Benefit and Cost Summary

$1,000 Per Person Calendar Year Maximum
Calendar Year Deductible and Maximums are from January 1st through December 31st. Coverage for Crowns terminates on the date that insurance ends.

City of Rosenberg

Basic Plan Features:

• $50 Calendar Year Cash Deductible per person with a limit of 3 deductibles per family.
• The deductible is waived for Preventive Services.
• The plan pays 100% of covered charges for Preventive Services, 80% of covered charges after the deductible for Basic Services, and 50% of covered charges after the deductible for Major Services to a maximum of $1,000 per Calendar Year, per covered person.
• The plan pays 50% of covered Orthodontia charges to a lifetime maximum of $1,000 for children up to the age of 19. The deductible does not apply to Orthodontia.

Additional Features:

• Indemnity Dental Plan – Members choose their own dentist!
• There are no waiting periods for any services (unless Employee/Dependents are a Late Entrant (1)).
• Access to a network access plan – a listing of dentists contracted with the Guardian to provide additional discounts off services and procedures to Guardian dental plan members. Locate these dentists on the web at www.theguardian.com or in your Dental Guard Directory.
• Dental Claims:
  P. O. Box 2459
  Spokane, WA 99210-2459
  Phone: 1-800-695-4542
  Fax: 509-468-4590
• Pre-determination Review – Guardian will gladly assist you and your dentist by determining what benefits could be payable for services and procedures over $200. Have your dentist fax your treatment plan to Guardian. Note that it is a pre-determination review and we will let your dentist know what benefits would be payable. (This includes orthodontic treatment if your plan includes it.)
• Dependent children are covered to age 20 or to age 26 if a full-time student. Please provide Guardian with documentation regarding student status beginning each semester.

(1) A late entrant is a person who becomes insured more than 31 days after he is eligible; or becomes insured again, after his coverage lapsed because he did not make required payments. We won’t cover charges incurred by a late entrant for:

• Group II (basis) services until 6 months from the date he is insured by this plan; and
• Group III (major) services until 12 months from the date he is insured by this plan and Group IV (orthodontics) services until 24 months from the date he is insured by this plan.