PMC 2024 Benefit Guide (English)

DENTAL PPO

BENEFIT

IN-NETWORK

OUT-OF-NETWORK*

Annual Deductible

Individual: $50 Family: $150

Individual: $50 Family: $150

Benefit Maximum Annual

$1,500

$1,000

Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral examinations; Topical fluoride (up to age 19); X-rays; Sealants (up to age 16); Space maintainers Basic Services Fillings; Simple Extractions; Oral surgery; Endodontics; Periodontics; Periodontal surgery; Consultations; Repairs of dentures, crowns, bridges, inlays and onlays Major Services Complex Extractions; Bridge and Dentures; Crowns, Inlays, Onlays, Implants and Veneers

Covered 100% (No deductible)

Covered 100% (No deductible)

Covered 90% after deductible

Covered 80% after deductible

Covered 60% after deductible

Covered 50% after deductible

Orthodontic Services (Dependents to age 19)

Not covered

Not covered

Reimbursement Level

N/A

Maximum Allowable Charge (MAC)

Coverage for Dependent Children

To Age 26

To Age 26

PLEASE BE ADVISED! * In - network dental providers are required to accept Guardian ’ s discounted rates for services, with no balance billing to members outside of deductibles and coinsurance. Utilizing out - of - network providers can result in balance billing.*

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