Guardian Managed DentalGuard

Transcription

Guardian
Managed DentalGuard
Groups of 2-50 employees
Managed DentalGuard Rates (DMO)
Two Tier
$16.35 Employee only
N/A
N/A
$43.27 Family*
Four Tier
$32.82 Employee/Spouse*
$33.97 Employee/Child(ren)
$50.32 Family*
HealthPass offers Guardian Managed DentalGuard
(In-Network only dental plan)
●
Only a $5.00 copay for each primary care office visit
(1st visit includes a cleaning, checkup and x-ray; 2nd visit includes second cleaning only)
No annual maximum on the plan
Most diagnostic and preventive services are provided at no additional cost
● Reasonable and fixed patient charges apply for basic and major
services – orthodontia benefits are included at no additional premium cost
● No deductible
● Unlimited ability to change dentists monthly
●
●
Affordable Care
With the Guardian Managed DentalGuard pre-paid plan, each member selects a
primary dental facility from the directory of participating general dentists. All covered
family members may choose different primary care dentists, or the same dentist based
on personal preference. The primary care dentist will perform all dental services and
coordinate referrals to network specialists when necessary. This process ensures
continuity of care and helps keep the plan cost-effective.
About the Plan
With Guardian Managed DentalGuard, you and your family can count on
accessible, concerned care. All covered services are based on a list of fixed patient
charges, so you’ll always know exactly what your out-of-pocket costs will be. Plus, there
are never any claim forms to complete! If you should need a dental specialist, the Managed
DentalGuard network i ncludes oral surgeons, periodontists, endodontists, orthodontists
and pediatric dental specialists. Your primary care dental office can obtain a specialists referral.
If you use a dentist who does not participate with the Managed DentalGuard network or do not obtain a
specialists referral, your procedures will not be covered.
Dental coverage can only be elected by a group enrolling in HealthPass medical coverage. If a group
begins their medical coverage on the 15th of the month, dental coverage will begin on the 1st of the
following month.
*Rates for Domestic Partners will be the same as rates for Employee/Spouse and Family for
groups enrolled in Four Tier; Family for groups enrolled in Two Tier.
This is a summary of plan information. Please refer to the Eligibility Guidelines for further information.
V1 of 1 10.12
888.313.7277
www.healthpassny.com
HealthPass Dental
Guardian Managed DentalGuard
Diagnostic
Copayment
101
Office Visit,All
$5
$20
102
Broken Appointment ( without 24 h
0150
Comprehensive Oral Examination No Charge
0120
Periodic Oral Exam
No Charge
0140
Limited Problem Focused Exam
No Charge
0210
Intraoral-complete series (incl bitewNo Charge
0220
Periapical-first film
No Charge
0230
Periapical-each add'l
No Charge
0240
Occlusal x-ray
No Charge
0270-74 Bitewing x-rays
No Charge
0330
Panoramic film
No Charge
0460
Pulp vitality test
No Charge
0470
Diagnostic casts
No Charge
Preventive
1110/20 Prophylaxis-adult/child
1201
Tropical Application of Fluoride
1203
Topical fl w/o prophy-child/adult
1310
Nutritional counseling
1330
Oral hygiene instruction
1351
Sealant-per tooth
1510
Space maint-fixed unilateral
1515
Space maint-fixed bilateral
1550
Recementation space maint
No Charge
No Charge
No Charge
No Charge
No Charge
$8
$54
$72
$12
Minor Restorative
Amalgam-1 surf primary
2110
2120
2130
Amalgam-4 or 4+ surf primary
2131
Amalgam-1 surf permanent
2140
2150
2160
Amalgam-4 or 4+ surf permanent
2161
2210
Silicate cement- per restoration
2330
Resin-1 surf anterior
2331
2332
2335
Resin-4+ or incisal, anterior
2336
Composite Resin Crown, Anterior P
2380
Resin - 1 surf Posterior Primary
2381
2382
2385
Resin - 1 Surf Posterior Permanen
2386
Resin - 2 Surfs Posterior Permane
2387
Resin - 3 Surf Posterior Permanen
2910
Recement inlay
2920
Recement crown
2940
Sedative filling
$15
$19
$23
$28
$17
$22
$26
$32
$15
$20
$26
$32
$38
$95
$55
$65
$80
$56
$75
$95
$18
$18
$17
Crowns & Fixed Bridges
2510
Inlay-metallic-1 surf*
2520
2530
2543
Onlay-metallic-3 Surfaces*
2544
Onlay-metallic-4 or more Surfaces*
2702
Crown supporting existing partial d
2703
Multiple crown and bridge unit trea
2740
Crown-porcelain/ceramic substrate
2750
Crown-porcelain fused to high nob
2751
Crown-porc to predominantly base
2752
Crown-porcelain fused to noble me
2790
Crown-full cast high noble metal*
2791
Crown-full cast predominantly base
2792
Crown-full cast noble metal
$280
$320
$370
$380
$395
$125
$125
$395
$395
$395
$395
$395
$395
$395
Copayment
2810
Crown-3/4 cast metallic*
$395
2930
Prefab stainless steel crown-prima
$110
2931
Prefab stainless steel crown-perma $110
2932
Prefabricated Resin Crown
$135
2950
Core buildup, including any pins
$100
2951
Pin retention-per tooth, in add'n to
$22
2952
Cast post & core in add'n to crown* $155
2954
Prefab post & core in add'n to crow $125
6210
Pontic-cast high noble metal*
$385
6211
Pontic-cast predominantly base me $385
6212
Pontic-cast noble metal
$385
6240
Pontic-porc fused to high noble me $385
6241
Pontic-porc fused to predom base
$385
6242
Pontic-porc fused to noble metal
$385
6520
Inlay-metallic-2 surfaces*
$320
6530
Inlay-metallic-3 or more surfaces*
$370
6543
Retainer onlay, metallic, three surfa $380
6544
Retainer onlay, metallic, four or mo $395
