Dental Coverage · Guardian is a leading provider of employee benefits and individual insurance...

IBEW Local 18

Dental Coverage

Here is your new dental coverage, which includes your enrollment form. Make sure you return the completed form, if applicable, to the Local 18 Benefit Service Center or during the annual open enrollment you can enroll on-line at www.mybenefitchoices.com/local18.

If you miss the deadline, the coverage may be delayed or you may not be eligible for enrollment this year.

HIGHLIGHTS:

• Choice of two dental plans • Single, two-party and family coverage available

Find out if your dentist is in Guardian’s network at www.guardiananytime.com.

COVER YOURSELF WITH GUARDIANGuardian is a leading provider of employee benefits and individual insurance coverage.

Founded in 1860, The Guardian Life Insurance Company of America is one of the largestmutual life insurance companies in the United States. As a mutual company, Guardian isfocused 100% on the needs of our customers – employers who choose Guardian and theiremployees covered by our plans. Today, more than six million employees and their familiesrely on Guardian as their employee benefits provider.

We have built our success on the time-tested values of quality, innovation and high-qualityservice. In July 2008 Standard & Poor’s upgraded Guardian’s credit rating to AA+ (VeryStrong). We’ve been around for 148 years insuring the people and businesses we protectand we’ll continue to provide benefits and services our customers have come to expectfrom us.

For more information on how we can protect you and your family, please visitwww.GuardianLife.com

Prepared for IBEW Local 18 Guardian Group Plan Number 00456998

UNDERSTAND YOUR COVERAGE:

o Review your benefits. o Complete your enclosed enrollment form, if applicable. o Sign and return form to the Local 18 Benefit Service Center.

Welcome Dear IBEW Local 18 Member, Welcome to The Guardian Life Insurance Company of America. We are pleased to inform you of the Dental options available through Guardian for the upcoming plan year. Guardian has been selected as your dental carrier because of competitive rates, extensive network choices and excellent service reputation. Our dental plans are designed to allow you convenient access to dental facilities and services. This booklet contains an overview of benefits available to you and your family. If you need help understanding how your plan works or questions on enrollment, the Local 18 Benefit Service Center is available to help Monday-Friday 8:30am-5pm at 800-842-6635. After you have enrolled in the dental plan, ID cards will be mailed to your mailing address. Simply call the member service number on your ID card with benefit or eligibility questions.

For questions on how to find a Provider, call the Guardian Hotline at 1-888-600-1600. Once you have been enrolled contact 1-800-541-7846 for PPO plans and 1-800-273-3330 for DHMO plans. PPO ID Cards Once you are enrolled you will receive two cards, both in the employees name. DHMO ID Cards Once you are enrolled you will Receive ID cards for yourself and any enrolled dependents. Ask the Local 18 Benefit Service Center to replace a lost ID card by contacting them at 1-800-842-6635.

Plan Details This booklet explains your basic plan options. Find a network dentist in minutes Use our Provider Online Search at www.guardiananytime.com (see page 13)

www.guardiananytime.com Enrollment Kit 00456998, 0001, EN

Why Dental Insurance?

Good oral hygiene is important, not only for looks, but for general health as well. A routine dental examination can detect symptoms of more than

125 diseases, including heart disease, diabetes, anemia, stomach ulcers, osteoporosis and kidney disease. Regular check ups and cleanings can

save you the pain and expense of future problems. Dental insurance will keep these visits affordable and is a cost-effective way to minimize health

care costs for you and your family. The American Dental Hygienists’ Association estimates that for every $1 spent on prevention or oral health care,

as much as $8 to $50 is saved on future emergency and restorative procedures. Using your dental insurance for regular dental check ups can

improve your health by helping you:

1) Prevent Oral Cancer: According to The Oral Cancer Foundation, someone dies from oral cancer every hour of every day in the United States

alone. When you have your dental cleaning, your dentist is also screening you for oral cancer, which is highly curable if diagnosed early.

2) Prevent Gum Disease: Gum disease is an infection in the gum tissues and bone that keep your teeth in place and is one of the leading causes

of adult tooth loss. If diagnosed early, it can be treated and reversed. If treatment is not received, a more serious and advanced stage of gum

disease may follow. Regular dental cleanings and check ups, flossing daily and brushing twice a day are key factors in preventing gum disease.

3) Help Maintain Good Physical Health: Recent studies have linked heart attacks and strokes to gum disease, resulting from poor oral hygiene.

A dental cleaning every six months helps to keep your teeth and gums healthy and could possibly reduce your risk of heart disease and strokes,

as well as many other serious conditions.

4) Keep Your Teeth: Since gum disease is one of the leading causes of tooth loss in adults, regular dental check ups and cleanings, brushing

and flossing are vital to keeping as many teeth as you can. Keeping your teeth means better chewing function and ultimately, better health.

