by other
than treating dentist) Occlusal adjustment - limited - per visit
$125.00
$140.00
$30.00
$15.00
$15.00
NO CHARGE$10.00
5110/5120 5130/5140 5211/5212 5213/5214 5410/11/21/22 5510/5610 5520/5640 5630 5650 5660 5710/11/20/21 5730/31/40/41 5750/51/60/61 5820/5821 5850/5851
Prosthodontics (Removable) Complete denture (including routine post
delivery care) Immediate denture (including routine post
delivery care) Partial dentures (including routine post
delivery care): Resin base - including clasps, rests, teeth Cast metal framework with resin base -
including clasps, rests, teeth Repairs & adjustments: Denture adjustments Repair denture base Replace missing or broken teeth – per tooth Repair or replace clasp Add tooth to existing partial Add clasp to existing partial Rebase denture Reline denture (chairside) Reline denture (laboratory) Interim partial denture (stayplate) Tissue conditioning
$190.00
$190.00
$155.00
$220.00
$10.00$10.00
$10.00$15.00$15.00$15.00$45.00$20.00$35.00$80.00$10.00
7110/7120 7130 7210 7220 7230 7240 7241 7250 7270 7280 7281 7285 7286 7310
Oral Surgery Extraction - single tooth Root removal - exposed roots Surgical removal of erupted tooth Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - completely
bony Removal of impacted tooth - completely
bony, with unusual surgical complications
Surgical removal of residual tooth roots (cutting procedure)
Tooth reimplantation and/or stabilization of accidentally evulsed tooth
Surgical exposure of impacted or unerupted tooth for orthodontic reasons
Surgical exposure of impacted or unerupted tooth to aid eruption
Biopsy of oral tissue - hard Biopsy of oral tissue - soft Alveoplasty in conjunction with extractions -
per quadrant
$5.00$10.00$30.00$45.00$60.00
$70.00
$75.00
$35.00
$55.00
$80.00
$55.00$35.00$35.00
$30.00
MDG
Codes ++
Covered Services
Patient
Charges
7320 7450 7451 7470 7510 7960
Oral Surgery (cont.) Alveoplasty not in conjunction with extractions - per quadrant Removal of odontogenic cyst/tumor – up to 1.25cm Removal of odontogenic cyst/tumor – over 1.25cm Removal of exostosis - maxilla or
mandible Incision & drainage of intraoral abscess Frenulectomy (separate procedure)
$40.00
$50.00
$100.00
$75.00$20.00$50.00
8601 8602 8070/8080/8090 8070/8080/8090 8670 8680
Orthodontic Treatment (covers 24 months active treatment)
Orthodontic evaluation and consultation Orthodontic treatment plan and
records, including x-rays, study models and photos
Comprehensive orthodontic treatment, including fabrication and insertion of fixed banding appliance and periodic visits, up to 24 months; dependent child to age 18 (as determined by the Member’s age on the date of banding)
Comprehensive orthodontic treatment, including fabrication and insertion of fixed banding appliance and periodic visits, up to 24 months; employee, spouse, or dependent child over age 18 (as determined by the Member’s age on the date of banding)
Periodic comprehensive orthodontic treatment visit
Orthodontic retention
$100.00
$150.00
$1975.00
$2175.00
NO CHARGE$300.00
9110 9215
Miscellaneous Services Palliative (emergency) treatment - per visit Local anesthesia
NO CHARGENO CHARGE
++ Covered Services are subject to exclusions, limitations and Plan provisions.
Other codes may be used to describe Covered Services.
** If high noble metal is used, there will be an additional patient charge for the actual cost of the high noble metal.
! Plan Schedules are only Valid for Covered Services rendered by
Participating Dentists in the State of California.
10
Fin
ding
a d
entis
t is
easy
Go
on
line
– it
just
tak
es m
inu
tes!
T
he b
est w
ay to
sav
e m
oney
thro
ugh
your
den
tal p
lan
is b
y se
eing
a d
entis
t in
your
pla
n’s
netw
ork.
Gua
rdia
n’s
Fin
d a
Pro
vide
r si
te
mak
es it
eas
y fo
r yo
u to
sea
rch
for
a de
ntis
t tha
t mee
ts y
our
need
s.
Gua
rdia
n’s
Fin
d a
Pro
vide
r si
te is
ava
ilabl
e to
you
24
hour
s a
day,
7 d
ays
a w
eek.