6750
Crown-porcelain fused to high nob
$395
6751
Crown-porc fused to predom base
$395
6752
Crown-porcelain fused to noble me $395
6780
Crown-3/4 cast high noble metal*
$395
6790
$395
6791
Crown-full cast predominantly base $395
6792
$395
6970
Cast post & core in add'n to abut*
$155
6972
Prefab post & core in add'n to abut $125
6973
Core buildup for abut, incl any pins $100
Endodontics
3110
Pulp cap-direct (excl rest)
3120
Pulp cap-indirect (excl rest)
3220
Therapeutic pulpotomy (excl rest)
3310
Anterior root canal (excl final rest)
3320
Bicuspid root canal (excl final rest)
3330
Molar root canal (excl final restr)
3346
Retreatment-anterior, by report
3347
Retreatment-bicuspid, by report
3348
Retreatment-molar, by report
3410
Apicoectomy/periradicular surg-ant
Apico/perirad surg-bicuspid (first ro
3421
Apico-perirad surg-molar (first root
3425
Apico/periradic surg (each add'l roo
3426
3430
Retrograde filling-per root
$10
$10
$25
$120
$145
$370
$315
$370
$445
$265
$300
$350
$110
$80
Dentures
Copayment
5410/11 Adjust complete denture-upper or l
$25
5421/22 Adjust partial denture-upper or low
$25
5510
Repair broken complete denture ba $50
5520
Replace Missing or Broken Teeth
$45
5610
Repair resin saddle or base
$55
5630
Repair or relace broken clasp
$70
5640
Replace broken teeth-per tooth
$45
5650
Add tooth to existing partial denture $65
Add clasp to existing partial dentur
$80
5660
5710
Rebase Complete Upper Denture
$200
5711
Rebase Complete Lower Denture
$200
5720/21 Rebase Partial Upper or Lower De $200
5730/31 Reline complete upper/lower (chai $110
5740/41 Reline upper/lower partial (chairsid $110
5750/51 Reline complete upper/lower dentu $150
5760/61 Reline upper/lower partial denture
$150
5820
Interim partial denture ( stay plate ) $175
5821
Interim partial denture ( stay plate ) $175
5850/51 Tissue conditioning, upper/lower-p
$45
Oral Surgery
7110
Single tooth extraction
7120
Each additional tooth extraction
7130
Root removal-exposed roots
7210
Surgical removal erupted tooth w/fl
7220
Removal of impacted tooth-soft tiss
7230
Removal of impacted tooth-partial
7240
Removal of impacted tooth-full bon
7241
Removal of impacted tooth-complic
7250
Surgical removal of residual tooth r
7270
Tooth reimplantation and/or stabiliz
7280
Surgical exposure of impacted or u
7281
Surgical exposure to aid eruption
7285
Biopsy of oral tissue- hard
7286
Biopsy of oral tissue- soft
Alveoplasty in conjunction w/ext-qu
7310
Alveoplasty w/o extract-quad
7320
7450
Removal odont cyst-Lesion up to 1
7451
Removal odont cyst-Lesion over 1.
7470
Removal of exostosis- maxilla or m
7510
Incision/drainage of abscess-intrao
7960
Frenulectomy (frenectomy or freno
$22
$22
$30
$90
$115
$150
$180
$225
$95
$210
$230
$195
$125
$85
$105
$140
$350
$540
$450
$105
$230
Cosmetic
2960
Labial veneer (laminate)-chairside
$295
Periodontics
4210
Gingivectomy or gingivoplasty-per
4211
Gingivectomy or gingivoplasty-per
4240
Gingival Flap Procedure, including
4249
Crown lengthening-hard & soft tiss
4260
Osseous surg incl flap entry/closur
4261
Osseous Surgery Inc.flap entry/clo
4270
Pedical soft tissue graft procedure
4271
Free soft tissue graft proc (incl don
4341
Periodontal scaling/root planing-pe
4355
Debridement to Enable Diagnosis
4910
Periodontal maintenance procedur
4920
Unscheduled dressing change ( oth
$235
$60
$275
$275
$392
$235
$290
$298
$40
$24
$22
$19
Orthodontics
102
Broken appointment ( without 24 h
$20
8601
Orthodontic evaluation and consula $100
8602
Orthodontic treatment plan and rec $150
x-rays, study models and diagnostic photos
8070
Comprehensive orthodontic treatm $2,425
8080
fabrication and insertion of fixed ba $2,425
8090
appliance and periodic visits up to $2,425
8670
Periodic comprehensive orthodonti $102
8680
Orthodontic retention
$425
9430
Office visit for observation, no othe
$0
9440
Emergency office visit after hours
$20
Dentures
5110/20 Complete upper or lower denture
5130/40 Immediate upper or lower Denture
5211
Upper partial-resin base
5212
Lower partial-resin base
5213/14 Upper or lower partial -Chrome ca
$452
$492
$381
$443
$500
Miscellaneous
9110
Emergency palliative treatment
$20
9215
Local anesthesia
No Charge
$30
9310
Consultation by other than primary
9430
Office Visit for Observation
No Charge
9440
Office Visit, after hours
$20
$20
9951
Occlusal adjustment-limited per vis
* Copayment is exclusive of the price of gold.
A complete description of benefits, limitations and exclusions is included in your subscription certificate.
Guardian
DentalGuard Preferred
(Dual Option DMO/PPO)
DentalGuard Preferred Rates (PPO)
Two Tier
Four Tier
N/A
N/A
$92.02 Family*
$107.96 Family*
HealthPass offers Guardian DentalGuard Preferred
(In-Network and Out-of-Network dental plan)
●
●
●
●
●
●
No referrals are needed to see a specialist
Unlimited ability to change dentists
Includes out-of-area emergency coverage
$50 deductible for In-Network services
$75 deductible for Out-of-Network services
Annual maximum of $1,000
Affordable & Flexible Care
Guardian DentalGuard Preferred combines the freedom of a PPO dental plan with
the economy of managed care. Whenever you or a family member needs dental
services, you may visit a carefully screened In-Network dentist or any dentist you
wish. If you visit an In-Network dentist, you will typically receive a higher level of
benefits and save on out-of-pocket costs.