5) Prevent the Need for Advanced Treatment: Your dentist and hygienist will be able to detect any early signs of problems with your teeth or

gums that can be easily treatable. If these problems go untreated, root canals, gum surgery and removal of teeth could become the only

treatment options available.

6) Have a Bright and White Smile: Your dental hygienist can remove most tobacco, coffee and tea stains. During your cleaning, your hygienist

will also polish your teeth to a beautiful shine.

7) Protect your children’s health: Tooth decay is the most common chronic childhood disease, five times more common than asthma and results

in a loss of 51 million school hours each year. Regular check ups can help prevent tooth decay in your children.

Sources: www.about.com, American Academy of Pediatrics

Prepared for IBEW Local 18 Guardian Group Plan Number 00456998

www.guardiananytime.com Enrollment Kit 00456998, 0001, EN

Network Managed DentalGuard DentalGuard PreferredCalendar year deductible

Family limit Individual No deductible

Waived for $0 $25 In-Network Out-of-Network

3 per family Preventive Preventive

Charges covered for you (co-insurance) In - Network only Preventive Care Basic Care (e.g. fillings) covered procedure. See Major Care

(e.g. cleanings) You pay a copay for each

Orthodontia (e.g. crowns, dentures) more information.

“Plan Details”, for

100% 100% In-Network Out-of-Network

90% 80% 60% 60% 80% 80%

Annual Maximum Benefit Unlimited $2,000 $2,000Lifetime Orthodontia Maximum Not Applicable $2,000Office visit copay $0 NoneNetwork Managed DentalGuard DentalGuard Preferred

Dental Plans YOUR GUARDIAN PLAN OFFERS:

Option 1: With your DHMO plan, you enjoy negotiated discounts from our network dentists. You pay a fixed copay for each covered service. Out-of-network visits are not covered. Option 2: With your PPO

plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO in -network dentist.

Family coverage For spouse/domestic partner and children up to age 26 National PPO network of more than 70,000 dentist locations Reliable claims payment four days on average

Let Guardian put its 30-plus years of dental benefits experience to work for you and your family.

4

Find out if your dentist is in Guardian’s network at www.guardiananytime.com Out-of-Network Benefits Based on usual, reasonable and customary rates for a given area

COMPARE THE PLANS Option 1: DHMO Option 2: PPO DentalGuard Preferred

CATEGORY PLAN DETAILS Option 1: Option 2:You Pay Plan paysNetwork only In-network Out-of-network

Preventive Care Cleaning (prophylaxis) $0 100% 100%Frequency:

Fluoride Treatments $0 100% 100%Limits: No Age Limits

Oral Exams $0 100% 100%X-rays $0 100% 100%

Basic Care Anesthesia* Restrictions Apply 90% 80%

Fillings (one surface $0 90% 80%Perio Surgery $60-155 90% 80%

Repair & Maintenance ofCrowns, Bridges & Dentures $0 90% 80%Root Canal $70-140 90% 80%Scaling & Root Planing (per quadrant) $15-25 90% 80%Simple Extractions $10 90% 80%Surgical Extractions $35-85 90% 80%

Major Care Bridges and Dentures $90-140 60% 60%Inlays, Onlays, Veneers** $40-80 60% 60%Single Crowns $100 60% 60%

Orthodontia Orthodontia $1,500-2,800Limits: Adults & Child(ren)

Cosmetic Care Bleaching $165 Not Covered Not CoveredThis is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **Crowns, Inlays,Onlays and Labial Veneers are covered only when needed because of decay or injury and only when the tooth cannot be restored withamalgam or composite filling material.

Please note: The plan detailslisted here are some of themost common services relatedto dental coverage. The co-insurance percentages for thePPO plan options correspondto the coverage categories ofPreventive, Basic, Major andOrthodontia listed in the table

EXCLUSIONS AND LIMITATIONSn Important Information about Guardian’s DentalGuard Indemnity and DentalGuard Preferred PPO plans: This policy

provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose ortreat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (exceptas covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimentaltreatments, 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 limitsbenefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic, and prosthodonticservices. The services, exclusions and limitations listed above do not constitute a contract and are a summaryonly. The Guardian plan documents are the final arbiter of coverage. Contract # GP-1-DG2000 et al.

n Important information about Guardian’s Managed DentalGuard Pre-Paid (Florida) Plan, Managed Dental Care’s DHMO(California) Plan and Managed DentalGuard, Inc.’s Managed DentalGuard DHMO (Texas) Plan: This plan provides pre-paiddental benefits through a network of participating general dentists and specialty care dentists. All covered services must beprovided by the member’s Primary Care Dentist. Specialty care services are covered only when referred by the member’s