•
Cus
tom
ize
your
sea
rch
by s
peci
alty
, lan
guag
es s
poke
n an
d m
ore
•
Get
sid
e-by
-sid
e co
mpa
rison
s of
den
tists
’ inf
orm
atio
n (ie
. offi
ce s
tatu
s, d
ista
nce)
•
Cre
ate
a qu
ick-
list o
f “fa
vorit
e” d
entis
ts —
for
easy
ref
eren
ce o
nlin
e
•
Get
map
s an
d di
rect
ions
to a
den
tist’s
offi
ce lo
catio
n
•
Vie
w y
our
resu
lts o
nlin
e or
hav
e th
em fa
xed
or e
mai
led
to y
ou
•
Sav
e yo
ur s
earc
h cr
iteria
for
easy
acc
ess
whe
n yo
u re
visi
t the
site
•
Cre
ate
a cu
stom
ized
dire
ctor
y of
den
tists
•
Nom
inat
e a
dent
ist t
o be
incl
uded
in a
net
wor
k
•
And
muc
h m
ore!
Just
go
to
ww
w.G
uar
dia
nA
nyt
ime.
com
an
d c
lick
on
“F
ind
a P
rovi
der
”. Y
ou
can
als
o f
ind
a d
enti
st o
n t
he
go
fro
m y
ou
r sm
art
ph
on
e –
sim
ply
do
wn
load
ou
r ap
p.
11
12
I would like to nominate my dentist for inclusion in the DentalGuard PreferredProvider Network. I understand that my name may be used whencontacting my dentist to inform him/her of my desire for them to join the
network. For more information, visit us online at www.GuardianLife.com.
DATE:
Employer:
Patient:
Address:
City/State/Zip: DENTIST Phone:
Fax:
E-mail:
IDENTIST INFO
Name:
Address:
City/State/Zip:
Phone:
Specialty:
Please submit completed form to: GuardianDentalGuard PreferredP.O. Box 2465Spokane, WA 99210-9817
or FAX to: 509-468-6550
DentalGuard Preferred Dentist Nomination Form$
13
14
Gua
rdia
nA
nytim
eSM
Mob
ile
Gu
ard
ian
’sn
etw
ork
inth
ep
alm
of
you
rh
and
.
The
best
way
tosa
vem
oney
thro
ugh
your
dent
alan
dvi
sion
bene
fits
isto
see
apr
ovid
erin
your
netw
ork.
Gua
rdia
nm
akes
itea
syto
find
ade
ntis
tor
visi
onpr
ovid
erne
aryo
u,on
line
oron
the
go!P
lus,
you
can
acce
ssyo
urm
embe
rID
card
topr
esen
taty
our
visi
t.C
hoos
ebe
twee
n:
Sea
rch
on
the
go
!
It’s
fast
and
easy
tofin
da
prov
ider
from
your
smar
tpho
neth
roug
hou
rG
uard
ian
Any
time
mob
ileap
p.It’
sea
syto
dow
nloa
dan
dus
e!S
impl
yse
arch
bylo
catio
nor
nam
e.
Vis
itw
ww
.Gua
rdia
nAny
time.
com
/mob
ile.
Vie
w/P
rin
tyo
ur
Mem
ber
IDC
ard
You
nolo
nger
need
tosh
owyo
urde
ntal
orvi
sion
prov
ider
apa
per
IDca
rd.S
impl
yac
cess
anim
age
ofyo
urca
rdth
roug
hG
uard
ian
Any
time
Mob
ilean
dsh
owth
emat
your
visi
t!
You
can
also
Fin
da
Pro
vide
rat
our
web
site
ww
w.G
uard
ianA
nytim
e.co
m.C
usto
miz
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urse
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side
-by-
side
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paris
ons,
orcr
eate
aqu
ick
listo
f“fa
vorit
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ovid
ers
and
mor
e!