About the Plan
With Guardian Preferred DentalGuard, you and your family can count on accessible,
concerned care. Plus, there are never any claim forms to complete for In-Network
services! If you choose to go Out-of-Network, most dentists will submit your claims
directly to Guardian - hassle free. Either an In-Network or Out-of-Network general
participating dentist may suggest you see a specialist. No referrals are needed for
specialist care. You are always free to see any specialist you would like or choose one
from your Guardian provider directory.
Dental coverage can only be elected by a group that is enrolling in HealthPass
medical coverage. If a group begins their medical coverage on the 15th of the month,
dental coverage will begin on the 1st of the following month.
*Rates for Domestic Partners will be the same as rates for Employee/Spouse and
Family for groups enrolled in Four Tier; Family for groups enrolled in Two Tier.
V1 of 1 10.12
888.313.7277
HealthPass
DentalGuard Preferred
$1,000 Maximum
$50 In-Network deductible / $75 Out-of-Network deductible
(waived for Preventive care)
X-rays and Sealants covered as basic
Out-of-Network covered at the 70th percentile
Virgin Groups & Employees: Crowns, Bridges, Prostho-and Periodontic coverage deferred for 12 months
Transfer Groups: Crowns, Bridges, Prostho-and Periodontic deferred 12 months for future hires only
Coinsurance
Sample Covered Charges
Code
Name
Diagnostic and Preventive
120
Periodic Examination
1110
Prophylaxis-adult (teeth cleaning)
210
Full mouth x-rays (basic service, subject to deductible)
In Network
100%
100%
80%
Out of Network
80%
80%
80%
Restorative
Fillings (amalgam)
2140
one surface – permanent
2150
two surfaces – permanent
2160
three surfaces – permanent
80%
80%
80%
80%
80%
80%
Endodontics
Root Canal therapy
3310
anterior
3320
bicuspid
3330
molar
50%
50%
50%
50%
50%
50%
Periodontics
4341
4210
4211
50%
50%
50%
50%
50%
50%
Crown and Bridge
2740
Porcelain Crown
2750-52
Porcelain with metal crown*
2790-92
Cast metal crown*
50%
50%
50%
50%
50%
50%
Prosthodontics
5110-20
5213
5730
5750
Complete denture (upper or lower)
Partial denture
Denture reline (chairside)
Denture reline (laboratory)
50%
50%
50%
50%
50%
50%
50%
50%
Oral Surgery
7110
7510
Extract single tooth
Incision and drainage of abscess
50%
50%
50%
50%
Impactions
7220
7230
7240
Extract impacted tooth, soft tissue
Extract impacted tooth, partial bony
Extract impacted tooth, full bony
50%
50%
50%
50%
50%
50%
N/A
N/A
N/A
N/A
Perio scaling & root planning, per quad.
Gingivectomy, per quadrant
Gingivectomy, per tooth, up to 2 teeth
Orthodontia – Comprehensive Treatment
Child to age 18
Member over age 18
* If high noble metal is used, there will be an additional patient charge for the actual cost of the high noble metal.
DentalGuard Dental Insurance Plan General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those
charges that are necessary to prevent, diagnose or treat dental disease, defect or injury. Deductibles apply. The plan does not pay for: oral hygiene
services (except as covered under Preventive Services), orthodontic (unless expressly provided for), cosmetic or experimental treatments, 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. GP-1-DG-2000 et al.
Guardian
Managed DentalGuard Plus
Managed DentalGuard Plus Rates (DMO)
Two Tier
N/A
N/A
$51.11 Family*
Four Tier
$61.74 Family*
HealthPass offers Guardian Managed DentalGuard Plus
(In-Network only dental plan)
●
Only a $5.00 copay for each primary care office visit
(1st visit includes a cleaning, checkup and x-ray; 2nd visit includes second cleaning only)
No annual maximum on the plan
Most diagnostic and preventive services are provided at no additional cost
● Reasonable and fixed patient charges apply for basic and major
services – orthodontia benefits are included at no additional premium cost
● No deductible
● Unlimited ability to change dentists monthly
●
●
Affordable Care
With the Guardian Managed DentalGuard Plus pre-paid plan, each member selects a
primary dental facility from the directory of participating general dentists. All covered
family members may choose different primary care dentists, or the same dentist based
on personal preference. The primary care dentist will perform all dental services and
coordinate referrals to network specialists when necessary. This process ensures
continuity of care and helps keep the plan cost-effective.
About the Plan
With Guardian Managed DentalGuard Plus, you and your family can count on
accessible, concerned care. All coveres services are based on a list of fixed patient
charges, so you’ll always know exactly what your out-of-pocket costs will be. Plus, there
are never any claim forms to complete! If you should need a dental specialist, the Managed
DentalGuard network i ncludes oral surgeons, periodontists, endodontists, orthodontists
and pediatric dental specialists. Your primary care dental office can obtain a specialists referral.
If you use a dentist who does not participate with the Managed DentalGuard network or do not obtain a
specialists referral, your procedures will not be covered.
Dental coverage can only be elected by a group enrolling in HealthPass medical coverage. If a group
begins their medical coverage on the 15th of the month, dental coverage will begin on the 1st of the
following month.
*Rates for Domestic Partners will be the same as rates for Employee/Spouse and Family for
groups enrolled in Four Tier; Family for groups enrolled in Two Tier.