Primary Care Dentist and approved in advance by Managed DentalGuard. Only those services listed in the plan are covered.Certain services are subject to annual or other periodic limitations. Where orthodontic benefits are specifically included, theplan provides for one course of comprehensive treatment per lifetime, per member. Unless specifically included, theManaged DentalGuard plan does not provide orthodontic benefits if comprehensive orthodontic treatment or retention is inprogress as of the member’s effective date under the Managed DentalGuard plan. The services, exclusions and limitationslisted here do not constitute a contract and are a summary only. The Managed DentalGuard plan documents are the finalarbiter of coverage. GP-1-MDG1, et al. or GP-1-MDG-FL-1-08, et al. (Florida), GP-1MDC1, et al.. or GP-1-MDC-CA-1-08, et al.(California), GP-1-MDG-TX1, et al. or GP-1-MDG-TX-1-08, et al. (Texas), GP-1-MDG-NY1, et al. or GP-1-MDG-NY-1-08, et al.(New York), GP-1-MDG-1-NJ, et al. or GP-1-MDG-NJ-1-08, et al. (New Jersey)

n Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person mayhave one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. Wewon’t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost orextracted after the covered person became insured by this plan. R3 – DG2000

2 per calendar year to age 19

Periodontal Maintenance $15 Frequency:

Sealants (per tooth) $0 90% 80%

2 per calendar year

DHMO

2 per calendar year 2 per calendar year

100% 100%

.

up to $2,000 lifetime80% 80%

4

PPO Dental Guard Preferred

2 per calendar year

The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia-Restrictions apply & may be subject to medical necessity. Silver fillings and white fillings for front teeth. Other types offillings may be paid at other benefit levels. (Additional cleanings are available for an additional co-pay).

^

^

per arch

In-

)

UNDERSTANDING YOUR BENEFITS—DENTAL

Basic care Moderately complex dental services. Most plans consider fillings and extractions to be basic care.

Co-insurance The portion of the covered charge paid by Guardian.

Copay (short for copayment) A fixed fee paid to a dentist at the time a dental service is performed. Some sample copays are shown in this booklet. A complete list is

shown in your certificate booklet.

Claims Payment Basis PPO & NAP

The usual cost for a specific dental service in your area. Amounts over the specified Usual Customary & Reasonable percentile (80%) are

usually the patient’s responsibility:

In-Network: Benefits are based on a negotiated contracted fee schedule, and no balance billing.

Out-of-Network: Benefits are based on usual, reasonable, and customary rates for a given area.

Deductible The amount of charges you and your family must pay each plan year before the plan pays you any benefits.

Dental office number The unique identification number assigned to a dental provider. Each family member must select a primary care dentist and enter his or

her number on the enrollment form.

Family limit Maximum number of deductibles your family must pay in each plan year before this plan starts paying benefits for all covered family

members for the rest of the plan year.

In-network charges Charges for services provided by dentists who are a member of your plan's network.

Major care More complex dental services. Most plans consider crowns and dentures to be major care.

Out-of-network charges Charges for services provided by dentists who are not members of your plan's network.

Plan year The 12 month period used to apply this plan's deductible and annual maximum. Your plan's plan year is the calendar year.

PPO (Preferred Provider Organization) Plan that lets you visit any dentist, but usually provides better benefits for the services of PPO network dentists. PPO dentists have

agreed to accept discounted fees as payment in full.

Pre-determination Review Guardian will gladly assist you and your dentist by determining what benefits could be payable for services and procedures over $300.

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. Pre-determination applies to PPO and Indemnity

plans only.

Pre-Paid Plan A plan that requires you to visit a network dentist. You pay a fixed copay to the dentist for each service performed. No benefits are

available for services of dentists who are not in the network.

Preventive care Most routine dental services. Most plans consider checkups and cleanings to be preventive care.

(DHMO)

5

(DHMO)

Your plan's plan year is calendar year.

Managed D

entalGuard - Plan Schedule

Plan U60G

CD

TC

overed Dental Services

Codes ++

Charges

Patient

EvaluationsD

0999O

ffice visit during regular hours, general dentist only *$0

D0180

Com

prehensive periodontal evaluation – new or established patient

0D

0170R

e-evaluation – limited, problem

focused (established patient, not post-operative visit)0

D0150

Com

prehensive oral evaluation – new or established patient

0D

0145O

ral evaluation for a patient under three years of age and counseling with prim

ary caregiver0

D0140

Limited oral evaluation – problem

focused0

D0120

Periodic oral exam

ination – established patient0

D0330

Panoram

ic film0

D0277

Vertical bitew

ings – 7 to 8 films

0D

0274B

itewings – four film

s0

D0273

Bitew

ings – three films

0D

0272B

itewings – tw

o films

0D

0270B

itewing – single film

0D

0240Intraoral – occlusal film

0D

0230Intraoral – periapical each additional film

0D

0220Intraoral – periapical first film

0D

0210Intraoral – com

plete series (including bitewings)

0R

adiographs/Diagnostic Im

aging (Including Interpretation)

