Dental Table – GA Insurance Hub

Plan Maxes		Basic	Preferred
Annual Maximum		$500/yr	$1,000/yr
Plan Deductible		Basic	Preferred
Deductible		$50 Annual	$50 Annual
Deductible limit		Max 3 per family	Max 3 per family
Services*	Plan Coverage	Basic	Preferred
Preventive Services	• Cleanings • Exams • Oral Cancer Screening (age 40+) • Radiographs – Bitewings • Radiographs – FMX • Fluoride (under age 16) • Sealants (under age 16) • Space Maintainers (under age 16)	Plan Pays 100% Deductible Waived	Plan Pays 100% Deductible Waived
Basic Services	• Emergency Pain • Restorations (Amalgams & Anterior Resin) • Restorations (Posterior Resin) • Crown Repairs • Bridge Repairs • Denture Repairs	Plan Pays 80%	Plan Pays 80%
Major Services1	• Simple Extractions • Surgical Extractions • Oral Surgery • Endodontics • Periodontal Maintenance • Non-Surgical Periodontics • Surgical Periodontics • Inlays • Onlays • Crowns • Bridges • Dentures • Implants • Anesthesia	Plan Pays 0%	Plan Pays 50%

1. 12 month waiting period on Major services Underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with the Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. | | DENTPROP20 The information on this sheet is a brief summary of your dental plan and the services it covers. There are some limitations on the expenses for which your dental plan pays. If you have specific questions regarding benefit coverage, limitations, exclusions, or non-covered services, please refer to your certificate of coverage/dental benefit booklet or contact BrightBenefits. Rates include insurance premiums and administrative fees for continuation, enrollment and marketing.