V1 of 1 10.12
888.313.7277
HealthPass Managed DentalGuard Plus
Diagnostic
Copayment
101
Office Visit,All
$5
$15
102
Broken Appointment ( without 24 hours not
0150
Comprehensive Oral Examination
No Charge
0120
Periodic Oral Exam
No Charge
0140
Limited Problem Focused Exam
No Charge
0210
Intraoral-complete series (incl bitewings) No Charge
0220
Periapical-first film
No Charge
0230
Periapical-each add'l
No Charge
0240
Occlusal x-ray
No Charge
0270-74 Bitewing x-rays
No Charge
0330
Panoramic film
No Charge
0460
Pulp vitality test
No Charge
0470
Diagnostic casts
No Charge
Preventive
1110/20 Prophylaxis-adult/child
1201
Tropical Application of Fluoride
1203
Topical fl w/o prophy-child/adult
1310
Nutritional counseling
1330
Oral hygiene instruction
1351
Sealant-per tooth
1510
Space maint-fixed unilateral
1515
Space maint-fixed bilateral
1550
Recementation space maint
No Charge
No Charge
No Charge
No Charge
No Charge
$6
$41
$54
$9
Minor Restorative
2110
2120
2130
2131
Amalgam-4 or 4+ surf primary
2140
$11
$15
$18
$21
$13
2150
2160
2161
2210
2330
2331
2332
2335
2336
2380
2381
2382
2385
2386
2387
2910
2920
2940
$16
$20
$24
$11
$15
$20
$24
$28
$31
$18
$20
$25
$17
$24
$30
$12
$12
$12
Amalgam-4 or 4+ surf permanent
Silicate cement- per restoration
Resin 4+ or incisal
Resin-4+
incisal, anterior
Composite Resin Crown, Anterior Primary
Resin - 1 Surf Posterior Permanent
Resin - 2 Surfs Posterior Permanent
Resin - 3 Surf Posterior Permanent
Recement inlay
Recement crown
Sedative filling
2510
2520
2530
2543
2544
2702
2703
2740
2750
2751
2752
2790
2791
2792
Onlay-metallic-3 Surfaces*
Onlay-metallic-4 or more Surfaces*
Crown supporting existing partial denture
Multiple crown and bridge unit treatment
plan per unit
Crown-porcelain/ceramic substrate
Crown-porcelain fused to high noble metal
Crown-porc to predominantly base metal
Crown-porcelain fused to noble metal
Crown-full cast predominantly base metal
$197
$225
$260
$265
$275
$125
$125
$275
$275
$275
$275
$275
$275
$275
Copayment
2810 Crown-3/4 cast metallic*
$275
2930 Prefab stainless steel crown-primary
$75
2931 Prefab stainless steel crown-permanent
$75
2932 Prefabricated Resin Crown
$95
2950 Core buildup, including any pins
$70
2951 Pin retention-per tooth, in add'n to rest
$15
2952 Cast post & core in add'n to crown*
$110
2954 Prefab post & core in add'n to crown
$90
6210 Pontic-cast high noble metal*
$270
6211 Pontic-cast predominantly base metal
$270
6212 Pontic-cast noble metal
$270
6240 Pontic-porc fused to high noble metal*
$270
6241 Pontic-porc fused to predom base metal
$270
6242 Pontic-porc fused to noble metal
$270
6520 Inlay-metallic-2 surfaces*
$225
6530 Inlay-metallic-3 or more surfaces*
$260
6543 Retainer onlay, metallic, three surfaces*
$265
6544 Retainer onlay, metallic, four or more surfaces*
$275
6750 Crown-porcelain fused to high noble metal*
$275
6751 Crown-porc fused to predom base metal
$275
6752 Crown-porcelain fused to noble metal
$275
6780 Crown-3/4 cast high noble metal*
$275
6790 Crown-full cast high noble metal*
$275
6791 Crown-full cast predominantly base metal
$275
6792 Crown-full cast noble metal
$275
6970 Cast post & core in add'n to abut*
$110
6972 Prefab post & core in add'n to abut
$90
6973 Core buildup for abut, incl any pins
$70
Endodontics
3110 Pulp cap-direct (excl rest)
3120
3220
3310
3320
3330
3346
3347
3348
3410
3421
3425
3426
3430
Pulp cap-indirect (excl rest)
Therapeutic pulpotomy (excl rest)
Anterior root canal (excl final rest)
Bicuspid root canal (excl final rest)
Molar root canal (excl final restr)
Retreatment-anterior, by report
Retreatment-bicuspid, by report
Retreatment molar by report
Retreatment-molar,
Apicoectomy/periradicular surg-anterior
Apico/perirad surg-bicuspid (first root)
Apico-perirad surg-molar (first root)
Apico/periradic surg (each add'l root)
Retrograde filling-per root
Periodontics
4210 Gingivectomy or gingivoplasty-per quad
4211 Gingivectomy or gingivoplasty-per tooth
4240 Gingival Flap Procedure, including Root Planing
4249 Crown lengthening-hard & soft tissue
4260 Osseous surg incl flap entry/closure-quad
Osseous Surgery Inc.flap entry/closure-quad 1
4261 to 4 teeth
4270 Pedical soft tissue graft procedure
4271 Free soft tissue graft proc (incl donor)
4341 Periodontal scaling/root planing-per quad
4355 Debridement to Enable Diagnosis
4910 Periodontal maintenance procedure
Unscheduled dressing change ( other than
4920 treating dentist)
Dentures
5110/2Complete upper or lower denture
5130/4Immediate upper or lower Denture
5211 Upper partial-resin base
5212 Lower partial-resin base
5213/1Upper or lower partial -Chrome cast
$8
$8
$18
$90
$110
$140
$115
$130
$160
$90
$100
$120
$42
$30
Dentures
5410/11
5421/22
5510
5520
5610
5630
5640
5650
5660
5710
5711
5720/21
5730/31
5740/41
5750/51
5760/61
5820
5821
5850/51
Adjust complete denture-upper or lower
Adjust partial denture-upper or lower
Repair broken complete denture base
Replace Missing or Broken Teeth
Repair resin saddle or base
Repair or relace broken clasp
Replace broken teeth-per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
Rebase Complete Upper Denture