D0431

Adjunctive pre-diagnostic test that aids in detection of m

ucosal abnormalities including prem

alignant and malignant lesions, not to include cytology or

Tests and Examinations

D0470

Diagnostic casts

0D

0460P

ulp vitality tests0

biopsy procedures50

D1999

Prophylaxis – adult or child, for each additional service in sam

e 12-month period + #

60D

1120P

rophylaxis – child, for the first two services in any 12-m

onth period + #0

D1110

Prophylaxis – adult, for the first tw

o services in any 12-month period + #

0D

ental Prophylaxis

D2999

Topical fluoride (adult or child), each additional service in the same 12-m

onth period + =20

D1206

Topical fluoride varnish; therapeutic application for moderate to high caries risk patients, for the first tw

o services in any 12-month period + =

0D

1204Topical application of fluoride (prophylaxis not included) – adult, for the first tw


0D

1203Topical application of fluoride (prophylaxis not included) – child, for the first tw


0Topical Fluoride Treatm

ent (Office Procedure)

D9999

Sealant – per tooth (non-m

olars) ^35

D1351

Sealant – per tooth (m

olars) ^0

D1330

Oral hygiene instructions

0D

1310N

utritional counseling for control of dental disease0

Other Preventive Services

D1555

Rem

oval of fixed space maintainer

0D

1550R

e-cementation of space m

aintainer0

D1525

Space m

aintainer – removable - bilateral

0D

1515S

pace maintainer – fixed - bilateral

0D

1510S

pace maintainer – fixed - unilateral

0Space M

aintenance (Passive Appliances)

D2161

Am

algam – four or m

ore surfaces, primary or perm

anent0

D2160

Am

algam – three surfaces, prim

ary or permanent

0D

2150A

malgam

– two surfaces, prim

ary or permanent

0D

2140A

malgam

– one surface, primary or perm

anent0

Am

algam R

estorations (Including Polishing)

D2394

Resin-based com

posite – four or more surfaces, posterior

0D

2393R

esin-based composite – three surfaces, posterior

0D

2392R

esin-based composite – tw

o surfaces, posterior0

D2391

Resin-based com

posite – one surface, posterior0

D2390

Resin-based com

posite crown, anterior

0D

2335R

esin-based composite – four or m

ore surfaces or involving incisal angle (anterior)0

D2332

Resin-based com

posite – three surfaces, anterior0

D2331

Resin-based com

posite – two surfaces, anterior

0D

2330R

esin-based composite – one surface, anterior

0R

esin-Based C

omposite R

estorations - Direct

D2644

Onlay – porcelain/ceram

ic – four or more surfaces

80D

2643O

nlay – porcelain/ceramic – three surfaces

80D

2642O

nlay – porcelain/ceramic – tw

o surfaces80

D2630

Inlay – porcelain/ceramic – three or m

ore surfaces75

D2620

Inlay – porcelain/ceramic – tw

o surfaces75

D2610

Inlay – porcelain/ceramic – one surface

60D

2544O

nlay – metallic – four or m

ore surfaces **80

D2543

Onlay – m

etallic – three surfaces **80

D2542

Onlay – m

etallic – two surfaces **

80D

2530Inlay – m

etallic – three or more surfaces **

75D

2520Inlay – m

etallic – two surfaces **

75D

2510Inlay – m

etallic – one surface **60

Inlay/Onlay R

estorations ^^

Page 1 of 5

V.08254

DHMO

6

Managed D


Plan U60G

CD

TC


Codes ++

Charges

Patient

D2794

Crow

n – titanium

95D

2792C

rown – full cast noble m

etal95

D2791

Crow

n – full cast predominantly base m

etal95

D2790

Crow

n – full cast high noble metal **

95D

2783C

rown – ¾

porcelain/ceramic

85D

2782C

rown – ¾

cast noble metal

85D

2781C

rown – ¾

cast predominantly base m

etal85

D2780

Crow

n – ¾ cast high noble m

etal **85

D2752

Crow

n – porcelain fused to noble metal

95D

2751C

rown – porcelain fused to predom

inantly base metal

95D

2750C

rown – porcelain fused to high noble m

etal **95

D2740

Crow

n – porcelain/ceramic substrate

$100C

rowns – Single R

estorations Only ^^

D2971

Additional procedures to construct new

crown under existing partial denture fram

ework

125D

2970Tem

porary crown (fractured tooth)

15D

2960Labial veneer (resin lam

inate) – chairside 40

D2957

Each additional prefabricated post – sam

e tooth8

D2954

Prefabricated post and core in addition to crow

n25

D2953

Each additional indirectly fabricated post – sam

e tooth10

D2952

Post and core in addition to crow

n, indirectly fabricated30

D2951

Pin retention – per tooth, in addition to restoration

0D

2950C

ore buildup, including any pins20

D2940

Sedative filling

0D

2934P

refabricated esthetic coated stainless steel crown – prim

ary tooth20

D2933

Prefabricated stainless steel crow

n with resin w

indow20

D2932

Prefabricated resin crow

n20

D2931

Prefabricated stainless steel crow

n – permanent tooth

10D

2930P

refabricated stainless steel crown – prim

ary tooth10

D2920

Recem

ent crown

0D

2915R

ecement cast or prefabricated post and core

0D

2910R

ecement inlay, onlay, or partial coverage restoration

0O

ther Restorative Services

D3120

Pulp cap – indirect (excluding final restoration)

