Individual dental insurance products are underwritten by The Guardian Life Insurance Company of America, New York, New York or by one of its wholly owned subsidiaries. Products are not available in all states. Policy limitations and exclusions apply. The actual limitations and exclusions that apply to your Dental Plan are governed by the policy forms approved for use in your state. Please refer to your policy for a complete list of limitations and exclusions. In the event of a conflict between this document and the language stated in your Guardian insurance policy, the language of the policy shall control. This policy provides DENTAL insurance only.
Dental provider networks vary by state, by market and by plan type
Rates are guaranteed for one year for your policy of benefits initially selected. Policies renew annually.
IMPORTANT INFORMATION ABOUT GUARDIAN’S DENTALGUARD INDEMNITY AND DENTALGUARD PREFERRED PPO PLANS
Dental PPO plans provide in-network and out-of-network benefits. Use of an in-network provider may result in reduce out of pocket costs.
Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. Waiting periods may also apply for some services
Individual dental plans do not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments, any treatment to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment.
Individual dental plans limit benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic and prosthodontic services.
Listed services, exclusions and limitations do not constitute a contract and are a summary only.
IMPORTANT INFORMATION REGARDING DENTAL HMO BENEFITS
Dental HMOs provide Pre-Paid dental benefits through a network of participating general dentists and specialty care dentists. All covered services must be provided by the member’s Primary Care Dentist. Specialty care services are covered only when referred by the member’s Primary Care Dentist and approved in advance by the Dental DHMO.
Only those services listed in the Dental HMO plan are covered. Certain services are subject to annual or other periodic limitations. Where orthodontic benefits are specifically included, your policy provides for one course of comprehensive treatment per lifetime, per member. Dental HMOs do not provide orthodontic benefits if comprehensive orthodontic treatment or retention is in progress as of the member’s effective date. Listed services, exclusions and limitations do not constitute a contract and are a summary only.
Products Underwritten by Guardian Life Insurance Company of America
DENTAL PPO PLANS Policy Form IP-DEN-16 ET. AL.
DENTAL HMO PLANS
FLORIDA Policy Form IP-1-MDG-DHMO-FL-OFF-17
NEW YORK Policy Form IP-MDG-NY-FP-OFF-17
Products Underwritten by Managed Dental Guard, Inc.
DENTAL HMO PLANS
TEXAS Policy: IP-1-MDG-DHMO-TX-17
Products Underwritten by First Commonwealth Inc. through its Illinois subsidiaries*
DENTAL HMO PLANS
ILLINOIS Policy: IP-FCW-DHMO-IL-17
*First Commonwealth Insurance Company — (IL), First Commonwealth Limited Health Services Corporation — (IL), First Commonwealth of Illinois, Inc.