Plan
Plan Name:
Guardian Family Basics, NS, OON, DentalGuard Preferred Network, Dep25, Adult/Family Dental, WP
Issuer Name:
Guardian
HIOS ID:
42640NY0350001
Annual Benefit Maximum:
$1,500
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, Pulp Cap, Root Canal, Scaling, Planing, Gingivectomy or Gingivoplasty, Gum Surgery, Tissue Grafting.
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
Limits on Services:
Yes
Lifetime Benefit Maximum:
N/A
Coverage Level:
Family
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: 40% Coins AD
FDP Fillings - Adult:
CI: 40% Coins AD
FDP Single Restoration Crowns - Adult:
CI: Not covered
FDP Pulp Cap - Adult:
CI: 40% Coins AD
FDP Bonding - Adult:
CI: 40% Coins AD
FDP Root Canal - Adult:
CI: 40% Coins AD
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
$100
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
CI: 40% Coins AD
FDPA Gingivectomy or Gingivoplasty - Adult:
CI: 40% Coins AD
FDPA Gum Surgery - Adult:
CI: 40% Coins AD
FDPA Routine Braces - Adult:
CI: Not covered
FDPA Partial Dentures - Adult:
CI: Not covered
FDPA Complete Dentures - Adult:
CI: Not covered
FDPA Dental Implants - Adults:
CI: Not covered
FDPA Bridges - Adults:
CI: Not covered
FDPA Veneers - Adult:
CI: Not covered
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):
N/A
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
$200
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
N/A
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: 40% Coins AD
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 40% Coins AD
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 40% Coins AD
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 40% Coins AD
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 40% Coins AD
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 40% Coins AD
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
CI: 40% Coins AD
FDP Gum Surgery - Adult:
CI: 40% Coins AD
FDP Tissue Grafting - Adult:
CI: 40% Coins AD
FDP Routine Braces - Adult:
CI: Not covered
FDP Partial Dentures - Adult:
CI: Not covered
FDP Complete Dentures - Adult:
CI: Not covered
FDP Dental Implants - Adults:
CI: Not covered
FDP Bridges - Adults:
CI: Not covered
FDP Veneers - Adult:
CI: Not covered
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):
N/A
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
N/A
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
N/A
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
N/A
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:
$78.21
Bronx:
$98.27
Broome:
$75.24
Cattaraugus:
$73.45
Cayuga:
$75.24
Chautauqua:
$73.45
Chemung:
$75.24
Clinton:
$70.38
Columbia:
$78.21
Dutchess:
$80.08
Erie:
$73.45
Fulton:
$78.21
Genesee:
$73.45
Greene:
$78.21
Herkimer:
$70.38
Jefferson:
$70.38
Kings:
$98.27
Lewis:
$70.38
Livingston:
$80.38
Madison:
$70.38
Monroe:
$80.38
Montgomery:
$78.21
Nassau:
$90.74
New York:
$98.27
Niagara:
$73.45
Oneida:
$70.38
Onondaga:
$75.24
Ontario:
$80.38
Orange:
$80.08
Orleans:
$73.45
Putnam:
$80.08
Queens:
$98.27
Rensselaer:
$78.21
Richmond:
$98.27
Rockland:
$98.27
Saratoga:
$78.21
Schenectady:
$78.21
Suffolk:
$90.74
Sullivan:
$80.08
Tioga:
$75.24
Tompkins:
$75.24
Ulster:
$80.08
Warren:
$78.21
Washington:
$78.21
Wayne:
$80.38
Westchester:
$98.27
Wyoming:
$73.45