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Guardian Managed DentalGuard - IL

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

Under this plan, you must be assigned to a Primary Care Dentist of your choice from our Network of contracted providers. All care must be provided or arranged by your Primary Care Dentist.

Out-of-Network Dentist

No coverage

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, topical fluoride

Most preventive services covered at 100% without any copay
No waiting period

Sample Copays: (see full copay schedule below)

  • Prophylaxis (dental cleaning) first 2 services in any 12-month period = $0 
  • Sealant – per tooth (molars) = $14 
Basic Services

Moderately complex dental services, including fillings and simple extractions

100% less your copay
No waiting period

Sample Copays: (see full copay schedule below)

  • Filling (amalgam – one surface; primary or permanent) = $28 
  • Simple extraction (extraction, erupted tooth or exposed root removal) = $35
Major Services

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

100% less your copay
No waiting period

Sample Copays: (see full copay schedule below)

  • Endodontic (root canal) therapy bicuspid tooth (excluding final restoration) = $300  
  • Crowns (porcelain/ceramic substrate) = $450 
Implants
0%
Not covered
Orthodontia
100% less your copay
No waiting period

Sample Copays: (see full copay schedule below) 

  • Children under 19 = $350 (note: copay in schedule of benefits below is higher, but is capped by the Out-of-Pocket Maximum for children under 19)  
  • Adults 19 and over = $2,800 
Special Affordable Care Act (ACA)
Pediatric Dental Benefit

This plan includes the pediatric dental Essential Health Benefit (EHB) as mandated by the Affordable Care Act (ACA), which is a comprehensive set of dental services for children under age 19. See full copayment schedule below for details.

Office Visit Charges
Flat charge per office visit in addition to your copay for each procedure
You Pay
(per insured member)
Charge for each Office Visit
$15
Deductibles
What you pay out-of-pocket before your plan pays benefits
You Pay
Preventive Services
$0
All Other Dental Services
$0
Maximum Payouts
The maximum amount Guardian will reimburse you for dental services received
Maximum Guardian Pays
Total Benefit Maximum
No maximum
Implant Maximum
Not covered
Orthodontia Maximum
No maximum
Your Out-of-Pocket Maximum
(for Children under 19 Only)
Once you pay this amount, Guardian will pay 100% of your child’s dental charges for the rest of the year
Maximum You Pay
(for Children under 19 Only)
1 insured child
$350
2 or more insured children
$700
Copayment Schedule

Full Copay Schedule

Limitations and Exclusions
(see your policy for further details)

Dental DHMO coverage in Illinois is underwritten by First Commonwealth Insurance Company (Illinois). Products are not available in all counties.  Current Dental Terminology (c) 2013 American Dental Association (ADA). All rights reserved. Note: Procedures listed above are for sample purposes only and do not encompass all covered services. Actual patient charges will vary based on the procedure and are listed on the full co-payment schedule.  Policy limitations and exclusions apply.  Those shown above are illustrative only.  The actual limitations and exclusions that apply to your Dental DHMO Plan are governed by the policy forms approved for use in Illinois.  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-FCW-DHMO-IL-17