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Guardian Dental Advantage Gold

Coverage Summary
(see your policy for further details)
Choose any Dentist
In-Network Dentist

Guardian’s negotiated rates save you up to 35% at In-Network Dentists

Out-of-Network Dentist

Reimbursement is based on the lower of your dentist’s fees or the amount that would be paid to dentists who have agreed to be reimbursed according to Guardian’s negotiated fee schedule

Your Plan Benefits
Guardian Pays
Waiting period is the time period following the coverage start date during which no benefits are paid
Preventive Services

Most routine dental services, including oral exams, cleanings, x-rays

100%
No waiting period
Basic Services

Moderately complex dental services, including fillings and simple extractions

70%
After a 6-month waiting period
Major Services

More complex dental services including crowns, complex extractions, oral surgery, periodontal, and endodontic services

50%
After a 12-month waiting period
Implants
50%
After a 12-month waiting period
Orthodontia

Applies to members under age 19 only

50%
After a 12-month waiting period
Deductibles
What you pay out-of-pocket before your plan pays benefits
You Pay
Preventive Services
$0 In-Network
$50 Out-of-Network
All Other Dental Services
$50
Maximum Payouts
The maximum amount Guardian will reimburse you for dental services received
Maximum Guardian Pays
Total Benefit Maximum

Benefit maximum payout increases every year for the 1st 3 years; one preventive visit required for each member each year

1st Year Max $1,000
2nd Year Max: $1,250
3rd Year Max: $1,500
4th Year & Beyond Max: $1,500
Implant Maximum

See limitations & exclusions below

Lifetime Max: $1,000
Orthodontia Maximum

Applies to members under age 19 only

Yearly Max: $500
Lifetime Maxi: $1,000
Limitations and Exclusions
(see your policy for further details)

We will not pay for:

  • Treatment for which no charge is made. This usually means treatment furnished by: (1) the covered person’s employer, labor union or similar group, in its dental or medical department or clinic; (2) a facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for or sponsored by any governmental body.
  • Treatment needed due to: (1) an on-the-job or job-related injury; or (2) a condition for which benefits are payable by Worker’s Compensation or similar laws.
  • Any service or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature.
  • Educational services, including, but not limited to: (1) oral hygiene instruction; (2) tobacco counseling; or (3) nutritional counseling.
  • Duplication of radiograph images, the completion of claim forms, OSHA or other infection control charges.
  • Any service performed in conjunction with, as part of, or related to a service which is not covered by this Policy.
  • Any service furnished solely for cosmetic reasons. This includes, but is not limited to: (1) characterization and personalization of a Dental Prosthesis; (2) bleaching of discolored teeth; and (3) odontoplasty.
  • The replacement of extracted or missing third molars (wisdom teeth).
  • Treatment of congenital or developmental malformations or the replacement of congenitally missing teeth, except when the service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part or when the service is needed to treat medically diagnosed congenital and developmental malformations for a newborn or newly adopted child.
  • Detailed and extensive oral evaluations.
  • Cephalometric radiographic images.
  • Oral /facial photographic images.
  • Pulp vitality tests or caries susceptibility tests.
  • The localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue.
  • Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation that is incidental to or results from a medical condition.
  • Overdentures and related services including root canal therapy on teeth supporting an overdenture.
  • Precision attachments.
  • Temporary or provisional Dental Prosthesis or Appliances except interim partial dentures (stayplates) to replace Anterior Teeth extracted while covered under this Policy.
  • A fixed bridge replacing the extracted portion of a hemisected tooth or the placement of more than one unit of a crown and/or bridge, per tooth.
  • Any service performed on a tooth or teeth with a guarded, questionable or poor prognosis.
  • Any restoration, service, Appliance or Dental Prosthesis used solely to: (1) alter vertical dimension; (2) restore or maintain occlusion; (3) treat a condition necessitated by attrition or abrasion; or (4) splint or stabilize teeth for periodontal reasons.
  • Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis.
  • Tooth re-implantation or tooth transplantation.
  • Any service, Appliance, Dental Prosthesis, modality or surgical service intended to treat or diagnose disturbances of the temporomandibular joint (TMJ) that are incidental to, or result from, a medical condition unless required due to state law.
  • Separate charges for local anesthetic.
  • Application of desensitizing medicaments and desensitizing resins for cervical and/or root surface.
  • Bite registration, bite analysis or occlusion analysis – mounted case.
  • Prescription medication.

Dental Insurance is underwritten by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Those shown above are illustrative only. 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 plan documents for a complete list of limitations and exclusions. Plan documents are the final arbiter of coverage. This policy provides DENTAL insurance only.

Policy Form #IP-DEN-16-ID