0D

3110P

ulp cap – direct (excluding final restoration)0

Pulp Capping

D3240

Pulpal therapy (resorbable filling) – posterior, prim

ary tooth (excluding final restoration)15

D3230

Pulpal therapy (resorbable filling) – anterior, prim

ary tooth (excluding final restoration)15

D3222

Partial pulpotom

y for apexogenesis - permanent tooth w

ith incomplete root developm

ent10

D3221

Pulpal debridem

ent, primary and perm

anent teeth10

D3220

Therapeutic pulpotomy (excluding final restoration) – rem

oval of pulp coronal to the dentinocemental junction and application of m

edicament

10Pulpotom

y

D3333

Internal root repair of perforation defects40

D3332

Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

70D

3331Treatm

ent of root canal obstruction; non-surgical access0

D3330

Root canal, m

olar (excluding final restoration)140

D3320

Root canal, bicuspid (excluding final restoration)

80D

3310R

oot canal, anterior (excluding final restoration)70

Endodontic Therapy (Including Treatment Plan, C

linical Procedures And Follow

-up Care)

D3348

Retreatm

ent of previous root canal therapy – molar

150D

3347R

etreatment of previous root canal therapy – bicuspid

95D

3346R

etreatment of previous root canal therapy – anterior

80Endodontic R

etreatment

D3950

Canal preparation and fitting of preform

ed dowel or post

20D

3430R

etrograde filling – per root15

D3426

Apicoectom

y/periradicular surgery (each additional root)40

D3425

Apicoectom

y/periradicular surgery – molar (first root)

100D

3421A

picoectomy/periradicular surgery – bicuspid (first root)

95D

3410A

picoectomy/periradicular surgery – anterior

90A

picoectomy/Periradicular Services

D4273

Subepithelial connective tissue graft procedures, per tooth

120D

4271Free soft tissue graft procedure (including donor site surgery)

110D

4270P

edicle soft tissue graft procedure100

D4268

Surgical revision procedure, per tooth

0D

4261O

sseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces per quadrant95

D4260

Osseous surgery (including flap entry and closure) – four or m

ore contiguous teeth or bounded teeth spaces per quadrant155

D4249

Clinical crow

n lengthening – hard tissue85

D4241

Gingival flap procedure, including root planing – one to three contiguous teeth or bounded teeth spaces per quadrant

35D

4240G

ingival flap procedure, including root planing – four or more contiguous teeth or bounded teeth spaces per quadrant

105D

4211G

ingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant

20D

4210G

ingivectomy or gingivoplasty – four or m

ore contiguous teeth or bounded teeth spaces per quadrant60

Surgical Services (Including Usual Postoperative C

are)

Page 2 of 5

V.08254

DHMO

Managed D


Plan U60G

CD

TC


Codes ++

Charges

Patient

D4355

Full mouth debridem

ent to enable comprehensive evaluation and diagnosis

15D

4342P

eriodontal scaling and root planing – one to three teeth per quadrant15

D4341

Periodontal scaling and root planing – four or m

ore teeth per quadrant$25

Non-Surgical Periodontal Service

D4999

Periodontal m

aintenance, each additional service in same 12-m

onth period + #60

D4920

Unscheduled dressing change (by som

eone other than treating dentist)0

D4910

Periodontal m

aintenance, for the first two services in any 12-m

onth period + #15

Other Periodontal Services

D5140

Imm

ediate denture – mandibular

D5130

Imm

ediate denture – maxillary

110D

5120C

omplete denture – m

andibular110

D5110

Com

plete denture – maxillary

110C

omplete D

entures (Including Routine Post-D

elivery Care)

Partial Dentures (Including R

outine Post-Delivery C

are)110

D5226

Mandibular partial denture – flexible base (including any clasps, rests and teeth)

140D

5225M

axillary partial denture – flexible base (including any clasps, rests and teeth)140

D5214

Mandibular partial denture – cast m

etal framew

ork with resin denture bases (including any conventional clasps, rests and teeth)

130D

5213M

axillary partial denture – cast metal fram

ework w

ith resin denture bases (including any conventional clasps, rests and teeth)130

D5212

Mandibular partial denture – resin base (including any conventional clasps, rests and teeth)

90D

5211M

axillary partial denture – resin base (including any conventional clasps, rests and teeth)90

