Summary of Benefits

Summary of Benefits

Dental Benefit Summary

Group ID:

00466845

Group Name:

EMPLOYER SOLUTIONS GROUP

Waiting Period:

1st of the month following 1 month(s)

Coverage Type: Class:

As of Date:

Plan Information

Your dental networks is: Dental - Premier Dental Group - Minnesota

Coverage Information

Contributory

0003 ALL ELIGIBLE NON-CORPORATE EMPLOYEES EXCEPT FLT-MED EMPLOYEES

11/07/2019

Dental - Premier Dental Group - Minnesota

What's the most cost-effective way to use dental insurance?

Calendar year deductible

You may go to any dentist, however those who belong to the Dental - Premier Dental Group Minnesota network will be most cost effective.

In Network None

Out of Network

$50, Once the annual deductible is met by each of three family members, no further deductibles apply.

Preventive

Waived

Waived

Basic

Waived

Not Waived

Major

Waived

Not Waived

Calendar Year Maximum Benefit

The amount shown in the out of network field is your combined Calendar Year maximum for both

in and out of network services.

$1,000

Maximum rollover

Yes

Yes

Monthly Switch

Not Available

Not Available

How much does the plan pay?

How much does the plan pay?

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Dental - Premier Dental Group - Minnesota

What's the most cost-effective way to use dental insurance?

Office Visit Co-pay (one office visit may cover multiple services) Preventive Care:

You may go to any dentist, however those who belong to the Dental - Premier Dental Group Minnesota network will be most cost effective.

In Network None

Out of Network None

100%

100%

Bitewing X-Rays

100%

100%

Full Mouth X-Rays

100%

100%

Cleaning

100%

100%

Oral Exams

100%

100%

Sealants (per tooth)

100%

100%

Basic Care:

90%

80%

Fillings (one surface)

90%

80%

General Anesthesia1

90%

80%

Scaling & Root Planing (per quadrant)

Simple Extractions

90% 90%

80% 80%

Major Care:

60%

50%

Dentures

60%

50%

Single Crowns

60%

50%

Orthodontia

Not Available

Not Available

General Exclusions

Important Information about Guardian's DentalGuard Indemnity and DentalGuard Preferred PPO plans: This policy provides dental insurance only. Coverage is limited to charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for:

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Oral hygiene services (except as covered under preventive services), Orthodontia (unless expressly provided for), Cosmetic or experimental treatments (unless they are expressly provided for). Any treatments to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract # GP-1-DEN -16 et al. Teeth lost or missing before a covered person becomes insured by this plan. A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won't pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan. R3-DG2000 1 Restrictions apply and may be subject to medical necessity. This Benefit Summary is for illustrative purposes. Your benefits booklet will show exactly what is covered and/or excluded under your plan. If there is a discrepancy between this Benefit Summary and your benefit booklet, the benefit booklet prevails. Definitions shown on this site are in summary form and are for general informational purposes. The terms of the insurance contract prevails.

Produced on 11/07/2019 at 12:11:16 EST

Summary of Benefits

Vision Benefit Summary

Group ID:

00466845

Group Name:

EMPLOYER SOLUTIONS GROUP

Waiting Period:

1st of the month following 1 month(s)

Plan Information

Your network is the VSP - Signature Full Feature

Coverage Information

Coverage Type: Class:

As of Date:

Contributory

0003 ALL ELIGIBLE NON-CORPORATE EMPLOYEES EXCEPT FLT-MED EMPLOYEES

11/07/2019

What's the most cost-effective way to use vision benefits?

Co-Pay First service provided Exams Materials

VSP - Signature Full Feature

You may go to any eye doctor however, if you go to a VSP network provider you will usually pay less.

In-Network

Out-Of-Network

Not applicable Exams $20.00 waived for conventional and planned replacement contact lenses $20.00

How often can I obtain service?

Exams: Every 12 months Lenses: Every 12 months Frames: Every 24 months Materials: Every 12 months

In-Network

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Out-Of-Network

What's the most cost-effective way to use vision benefits?

Eye exams

Lenses Single vision lenses

Lined bifocal lenses

Lined trifocal lenses

Lenticular lenses

Contact Lenses Conventional Planned replacement and disposable Medically necessary

Evaluation and fitting Frames

Lens & Frame Allowance Cosmetic Extras Laser correction surgery

Hearing

VSP - Signature Full Feature

You may go to any eye doctor however, if you go to a VSP network provider you will usually pay less.

In-Network

Out-Of-Network

Copay applies

Amount over: $46.00

Copay applies Copay applies Copay applies Copay applies

Amount over: $47.00

Amount over: $66.00

Amount over: $85.00

Amount over: $125.00

Amount over: $120.00 Amount over $120.00

Amount Over $120 Amount Over $120

Copay Applies

15% off professional fee $120.00, 20% discount on amount over $120.00.

No discounts Discounted at an average of 30%. Average 15% discount off usual price or 5% off promotional

price. No discounts

Amount over: $210.00

Not Covered Amount over:

$47.00 No discounts No discounts No discounts

No discounts

Vision and General Exclusions

Important information This policy provides vision care limited benefits health insurance only. It does not provide basic hospital, basic medical or major

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