Rebase Complete Lower Denture
Rebase Partial Upper or Lower Denture
Reline complete upper/lower (chairside)
Reline upper/lower partial (chairside)
Reline complete upper/lower denture (lab)
Reline upper/lower partial denture (lab)
Interim partial denture ( stay plate )
Interim partial denture ( stay plate )
Tissue conditioning, upper/lower-per unit
Copayment
$20
$20
$35
$32
$40
$50
$32
$45
$55
$140
$140
$140
$75
$75
$105
$105
$125
$125
$33
Oral Surgery
7110
Single tooth extraction
7120
Each additional tooth extraction
7130
Root removal-exposed roots
7210
Surgical removal erupted tooth w/flap
7220
Removal of impacted tooth-soft tissue
7230
Removal of impacted tooth-partial bony
7240
Removal of impacted tooth-full bony
7241
Removal of impacted tooth-complications
7250
Surgical removal of residual tooth roots
7270
Tooth reimplantation and/or stabilization
Surgical exposure of impacted or unerupted
tooth for orthodontic reasons
7280
7281
Surgical exposure to aid eruption
7285
Biopsy of oral tissue- hard
7286
Biopsy of oral tissue- soft
7310
Alveoplasty in conjunction w/ext-quad
7320
Alveoplasty w/o extract-quad
7450
Removal odont cyst-Lesion up to 1.25 cm
7451
Removal odont cyst
cyst-Lesion
Lesion over 1
1.25
25 cm
7470
Removal of exostosis- maxilla or mandible
7510
Incision/drainage of abscess-intraoral
7960
Frenulectomy (frenectomy or frenotomy)
$77
$65
$40
$28
$38
$45
$115
$185
$142
$35
$75
Cosmetic
2960
Labial veneer (laminate)-chairside
$225
$75
$20
$90
$105
$140
Orthodontics
102
Broken appointment ( without 24 hours notice)
8601
Orthodontic evaluation and consulatation
8602
Orthodontic treatment plan and records inc.
x-rays, study models and diagnostic photos
$85
$105
$110
$30
$18
$16
8070
8080
8090
8670
8680
9430
Comprehensive orthodontic treatment inc.
fabrication and insertion of fixed banding
appliance and periodic visits up to 24 mos
Periodic comprehensive orthodontic treatment
Orthodontic retention
Office visit for observation, no other service
$14
9440
Emergency office visit after hours
$330
$360
$275
$315
$365
Miscellaneous
9110
Emergency palliative treatment
9215
Local anesthesia
9310
Consultation by other than primary provider
9430
Office Visit for Observation
9440
Office Visit, after hours
9951
Occlusal adjustment-limited per visit
* Copayment is exclusive of the price of gold.
A complete description of benefits, limitations and exclusions is included in your subscription certificate.
$17
$17
$24
$30
$37
$52
$60
$75
$34
$70
$15
$100
$150
$2,425
$2,425
$2,425
$0
$425
$0
$15
$15
No Charge
$22
No Charge
$15
$15
Guardian
DentalGuard Preferred Plus
(Dual Option DMO/PPO)
DentalGuard Preferred Plus Rates (PPO)
Two Tier
Four Tier
N/A
N/A
$108.58 Family*
$127.39 Family*
HealthPass offers Guardian DentalGuard Preferred Plus
(In-Network and Out-of-Network dental plan)
●
●
●
●
●
●
No referrals are needed to see a specialist
Unlimited ability to change dentists
Includes out-of-area emergency coverage
$50 deductible for In-Network services
$50 deductible for Out-of-Network services
Annual maximum of $1,500 In-Network and $1,000 Out-of-Network
Affordable & Flexible Care
Guardian DentalGuard Preferred Plus combines the freedom of a PPO dental plan
with the economy of managed care. Whenever you or a family member needs
dental services, you may visit a carefully screened In-Network dentist or any dentist
you wish. If you visit an In-Network dentist, you will typically receive a higher level
of benefits and save on out-of-pocket costs.
About the Plan
With Guardian DentalGuard Plus, you and your family can count on accessible,
concerned care. Plus, there are never any claim forms to complete for In-Network
services! If you choose to go Out-of-Network, most dentists will submit your claims
directly to Guardian - hassle free. Either an In-Network or Out-of-Network general
participating dentist may suggest you see a specialist. No referrals are needed for
specialist care. You are always free to see any specialist you would like or choose one
from your Guardian provider directory.
Dental coverage can only be elected by a group that is enrolling in HealthPass
medical coverage. If a group begins their medical coverage on the 15th of the month,
dental coverage will begin on the 1st of the following month.
V1 of 1 10.12
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HealthPass DentalGuard Preferred Plus
$1500 maximum in network,
$1000 maximum out of network $50 deductible in network waived for preventive/$50 deductible out of network
Virgin Groups & Employees: Deferred Crowns, Bridges, Prostho & Perio for all Employees 12 months Transfer:Deferred Crowns, Bridges, Prostho & Perio for 12 months for future employees Out of network covered at 80th percentile
Sample Covered Charges
Coinsurance
Code
ED
Name
Diagnostic and Preventive
120
1110
210
In‐Network
Out‐of‐Network
Periodic Examination
Prophylaxis‐adult (teeth cleaning)
Full mouth x-rays
100%
100%
90%
80%
80%
80%
one surface ‐ permanent
two surfaces ‐ permanent
three surfaces ‐ permanent
90%
90%
90%
80%
80%
80%
anterior
bicuspid
molar
60%
60%
60%
50%
50%
50%
Perio scaling & root planing, per quad.