D5422

Adjust partial denture – m

andibular5

D5421

Adjust partial denture – m

axillary5

D5411

Adjust com

plete denture – mandibular

5D

5410A

djust complete denture – m

axillary5

Adjustm

ents to Dentures

D5520

Replace m

issing or broken teeth – complete denture (each tooth)

0D

5510R

epair broken complete denture base

0R

epairs To Com

plete Dentures

D5650

Add tooth to existing partial denture

D5640

Replace broken teeth – per tooth

0D

5630R

epair or replace broken clasp0

D5620

Repair cast fram

ework

0D

5610R

epair resin denture base0

Repairs To Partial D

entures

D5671

Replace all teeth and acrylic on cast m

etal framew

ork (mandibular)

0D

5670R

eplace all teeth and acrylic on cast metal fram

ework (m

axillary)0

D5660

Add clasp to existing partial denture

0 0

D5721

Rebase m

andibular partial denture0

D5720

Rebase m

axillary partial denture0

D5711

Rebase com

plete mandibular denture

0D

5710R

ebase complete m

axillary denture0

Denture R

ebase Procedures

D5761

Reline m

andibular partial denture (laboratory)0

D5760

Reline m

axillary partial denture (laboratory)0

D5751

Reline com

plete mandibular denture (laboratory)

0D

5750R

eline complete m

axillary denture (laboratory)0

D5741

Reline m

andibular partial denture (chairside)0

D5740

Reline m

axillary partial denture (chairside)0

D5731

Reline com

plete mandibular denture (chairside)

0D

5730R

eline complete m

axillary denture (chairside)0

Denture R

eline Procedures

D5821

Interim partial denture (m

andibular)45

D5820

Interim partial denture (m

axillary)45

Interim Prosthesis

D5851

Tissue conditioning, mandibular

0D

5850Tissue conditioning, m

axillary0

Other R

emovable Prosthetic Services

D6245

Pontic – porcelain/ceram

ic90

D6242

Pontic – porcelain fused to noble m

etal90

D6241

Pontic – porcelain fused to predom

inantly base metal

90D

6240P

ontic – porcelain fused to high noble metal **

90D

6214P

ontic – titanium

90D

6212P

ontic – cast noble metal

90D

6211P

ontic – cast predominantly base m

etal90

D6210

Pontic – cast high noble m

etal **90

Fixed Partial Denture Pontics ^^

D6604

Inlay – cast predominantly base m

etal, two surfaces

75D

6603Inlay – cast high noble m

etal, three or more surfaces **

75D

6602Inlay – cast high noble m

etal, two surfaces **

75D

6601Inlay – porcelain/ceram

ic – three or more surfaces

75D

6600Inlay – porcelain/ceram

ic – two surfaces

75Fixed Partial D

enture Retainers – Inlays/O

nlays ^^

Page 3 of 5

V.08254

DHMO

Managed D


Plan U60G

CD

TC


Codes ++

Charges

Patient

D6634

Onlay – titanium

75

D6624

Inlay – titanium

75D

6615O

nlay – cast noble metal, three or m

ore surfaces80

D6614

Onlay – cast noble m

etal, two surfaces

80D

6613O

nlay – cast predominantly base m

etal, three or more surfaces

80D

6612O

nlay – cast predominantly base m

etal, two surfaces

80D

6611O

nlay – cast high noble metal, three or m

ore surfaces **80

D6610

Onlay – cast high noble m

etal, two surfaces **

80D

6609O

nlay – porcelain/ceramic, three or m

ore surfaces80

D6608

Onlay – porcelain/ceram

ic, two surfaces

80D

6607Inlay – cast noble m

etal, three or more surfaces

75D

6606Inlay – cast noble m

etal, two surfaces

75D

6605Inlay – cast predom

inantly base metal, three or m

ore surfaces$75

Fixed Partial Denture R

etainers – Inlays/Onlays ^^ (continued)

D6794

Crow

n – titanium

95D

6792C

rown – full cast noble m

etal95

D6791

Crow

n – full cast predominantly base m

etal95

D6790

Crow

n – full cast high noble metal **

95D

6783C

rown – ¾

porcelain/ceramic

85D

6782C

rown – ¾

cast noble metal

85D

6781C

rown – ¾

cast predominantly base m

etal85

D6780

Crow

n – ¾ cast high noble m

etal **85

D6752

Crow

n – porcelain fused to noble metal

95D

6751C

rown – porcelain fused to predom

inantly base metal

95D

6750C

rown – porcelain fused to high noble m

etal **95

D6740

Crow

n – porcelain/ceramic

100Fixed Partial D

enture Retainers – C

rowns ^^

D6999

Multiple crow

n and bridge unit treatment plan – per unit, six or m

ore units per treatment plan ^^

125D

6977E

ach additional prefabricated post – same tooth

8D

6976E

ach additional cast post – same tooth

10D

6973C

ore build up for retainer, including any pins20

D6972

Prefabricated post and core in addition to fixed partial denture retainer

25D

6970P

ost and core in addition to fixed partial denture retainer, indirectly fabricated30

