Plan
Plan Name:
Guardian Family Essentials, NS, OON DentalGuard Preferred Network, Dep25, Adult/Family Dental
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:
None
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
Lifetime Benefit Maximum:
N/A
Coverage Level:
Individual
Benefits Excluded from In Network MOOP:
N/A
Benefits Excluded from Out of Network MOOP:
N/A
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:
$100
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:
$425
FDP Deductible Pediatric 2+ Children:
$100
FDP MOOP Pediatric 2+ Children:
$850
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: 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):
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:
$23.44
Bronx:
$28.33
Broome:
$22.67
Cattaraugus:
$22.18
Cayuga:
$22.67
Chautauqua:
$22.18
Chemung:
$22.67
Clinton:
$21.35
Columbia:
$23.44
Dutchess:
$23.77
Erie:
$22.18
Fulton:
$23.44
Genesee:
$22.18
Greene:
$23.44
Herkimer:
$21.35
Jefferson:
$21.35
Kings:
$28.33
Lewis:
$21.35
Livingston:
$24.02
Madison:
$21.35
Monroe:
$24.02
Montgomery:
$23.44
Nassau:
$26.38
New York:
$28.33
Niagara:
$22.18
Oneida:
$21.35
Onondaga:
$22.67
Ontario:
$24.02
Orange:
$23.77
Orleans:
$22.18
Putnam:
$23.77
Queens:
$28.33
Rensselaer:
$23.44
Richmond:
$28.33
Rockland:
$28.33
Saratoga:
$23.44
Schenectady:
$23.44
Suffolk:
$26.38
Sullivan:
$23.77
Tioga:
$22.67
Tompkins:
$22.67
Ulster:
$23.77
Warren:
$23.44
Washington:
$23.44
Wayne:
$24.02
Westchester:
$28.33
Wyoming:
$22.18