Gingivectomy, per quadrant
Gingivectomy, per tooth, up to 2 teeth
60%
60%
60%
50%
50%
50%
Porcelain Crown
Porcelain with metal crown**
Cast metal crown**
60%
60%
60%
50%
50%
50%
Complete denture (upper or lower)
Partial denture
Denture reline (chairside)
Denture reline (laboratory)
60%
60%
60%
60%
50%
50%
50%
50%
Extract single tooth
Incision and drainage of abscess
60%
60%
50%
50%
Extract impacted tooth, soft tissue
Extract impacted tooth, partial bony
Extract impacted tooth, full bony
60%
60%
60%
50%
50%
50%
N/A
N/A
N/A
N/A
Restorative
Fillings (amalgam)
2140
2150
2160
Endodontics
Root Canal therapy
3310
3320
3330
Periodontics
4341
4210
4211
Crown and Bridge
2740
2750‐52
2790‐92
Prosthodontics
5110‐20
5213
5730
5750
Oral Surgery
7110
7510
Impactions
7220
7230
7240
Orthodontia - Comprehensive Treatment*
Child to age 18
Member over age 18
* The copay listed is for banding only. See the Ortho Schedule of Benefits for a complete listing of all services and copays.
** If high noble metal is used, there will be an additional patient charge for the actual cost of the high noble metal.
'DentalGuard Dental Insurance Plan General Limitations and Exclusions: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental
disease, defect or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under Preventive Services), orthodontic (unless expressly provided for), cosmetic or experimental
treatments, any treatments to the extent benefits are payable by any other payer 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. GP-1-DG2000 et al.
Guardian
VisionGuard
VisionGuard Rates (PPO)
Two Tier
$5.43 Employee only
N/A
N/A
$11.67 Family*
Four Tier
$5.43 Employee only
$14.73 Family*
About VisionGuard
Regular eye exams can detect diseases like glaucoma, diabetes, and
other possible causes of blindness in their early stages. Guardian
VisionGuard provides access to the Davis Vision network. Exams and
materials are covered, and members can visit any doctor they wish,
using both in and out-of-network benefits, although members can save
significantly by using an in-network provider.
Network Discounts- Generous network discounts include up to 25% off
laser vision correction, discounts on additional glasses, and cosmetic
enhancements such as tints, special lenses, and scratch-resistant
coating.
Contact Lens Benefits- Contact lens benefits allow members to
choose contact lenses instead of eyeglasses. A contact lens allowance
counts toward contact lenses and the contact lens exam (fitting and
evaluation).
Benefits and Lens Upgrades- Optional benefit and lens upgrades are
available, including lens tinting, progressive lenses, anti-reflective
coating, polycarbonate lenses, safety glasses, and additional glasses.
Vision coverage can only be elected by a group enrolling in HealthPass medical
coverage. If a group begins their medical coverage on the 15th of the month, vision
coverage will begin on the 1st of the following month.
V1 of1 10.12
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VisionGuard Features
Benefits
In-Network
Out-of-Network
Copay
$10.00 Exam
$25.00 Materials
$10.00 Exam
$25.00 Materials
Eye Exam: Every 12 months
Covered in full after copay
$50 Max after copay
Lenses
Frequency: Every 24 months
Single Vision
Lined Bifocal
Lined Trifocal
Lenticular
$48.00 Maximum after copay
$210 max after copay
From formulary, $25 copay
Not from formulary max
Guardian will pay $130**
$105 max**
$130 retail allowance after
copay*
$48 max after copay
Contact Lenses*
Medically Necessary
Elective
Frames
*If you choose contact lenses, you will not be eligible to receive lenses for 24 months and a frame for 24 months
following the date contacts were obtained.
* Frames from Davis’ Fashion or Designer collections are covered in full in excess of this plan’s materials copay.
Frames from Davis’ Premier collection are covered in full in excess of a $25 copay applied in addition to the plan’s
materials copay. Frames from a Davis network provider that are not in the collections are covered up to the plan’s
retail allowance in excess of the plan’s materials copay.
** In-network elective contact lenses from Davis Vision’s formulary are covered in full in excess of the copay.
In-network elective contacts lenses that are not part of the formulary are covered up to the elective contact allowance
and the copay is waived.
Two Year Lock-In
o If you enroll in the plan, you will not be able to drop coverage for yourself or your dependents
until the group enrollment of 24 months has been completed or all HealthPass coverage is cancelled.
Important Information: This policy provides vision care limited benefits health insurance only. It does not provide basic
hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.
Coverage is limited to those charges that are necessary for a routine vision examination. Co-pays apply. The plan
does not pay for: orthoptics or vision training and any associated supplemental testing; medical or surgical treatment
of the eye; and eye examination or corrective eyewear required by an employer as a condition of employment;
replacement of lenses and frames that are furnished under this plan, which are lost or broken (except at normal
intervals when services are otherwise available or a warranty exists). The plan limits benefits for blended lenses,
oversized lenses, photochromic lenses, tinted lenses, progressive multifocal lenses, coated or laminated lenses, a
frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and optional cosmetic processes. 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.
This handout is for illustrative purposes. You will receive benefit booklets when your enrollment application
is processed. If there is a discrepancy between this handout and your benefit booklet, the benefit booklet
prevails.
Guardian EverGuard
Guardian’s Voluntary Package Provides Comprehensive Coverage:
Term Life Insurance
$25,000
Employee Age
Monthly Premium
AD&D
$75,000
Disability Income
$1,000 per month
18 - 39
40 - 54
55+
$10.00
$22.50
$45.00
Term Life
Coverage Amount
$25,000 of Term Life insurance on eligible employees. Amount is reduced by 35% upon attainment of
age 65 and an additional 25% of the original amount upon attainment of age 70.
Seatbelt & Airbag Supplement
Benefit amounts will be increased if death is a direct result of an automobile accident
a. $10,000 for employee if properly wearing a seatbelt.
b. $15,000 for employee w h i l e p r o p e r l y wearing a seatbelt and sitting in a seat with a
properly functioning airbag.
Conversion Feature
Allows qualified terminated employees to convert group coverage to a permanent whole life policy.
Accidental Death & Dismemberment (AD&D)
Provides an employee benefit of $75,000 in the event of a covered accidental death or a percentage of that amount for other losses of hearing or
loss of limb. Benefit amounts vary based on loss.
Disability Income
Covered Disabilities
Accidents and sicknesses, disabilities incurred on and off the job, maternity,
mental and emotional disorders/alcohol and drug abuse (limitations apply).