D6930

Recem

ent fixed partial denture0

Other Fixed Partial D

enture Services

D7140

Extraction, erupted tooth or exposed root (elevation and/or forceps rem

oval)10

D7111

Extraction, coronal rem

nants – deciduous tooth10

Extractions

D7261

Prim

ary closure of a sinus perforation250

D7250

Surgical rem

oval of residual tooth roots (cutting procedure)40

D7241

Rem

oval of impacted tooth – com

pletely bony, with unusual surgical com

plications85

D7240

Rem

oval of impacted tooth – com

pletely bony80

D7230

Rem

oval of impacted tooth – partially bony

70D

7220R

emoval of im

pacted tooth – soft tissue50

D7210

Surgical rem

oval of erupted tooth requiring elevation of mucoperiosteal flap and rem

oval of bone and/or section of tooth35

Surgical Extractions (Includes Local Anesthesia, Suturing, If N

eeded, And R

outine Postoperative Care)

D7288

Brush biopsy – transepithelial sam

ple collection65

D7286

Biopsy of oral tissue – soft

40D

7285B

iopsy of oral tissue – hard (bone, tooth)45

D7283

Placem

ent of device to facilitate eruption of impacted tooth

35D

7280S

urgical access of an unerupted tooth90

Other Surgical Procedures

D7321

Alveoloplasty not in conjunction w

ith extractions – one to three teeth or tooth spaces, per quadrant30

D7320

Alveoloplasty not in conjunction w

ith extractions – four or more teeth or tooth spaces, per quadrant

45D

7311A

lveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

16D

7310A

lveoloplasty in conjunction with extractions – four or m

ore teeth or tooth spaces, per quadrant35

Alveoloplasty – Surgical Preparation O

f Ridge For D

entures

D7451

Rem

oval of benign odontogenic cyst or tumor – lesion diam

eter greater than 1.25 cm110

D7450

Rem

oval of benign odontogenic cyst or tumor – lesion diam

eter up to 1.25 cm60

Surgical Excision Of Intra-O

sseous Lesions

D7473

Rem

oval of torus mandibularis

75D

7472R

emoval of torus palatinus

75D

7471R

emoval of lateral exostosis (m

axilla or mandible)

75Excision O

f Bone Tissue

D7511

Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of m

ultiple fascial spaces)30

D7510

Incision and drainage of abscess – intraoral soft tissue25

Surgical Incision

D7963

Frenuloplasty100

D7960

Frenulectomy (frenectom

y or frenotomy) – separate procedure

60O

ther Repair Procedures

Page 4 of 5

V.08254

DHMO

Managed D


Plan U60G

CD

TC


Codes ++

Charges

Patient

D9242

Intravenous conscious sedation/analgesia – each additional 15 minutes +++

75D

9241Intravenous conscious sedation/analgesia – first 30 m

inutes +++195

D9221

Deep sedation/general anesthesia – each additional 15 m

inutes +++75

D9220

Deep sedation/general anesthesia – first 30 m

inutes +++195

D9215

Local anesthesia0

D9120

Fixed partial denture sectioning15

D9110

Palliative (em

ergency) treatment of dental pain – m

inor procedure$0

Unclassified Treatm

ent

D9310

Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatm

ent)30

Professional Consultation

D9450

Case presentation, detailed and extensive treatm

ent planning0

D9440

Office visit – after regularly scheduled hours

50D

9430O

ffice visit for observation (during regularly scheduled hours) – no other services performed

0Professional Visits

D9972

External bleaching – per arch

165D

9971O

dontoplasty – one to two teeth

10D

9951O

cclusal adjustment – lim

ited0

Miscellaneous Services

Current D

ental Terminology (C

DT) ©

Am

erican Dental A

ssociation (AD

A)

Broken appointm

ent 25

+++*#** ^ =

+++ ^^

apply. Plan docum

ents are the final arbiter of coverage.D

ental Care entities referenced are w

holly-owned subsidiaries of The G

uardian Life Insurance Com

pany of Am

erica. Limitations and exclusions

DentalG

uard, Inc., (FL, NY

) - The Guardian Life Insurance C

ompany of A

merica. A

ll First Com

monw

ealth, Managed D

entalGuard, Inc., and M

anaged S

ervices Corporation, (M

I) - First Com

monw

ealth Inc., (CA

) - Managed D

ental Care, (TX

) - Managed D

entalGuard, Inc. (D

HM

O), (N

J) - Managed

Underw

ritten by: (IL) - First Com

monw

ealth Insurance Com

pany, (MO

) - First Com

monw

ealth of Missouri, (IN

) - First Com

monw

ealth Limited H

ealth

The Guardian Life Insurance C

ompany of A

merica, N

ew Y

ork, NY

100042008-6567

or periodontal osseous surgery.scaling and root planing or periodontal osseous surgery) by a participating periodontal S

pecialist. Active periodontal therapy includes periodontal scaling and root planing

may be perform

ed by a participating periodontal Specialist if done w

ithin three to six months follow

ing completion of approved, active periodontal therapy (periodontal

Routine prophylaxis or periodontal m

aintenance procedure - a total of four services in any 12-month period. O

ne of the covered periodontal maintenance procedures

Sealants are lim

ited to permanent teeth up to the 16th birthday.

