2023 | VEO Employee Benefit Guide

DENTAL GUARD PPO PREMIUM PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual: $50 Family: $150

Individual:

$75

Family:

$225

Aggregate Benefit Maximum For treatment of TMJ disorders For orthodontic treatment For all other covered dental expenses Diagnostic/Preventive Services Include: Periodic Oral Evaluation Cleaning, Fluoride Treatment & Sealants X-rays Space Maintainers Basic Services Include: Fillings Simple Extractions & Oral Surgery (Includes surgical extractions) Periodontics & Endodontics

$1,000 $2,500 $5,000

$1,000 $2,500 $5,000

0% of PPO negotiated contracted fee deductible waived

10% of R&C* charge deductible waived

20% of PPO negotiated contracted fee after deductible

30% of R&C* charge after deductible

Major Services Include: Bridges Dentures Inlays, Onlays & Crowns

30% of PPO negotiated contracted fee after deductible 40% of PPO negotiated contracted fee deductible waived

50% of R&C* charge after deductible

Orthodontic Include: Child(ren) and Adults

50% of R&C* charge deductible waived

*Out-of-Network UCR is 90%. Certain services may be covered under the Medical Plan. Contact Member Services for more details.

Allows a portion of unused benefit maximum to carry over to next years benefit maximum amount. To qualify, you must have had a dental service performed and claim submitted within the plan year. You must not exceed the paid claims threshold.

Maximum Rollover

IN-NETWORK ONLY MAXIMUM ROLLOVER AMOUNT

MAXIMUM ROLLOVER ACCOUNT LIMIT

ANNUAL BENEFIT MAXIMUM

MAXIMUM ROLLOVER AMOUNT

THRESHOLD

$5,000

$1,000

$500

$750

$1,500

You can also find a dentist on the go from your smart phone. Simply download our app at www.GuardianAnytime.com/mobile.

www.guardiananytime.com When searching for providers, select “ PPO ” Plan and “ Dental Guard Preferred ” Network

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail.