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Guardian Dental Advantage Silver

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

80%
No waiting period
Basic Services

Moderately complex dental services, including fillings and simple extractions

50%
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
0%
Not covered

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This policy provides DENTAL insurance only. The expected benefit ratio for this policy is 60 percent. This ratio is the portion of future premiums that the company expects to return as benefits, when averaged over all people with this policy.

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 $500
2nd Year Max: $750
3rd Year Max: $1,000
4th Year & Beyond Max: $1,000
Implant Maximum

See limitations & exclusions below

Lifetime Max: $700
Orthodontia Maximum

Applies to members under age 19 only

Not covered
Limitations and Exclusions
(see your policy for further details)

We will not pay for:

A. Cosmetic Services 

We do not Cover cosmetic services or surgery unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect, except as described in the Orthodontic Services sections of this Schedule of Benefits. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeals sections of this Policy unless medical information is submitted. 

B. Experimental or Investigational Treatment.

We do not Cover any health care service, procedure, treatment, or device that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under this Policy for non-investigational treatments. See the Utilization Review and External Appeal sections of this Policy for a further explanation of Your Appeal rights.

C. Felony Participation.

We do not Cover any illness, treatment or medical condition due to Your participation in a felony, riot or insurrection.

D. Government Facility.

We do not Cover care or treatment provided in a Hospital that is owned or operated by any federal, state or other
governmental entity, except as otherwise required by law.

E. Medical Services.

We do not Cover medical services or dental services that are medical in nature, including any Hospital charges or prescription drug charges.

F. Medically Necessary.

In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Policy.

G. Medicare or Other Governmental Program.

We do not Cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid).

H. Military Service.

We do not Cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units.

I. No-Fault Automobile Insurance.

We do not Cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if You do not make a proper or timely claim for the benefits available to You under a mandatory no-fault policy.

J. Services Not Listed.

We do not Cover services that are not listed in this Policy as being Covered.

K. Services Separately Billed by Hospital Employees.

We do not Cover services rendered and separately billed by employees of Hospitals, laboratories or other institutions.

L. Services with No Charge.

We do not Cover services for which no charge is normally made.

M. Workers’ Compensation.

We do not Cover services if benefits for such services are provided under any state or federal Workers’ Compensation, employers’ liability or occupational disease law.

 

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. 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-NY