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William Gammon Insurance
and your employer.

Your Benefit Resources Center

Dental Insurance

Dental care is an important part of your overall health care. Being protected by dental insurance and using it wisely are essential safeguards for you and your family.

The dental coverage is underwritten by Guardian. You, and your family members, may select either the Managed DentalGuard DHMO Plan (DMO), Value Plan or the Network Access (NAP) Plan and can change your election annually.

  • The DMO Plan offers the most savings but all care must be received from a Managed DentalGuard Provider.
  • The Value Plan offers significant savings for in-network services.
  • The NAP Plan offers greater savings if your dentist does not participate in the Guardian DentalGuard Network.
Effective Date: October 1, 2013
Policy Number: 486208
Dental Insurance
Plan Highlights

Plan Name

Summary of
Benefits
Plan Type
Provider
Network
Deductible
Individual
Family
Waived for
Annual Benefit
Max
Preventive
Services
Oral Exams
X-Rays
Fluoride Treatment3
Sealants3
Space Maintainer
Basic Services
Fillings
Crowns
Bridges
Dentures
General Anesthesia
Root Canal
Perio Surgery
Scaling
Root Planing
Extractions
Major Services
Bridges
Dentures
Single Crowns
TMJ
Inlays
Onlays
Veneers
Orthodontic
Services
Lifetime Max
Available to
Maximum Rollover
Rollover Threshold
Rollover Amount
Rollover Limit
Dependent Age
Limit
Certificate of Coverage
Plan 1

MDG1

DMO
 
None
None
N/A
Unlimited
 
$5 CoPay
 
 
 
 
 
 
Discounted
Fee Schedule
 
 
 
 
 
 
 
 
 
Discounted
Fee Schedule
 
 
 
 
 
 
N/A
N/A
N/A
 
No
N/A
N/A
N/A
26
 
View COC
Pending
PPO Plan 2

Value2

100/100/60/0
 
$50
$150
Preventive
$1,000
 
0%,
paid at 100%
 
 
 
 
 
0%,
paid at 100%
 
 
 
 
 
 
 
 
 
40%,
paid at 60%
 
 
 
 
 
 
Not Covered
 
 
 
Yes
$500
$250
$1,000
26
 
View COC
Pending
PPO Plan 2

NAP 

100/80/50/0
 
$50
$150
Preventive
$1,000
 
0%,
paid at 100%
 
 
 
 
 
20%,
paid at 80%
 
 
 
 
 
 
 
 
 
50%,
paid at 50%
 
 
 
 
 
 
Not Covered
 
 
 
Yes
$500
$250
$1,000
26
 
View COC
Pending
PPO Plan 3

Value2

100/100/60/50
 
$50
$150
Preventive
$1,500
 
0%,
paid at 100%
 
 
 
 
 
0%,
paid at 100%
 
 
 
 
 
 
 
 
 
40%,
paid at 60%
 
 
 
 
 
 
50%,
paid at 50%
 
 
Yes
$700
$350
$1,250
26
 
View COC
Pending
PPO Plan 3

NAP 

100/80/50/50
 
$50
$150
Preventive
$1,500
 
0%,
paid at 100%
 
 
 
 
 
20%,
paid at 80%
 
 
 
 
 
 
 
 
 
50%,
paid at 50%
 
 
 
 
 
 
50%,
paid at 50%
 
 
Yes
$700
$350
$1,250
26
 
View COC
Pending
Notes
  1. All care must be provided by a Managed DentalGuard provider.
  2. The Value Plan is not recommended unless your dentist is a DentalGuard provider.
  3. Age limits apply. Refer to your Certificate of Coverage for specific plan details.
  4. View DMG Price Schedule.
This is only a Summary of Benefits. Limitations and exclusions apply.
Refer to your Certificate of Coverage for specific plan details.