Plan
Plan Name:
Guardian Family Essentials, NS, OON DentalGuard Preferred Network, Dep25, Adult/Family Dental, WP
Issuer Name:
Guardian
HIOS ID:
42640NY0320001
Annual Benefit Maximum:
$1,000
Plan Brochure Link:
Out of Network Coverage:
Y
Dental Plan Type
Dental Plan Type:
Adult & Family Dental Plan
Plan Information
Dep Age:
Age 25
Plan Type:
PPO
Standard or Non-Standard Plan:
Non-Standard
Waiting Periods:
6 months for Fillings and Simple Extractions. 12 months for Single Restoration Crowns, Pulp Cap, Root Canal, Scaling, Planing, Gingivectomy or Gingivoplasty, Gum Surgery, Tissue Grafting, Partial Dentures, Complete Dentures, Bridges and Veneers.
Deductible Adult Individual:
$50
Limit Description:
1 exam per 6 months; 1 cleaning per 6 months; 1 Full mouth X-ray or panoramic X-ray per 60 months; 1 bitewing X-ray per 12 months, replacement of major restorations and prosthetics every 60 months
Limits on Services:
Yes
Lifetime Benefit Maximum:
N/A
Coverage Level:
Couple
Benefits Excluded from In Network MOOP:
Cosmetic services, experimental or investigational treatment, felony participation, government facility, medical services, medically necessary, medicare or other governmental program, military service, no fault automobile insurance, services not listed, s
FDP In Network Cost Sharing Adult Benefits
FDP Office Visit With No Additional Services - Adult:
CI: No charge AD
FDP Oral Evaluation - Adult:
CI: No charge AD
FDP Complete Set of X-Rays - Adult:
CI: No charge AD
FDP Topical Fluoride - Adult:
CI: Not covered
FDP Polishing - Adult:
CI: No charge AD
FDP Sealant (per tooth) - Adult:
CI: Not covered
FDP Spacers - Adult:
CI: Not covered
FDP Simple Extraction - Adult:
CI: 50% Coins AD
FDP Fillings - Adult:
CI: 50% Coins AD
FDP Single Restoration Crowns - Adult:
CI: 50% Coins AD
FDP Pulp Cap - Adult:
CI: 50% Coins AD
FDP Bonding - Adult:
CI: 50% Coins AD
FDP Root Canal - Adult:
CI: 50% Coins AD
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
$50 per member
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
CI: 50% Coins AD
FDPA Gingivectomy or Gingivoplasty - Adult:
CI: 50% Coins AD
FDPA Gum Surgery - Adult:
CI: 50% Coins AD
FDPA Routine Braces - Adult:
CI: Not covered
FDPA Partial Dentures - Adult:
CI: 50% Coins AD
FDPA Complete Dentures - Adult:
CI: 50% Coins AD
FDPA Dental Implants - Adults:
CI: Not covered
FDPA Bridges - Adults:
CI: 50% Coins AD
FDPA Veneers - Adult:
CI: 50% Coins AD
FDPA TMJ - Adult:
CI: Not covered
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
$50
FDP MOOP Pediatric Individual:
$400
FDP Deductible Pediatric 2+ Children:
$100
FDP MOOP Pediatric 2+ Children:
$800
FDP Dental Check-Up - Child:
CI: No charge AD
FDP Basic Dental Care - Child:
CI: 50% Coins AD
FDP Orthodontia - Child:
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child:
CI: Not covered
FDP Major Dental Care - Child:
CI: 50% Coins AD
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
$100
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
$100 per member
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
None
FDP Office Visit With No Additional Services - Adult (Out of Network Cost Sharing Adult Benefits):
CI: No charge AD
FDP Oral Evaluation - Adult (Out of Network Cost Sharing Adult Benefits):
CI: No charge AD
FDP Complete Set of X-Rays - Adult (Out of Network Cost Sharing Adult Benefits):
CI: No charge AD
FDP Prophylaxis - Adult (Out of Network Cost Sharing Adult Benefits):
CI: No charge AD
FDP Topical Fluoride - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Polishing - Adult (Out of Network Cost Sharing Adult Benefits):
CI: No charge AD
FDP Sealant (per tooth) - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Spacers - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Simple Extraction - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
CI: 50% Coins AD
FDP Gum Surgery - Adult:
CI: 50% Coins AD
FDP Tissue Grafting - Adult:
CI: 50% Coins AD
FDP Routine Braces - Adult:
CI: Not covered
FDP Partial Dentures - Adult:
CI: 50% Coins AD
FDP Complete Dentures - Adult:
CI: 50% Coins AD
FDP Dental Implants - Adults:
CI: Not covered
FDP Bridges - Adults:
CI: 50% Coins AD
FDP Veneers - Adult:
CI: 50% Coins AD
FDP TMJ - Adult:
CI: Not covered
FDP Out of Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
$100
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
$200
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Dental Check-Up - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: No charge AD
FDP Basic Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: Not covered
FDP Major Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Network Information (Family Dental)
FDP Out of Country Coverage:
N
FDP Out of Service Area Coverage:
Y
FDP Out of Service Area Coverage Description:
Coverage is provided outside of the Service Area.
FDP National Network:
Y
FDP Network Name:
DentalGuard Preferred - Individual
FDP Network URL:
Counties
Albany:
$42.87
Bronx:
$51.80
Broome:
$41.44
Cattaraugus:
$40.56
Cayuga:
$41.44
Chautauqua:
$40.56
Chemung:
$41.44
Clinton:
$39.04
Columbia:
$42.87
Dutchess:
$43.47
Erie:
$40.56
Fulton:
$42.87
Genesee:
$40.56
Greene:
$42.87
Herkimer:
$39.04
Jefferson:
$39.04
Kings:
$51.80
Lewis:
$39.04
Livingston:
$43.93
Madison:
$39.04
Monroe:
$43.93
Montgomery:
$42.87
Nassau:
$48.25
New York:
$51.80
Niagara:
$40.56
Oneida:
$39.04
Onondaga:
$41.44
Ontario:
$43.93
Orange:
$43.47
Orleans:
$40.56
Putnam:
$43.47
Queens:
$51.80
Rensselaer:
$42.87
Richmond:
$51.80
Rockland:
$51.80
Saratoga:
$42.87
Schenectady:
$42.87
Suffolk:
$48.25
Sullivan:
$43.47
Tioga:
$41.44
Tompkins:
$41.44
Ulster:
$43.47
Warren:
$42.87
Washington:
$42.87
Wayne:
$43.93
Westchester:
$51.80
Wyoming:
$40.56