Definition of Disability
Two year own occupation, during first 24 months. ADL disabled thereafter when considered
critically disabled with zero day residual benefit.
Monthly Benefit
66 2/3% of an employee’s salary to a monthly maximum of $1,000
Minimum Monthly Benefit
Elimination Period
Duration of Benefits
Covered Earnings
$50/month
30 day accident/ 90 day sickness
To age 65
Standard Including Bonuses and Commissions
Income With Which This Plan
Integrates
Payments are directly reduced by any Social Security disability benefits paid to the employee and his or her
family. We also integrate disability benefits with other forms of income the employee receives or is eligible
to receive.
Pre-Existing Condition Limit
12 months prior/12 months insured exclusion period, continuity of coverage
Important information: We pay no benefits if the insured’s death is due to suicide within two years from the insured’s original effective date. We pay no benefits for the insured where death or dismemberment occurs
while driving an automobile legally intoxicated; while voluntarily using a non-prescription substance; through intentional self-injury; while participating in a civil disorder or committing a felony; while the member of a flight
crew or a trainee in an aircraft; by declared or undeclared war or armed aggression; while a member of any armed force; or as the result of a disease or a bodily infirmity. GP-1-R-ADCL1-00. We do not pay benefits for
charges relating to a covered person: taking part in any war or act of war (including service in the armed force); committing a felony or taking part in any riot or other civil disorder; or intentionally injuring themselves or
attempting suicide while sane or insane. We do not pay benefits during any period in which a covered person is confined to a correctional facility, an employee is not under the care of a doctor, and the employee’s loss of
earnings is not solely due to disability. This policy does not provide “basic hospital,” “basic medical,” or “major medical” insurance as defined by the New York State Insurance Department. If the plan is new (not
transferred): This LTD plan does not pay charges relating to a pre-exisitng condition. A pre-existing condition includes pregnancy and any condition for which an employee consults with a physician, receives treatment or
takes prescribed drugs. Please refer to plan documents for specific time periods. A person is ADL disabled if he or she is: (a) physically unable to perform 2 or more Activities of Daily Living (ADL) without continuous
physical assistance or (b) cognitively impaired, and requires verbal cueing to protect himself/herself or others. ADL’s are bathing, dressing, toileting, transferring, continence and eating.
Contract #’s GP-1-LT2K-1.0 et al.
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Guardian EverGuard Plus
Guardian’s Voluntary Package Provides Comprehensive Coverage:
Term Life Insurance
AD&D
Disability Income
$50,000
$100,000
$1,500 per month
Employee Age
18 - 39
40 - 54
55+
Monthly Premium
$18.00
$36.00
$72.00
Term Life
Coverage Amount
$50,000 of Term Life insurance on eligible employees. Amount is reduced by 35% upon attainment of
age 65 and an additional 25% of the original amount upon attainment of age 70.
Seatbelt & Airbag Supplement
Benefit amounts will be increased if death is a direct result of an automobile accident:
a. $10,000 for employee if properly wearing a seatbelt.
b. $15,000 for employee w h i l e p r o p e r l y wearing a seatbelt and sitting in a seat with a
properly functioning airbag.
Conversion Feature
Allows qualified terminated employees to convert group coverage to a permanent whole life policy.
Accidental Death & Dismemberment (AD&D)
Provides an employee benefit of $100,000 in the event of a covered accidental death or a percentage o f t hat amount for other losses of
hearing or loss of limb. Benefit amounts vary based on loss.
Disability Income
Covered Disabilities
Accidents and sicknesses, disabilities incurred on and off the job, maternity,
mental and emotional disorders/alcohol and drug abuse (limitat i o n s a p p l y ) .
Definition of Disability
Two year own occupation, during first 24 months. ADL disabled thereafter when considered
critically disabled with zero day residual benefit.
Monthly Benefit
Minimum Monthly Benefit
66 2/3% of an employee’s salary to a monthly maximum of $1,500.
$50/month
Elimination Period
Duration of Benefits
30 day accident/90 day sickness
To age 65
Covered Earnings
Standard Including Bonuses and Commissions
Payments are directly reduced by any Social Security disability benefits paid to the employee and his or
her family. We also integrate disability benefits with other forms of income the employee receives
or is eligible to receive.
12 months prior/12 months insured exclusion period, continuity of c o v e r a g e
Income With Which This Plan
Integrates
Pre-Existing Condition Limit
Important information: We pay no benefits if the insured’s death is due to suicide within two years from the insured’s original effective date. We pay no benefits for the insured where death or dismemberment occurs
while driving an automobile legally intoxicated; while voluntarily using a non-prescription substance; through intentional self-injury; while participating in a civil disorder or committing a felony; while the member of a flight
crew or a trainee in an aircraft; by declared or undeclared war or armed aggression; while a member of any armed force; or as the result of a disease or a bodily infirmity. GP-1-R-ADCL1-00. We do not pay benefits for
charges relating to a covered person: taking part in any war or act of war (including service in the armed force); committing a felony or taking part in any riot or other civil disorder; or intentionally injuring themselves or
attempting suicide while sane or insane. We do not pay benefits during any period in which a covered person is confined to a correctional facility, an employee is not under the care of a doctor, and the employee’s loss
of earnings is not solely due to disability. This policy does not provide “basic hospital,” “basic medical,” or “major medical” insurance as defined by the New York State Insurance Department. If the plan is new (not
transferred): This LTD plan does not pay charges relating to a pre-existing condition. A pre-existing condition includes pregnancy and any condition for which an employee consults with a physician, receives treatment
or takes prescribed drugs. Please refer to plan documents for specific time periods. A person is ADL disabled if he or she is: (a) physically unable to perform 2 or more Activities of Daily Living (ADL) without
continuous physical assistance or (b) cognitively impaired, and requires verbal cueing to protect himself/herself or others. ADL’s are bathing, dressing, toileting, transferring, continence and eating.
Contract #’s GP-1-LT2K-1.0 et al.