15
TH
ISPAG
EIN
TEN
TIO
NALLY
LEFT
BLAN
K
1
Employer:
Thermal Management Solutions, LLC DBA Santier10113 Carroll Canyon RoadSan Diego, CA 92131
www.guardianlife.com Enrollment Kit 317159, 0001, EN
Guardian Group Plan Number: 317159Plan Administrator: Shelly Valdez
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
DATE FORM PUBLISHED: Nov 24, 2013
Please print clearly to ensure accurate processing
CEF2005
The Guardian Life Insurance Company of America Managed Dental Care of CaliforniaA wholly owned subsidiary of Guardian
EMPLOYER USE ONLY q New Application q Add Dependent(s) q Drop Dependent(s) q Change Address q Change Name q Drop Coverage as of: / /
Class
all eligible employees
Hours Worked Division Benefits Effective
/ /
Keep a copy for your records and return form to: Midwest Regional Office, P.O. Box 8012, Appleton, WI 54912-8012
ABOUT YOURSELF Print clearly in black or blue ink.First, Middle Initial, Last Name q Add q Change q Drop Sex
q M q F
Date of Birth (mm/dd/yyyy)
/ /
Social Security Number
- -
Address City State Zip
Preferred E-mail Day Phone Eve Phone The best way to reach you:
q E-mail q Day Phone q Eve Phone
Job Title Work Status Date work status began
q Full-Time q Part-Time q Retired q COBRA/State Continuation / /
Are you married? q Yes q No If you have a domestic partner (DP), is your partnership registered
with the State of California? q Yes q No
Do you have children or other dependents? q Yes q No
ABOUT YOUR DEPENDENTS q A sheet with information about additional dependents is attached.Spouse First, Middle Initial, Last Name
q Add q Change q Drop
Sex
q M q F
Date of Birth (mm/dd/yyyy)
/ /
Social Security Number
- -
Marriage Date (mm/dd/yyyy)
/ /
Child 1 q Add q Change q Drop Sex
q M q F
Date of Birth (mm/dd/yyyy)
/ /
Social Security Number
- -
q Full-time student, at (school): Attending Since
/ /
Child 2 q Add q Change q Drop Sex
q M q F
Date of Birth (mm/dd/yyyy)
/ /
Social Security Number
- -
q Full-time student, at (school): Attending Since
/ /
Child 3 q Add q Change q Drop Sex
q M q F
Date of Birth (mm/dd/yyyy)
/ /
Social Security Number
- -
q Full-time student, at (school): Attending Since
/ /
Child 4 q Add q Change q Drop Sex
q M q F
Date of Birth (mm/dd/yyyy)
/ /
Social Security Number
- -
q Full-time student, at (school): Attending Since
/ /
To drop coverage for yourself or your dependents, check the box(es) to the right of the name(s) and select the coverage(s) to drop below. Attach a separate sheet ifyou wish to drop more than one dependent from different coverages.q Dental
2
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER
CHOOSE YOUR DENTAL COVERAGE Check one box only
Option 1: Pre-Paid Option 2: PPO
Employee alone q q q I waive this coverage
Entire family q q q I waive this coverage
List dental office location number(s) (Pre-Paid Plan only)
Employee ________________ Spouse ________________ Child(ren) ________________
q A separate sheet with additional dental office numbers for dependents is attached.
If you or your family have lost dental coverage, please explain below. Late entry penalties may apply.
Reason for Loss of coverage: q Termination of Employment q Divorce q Death of Spouse q Termination or Expiration of coverage Date of coverage loss
/ /
If you are waiving coverage, are you covered under another dental plan?
q Yes q No
If you are waiving dependent coverage, are your dependents covered under another
dental plan? q Yes q No
IMPORTANT NOTES
n Proof of insurability does not apply to dental, but if you waive dental coverage and later decide to enroll, you may be subject to a late entrant penalty and your
dental benefits may be limited for a period of time. Guardian may waive late-entrant penalties if you lose dental coverage due to termination of the plan, loss
of employment, death of spouse, divorce or where a court has ordered coverage be provided for an eligible spouse or eligible children, provided you apply
within 30 days.
n Late entrant penalties or proof of insurability do not apply to Pre-Paid dental coverage. The Pre-Paid dental plan refers to, as applicable, Managed
DentalGuard dental HMO plans underwritten by Managed Dental Care. Eligibility for this coverage is only available at the open enrollment period.
SIGNATURE
n I hereby apply for the group benefit(s) that I have chosen above.
n I understand that I must meet eligibility requirements for all coverages
that I have chosen above.
n I understand that my dependent(s) cannot be enrolled for a coverage if I
am not enrolled for that coverage.
n I agree that my employer may deduct premiums from my pay or add
premiums to my dues; if they are required for the coverage I have
chosen above.
n I attest that the information provided above is true and correct to the
best of my knowledge.
n Any person who with intent to defraud or knowing that he/she is
facilitating a fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement may be guilty of
insurance fraud.
SIGNATURE OF EMPLOYEE X DATE
Thank
You
qC
hec
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eco
vera
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you
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t
qIn
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soci
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ign
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pla
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Ple
ase
rem
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to:
Date
form
subm
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©2
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0001
