DENTAL

Guardian –PPO- In Network and Out of Network

  • Preventive care 100% In and Out of Network
  • Basic Care 80% In and Out of Network
  • Major Care 50% In and Out Network
  • Orthodontia 50% In and Out of Network
  • Annual Maximum Benefit $1500.00

Employee deduction per week:

Employee $5.00
Employee/ Child(ren) $11.00
Employee/Spouse $9.00
Family $15.00

VISION

VSP Network

  • Copayment – $25.00
  • One Routine Eye Exam Once a Year.
  • Contact lens Exam Every 2 years.
  • Frames -80% of amount over $120.
  • Hardware – Avg. 30% of retail price.

Employee deduction per week:

Employee $1.00
Employee/ Child(ren) $1.78
Employee/Spouse $1.75
Family $2.82

Guardian Enrollment/Change Form