10.12
(888) 313-7277
COBRA Administration
What is COBRA & State Continuation of Coverage
COBRA & State Continuation of Coverage is required by federal and state
mandates. The mandates require employers that offer group health care
plans to employees to also offer employees with a change in
employment status the opportunity to temporarily continue their group
health coverage. COBRA participants generally pay 100% of their premium plus a 2% administrative fee.
HealthPass COBRA Administration Services
For the employer, administrating COBRA can be a burden. HealthPass
eases this burden by offering COBRA Administration Services. With
COBRA Administration Services HealthPass will process premiums and
terminate coverage at the end of the eligibility period. In addition COBRA
members are: billed directly at their home, receive a seperate renewal and
have access to HealthPass Member Services.
To make COBRA Administration even easier HealthPass will:
• Generate and send COBRA enrollment forms to former employees
and/or qualified dependents
• Provide prompt notifications to COBRA enrollees, letters and notices
in English or Spanish
• Online payment, auto-debit and manual payments for COBRA
enrollees
• Assure COBRA compliance
V1of1 10..12
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TaxSaver
Section 125
Premium Only Plan (POP) - Is one of the simplest benefits an employer can offer, and it delivers real savings to
employees and their company. By allowing employees to pay their portion of premium costs BEFORE taxes, employees
typically save 25% or more and the employer benefits from nearly 8% in FICA savings. However, to deduct employee premium
costs pre-tax, you MUST have a plan document. Now you can create and download your customized plan document in
minutes and have your plan up and running in a few days. This product is available to both HealthPass and non HealthPass
groups.
By taking advantage of Section 125 of the Internal Revenue Code, employers can save money for their employees and
themselves. HealthPass makes available a Section 125 POP kit online at www.healthpass.com.
The Pre-Tax Solution - By answering a few basic questions about your business, we’ll create a complete
self administrative guide for your Premium Only Plan that you can download immediately, print, sign, and implement. The kit
includes everything you need to start and maintain your plan:
● Answers to frequently asked questions
● Signature - ready board resolution
● An implementation checklist
● Employee Summary
● Election waiver form
● Compliance Guidelines
● Customized plan document
Employer Benefits and Examples of Savings - Employers can save money on their annual payroll taxes of social
security, FUTA and SUTA. By allowing employees to contribute to their health coverage on a pre-tax basis, employers no
longer pay these payroll taxes on the pre-tax contribution to the health insurance premium.
Annual Payroll
Annual Pre-Tax Employee Contribution
Annual Taxable Payroll
Annual FICA Tax (9.93%)
Annual FICA Savings from Pre-Tax Contribution
Without Plan
$300,000
$0
$300,000
$29,790
$0
With Plan
$300,000
$21,000
$279,000
$27,704
$2,085
Without Plan
$400,000
$0
$400,000
$39,720
$0
With Plan
$400,000
$28,000
$372,000
$36,939.60
$2,780.40
Without Plan
$500,000
$0
$500,000
$49,650
$0
With Plan
$500,000
$35,000
$465,000
$46,174.50
$3,475.50
Employee Benefits and Example of Savings - Employees also get to participate in the savings when a Section 125 Plan
is put into place. By using pre-tax dollars to pay for their coverage, employees reduce their taxable income, thus limiting the
amount of withholding.
Annual Income
Annual Pre-Tax Employee Contribution
Taxable Income
Estimated Taxes (40.48%)
Annual After-Tax Employee contribution
Net Take Home Pay
Annual Employee Savings from Pre-Tax Contribution
Without Plan
$30,000
$0
$30,000
$12,144
$1,500
$16,356
$0
With Plan
$30,000
$1,500
$28,500
$11,536.80
$0
$16,963.20
$607.20
Without Plan
$40,000
$0
$40,000
$16,192
$2,000
$21,808
$0
With Plan
$40,000
$2,000
$38,000
$15,382.40
$0
$22,617.60
$809.60
Without Plan
$50,000
$0
$50,000
$20,240
$2,500
$27,260
$0
With Plan
$50,000
$2,500
$47,500
$19,228
$0
$28,272
$1,012
Note: While paying for the employee portion of the medical and dental premiums under a Section 125 plan is encouraged, it is suggested that
employees do not use pre-tax dollars to pay for EverGuard or EverGuard Plus coverage as it will result in a taxable disability benefit. Consult your
accountant or tax-advisor for further clarification.
V1of1 10.12
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HealthPass Brings You Medical Cost Advocate!
Utilizing Medical Cost Advocate can save clients
both time and money!
What is Medical Cost Advocate:
MCA is a unique consumer directed health care service that saves employees
money on their health care. In today’s environment where additional costs are
being shifted to the consumer, MCA offers a last line of defense for reducing out
of pocket costs. MCA will negotiate any medical bills that total $250 or more, and have
the expertise and the know-how to save employees money!
The Benefits of Medical Cost Advocate:
MCA is the expert source to review and negotiate all out of pocket costs
Negotiates directly with health care providers
Save employees 20-50% on average
Works with any health plan or expense - medical or dental
User friendly and web-based
Risk free - save money or pay MCA nothing
How it works:
MCA works on a success based fee structure - employees will only be
charged when MCA saves them money. MCA’s fee is 35% of employees
savings. For example if MCA saves your client $1,000, MCA’s fee will be
$350. If MCA can not save your client money, there is no charge!
MCA will review and negotiate any medical bill regardless of insurance status or procedure.
MCA is an ideal companion for HSA, HRA, and FSA accounts, and Health Advocate!
Bill Type
In-Network
Out-of-Network
Uninsured
Partial &
Bills Toward Co-Insurance Non-Covered Pre-payments
Full &
Balance
Charge
Deductibles
Excess Charges
Services
& Installments
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
For additional information, call 212.252.8010 x201
or visit www.medicalcostadvocate.com/group/hp.aspx
The HealthPass group code is HPS100
✔
✔
✔

Guardian Managed DentalGuard

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