Fluoride Treatment - a total of four services in any 12-m

onth period.

other covered surgical services.P

rocedure codes D9220, D

9221, D9241 and D

9242 are limited to a participating oral surgery S

pecialist. Additionally, these services are only covered in conjunction w

ith The P

atient Charge for these services is per unit.

retrospective review). O

ther codes may be used to describe C

overed Services.

Covered S

ervices are subject to exclusions, limitations and P

lan provisions as described in Mem

ber’s Plan booklet and the M

anual (including the Quality M

anagement

in the same 12-m

onth period, see codes D1999, D

2999 and D4999 for the applicable P

atient Charge.

The Patient C

harges for codes D1110, D

1120, D1203, D

1204, D1206 and D

4910 are limited to the first tw

o services in any 12-month period. For each additional service

If high noble metal is used, there w

ill be an additional Patient C

harge for the actual cost of the high noble metal.

Fee is $5 or $10.for the O

ffice Visit Fee w

hen the Plan S

chedule suffix listed on the ID C

ard and Eligibility R

eport is a "G". The ID

Card and E

ligibility Report w

ill indicate if the Office V

isit The M

ember w

ill be responsible for the Office V

isit Fee when the P

lan Schedule suffix listed on the ID

Card and E

ligibility Report is an "M

". The Plan w

ill be responsible

Page 5 of 5

V.08254

DHMO

Guardian Life Insurance C

ompany of A

merica.

DentalG

uard, Inc. in NJ and TX

. Managed D

ental Care, First C

omm

onwealth and M

anaged DentalG

uard, Inc. are wholly ow

ned subsidiaries of The M

anaged DentalG

uard is underwritten by M

anaged Dental C

are in CA

; First Com

monw

ealth in IL, MO

, MI and IN

; Guardian in FL and N

Y, and M

anaged

Managed D

entalGuard O

rthodontic Plan Schedule – Option W

Codes C

DT

Patient C

overed Services and Patient Charges

Orthodontics

Charges

In Progress

Orthodontics

D8090

Com

prehensive orthodontic treatment of the adult dentition **

D8080

Com

prehensive orthodontic treatment of the adolescent dentition **

D8070

Com

prehensive orthodontic treatment of the transitional dentition **

Adult:

2800 C

hild: $1500

*** ***

D8680

Orthodontic

D8670

Periodic orthodontic treatm

ent visit 0

***

D8660

Pre-orthodontic treatm

ent visit (includes treatment plan, records, evaluation and consultation)

250 ***

B

roken

retention 400

***

** C

hild orthodontics is limited to dependent children under age 19; adult orthodontics is lim

ited to dependent children age 19 and above

Current D

ental Terminology (C

DT) ©

Am

erican Dental A

ssociation (AD

A)

v.08192

*** Treatm

ent in progress: Orthodontic Treatm

ent – Com

prehensive orthodontic treatment is started w

hen the teeth are banded. and em

ployee or spouse. A M

ember’s age is determ

ined on the date of banding.

Takeover Treatment-in-P

rogress section. orthodontic retention is equal to 85%

of the Participating O

rthodontic Specialty C

are Dentist’s usual fee.. A

lso refer to the Orthodontic

comprehensive orthodontic treatm

ent is started prior to the Mem

ber’s eligibility to receive benefits under this plan, the Patient C

harge for fee. In this situation retention services w

ould also be at 85% of the P

articipating Orthodontic S

pecialty Care D

entist’s usual fee. When

who is w

illing to complete the treatm

ent at a patient charge equal to 85% of the P


pecialty Care D

entist’s usual eligibility to receive benefits under this plan m

ay be covered if the Mem

ber identifies a Participating O

rthodontic Specialty C

are Dentist

Orthodontic treatm

ent procedures which are listed on the P

lan Schedule and w

ere started but not completed prior to the M

ember’s

++ C

overed Services are subject to exclusions, lim

itations and Plan provisions as described in M

ember’s P

lan Booklet and the M

anual.

The Plan Covers:

performed by a P


pecialist Dentist.

Mem

ber. We m

ust preauthorize treatment, and it m

ust be and P

atient Charges, lim

ited to one (1) course of treatment per

• Orthodontic services as listed under C

overed Dental S

ervices

treatment.

• Up to tw

enty-four (24) months of com

prehensive orthodontic

interim and final records.

• Treatment plan and records, including initial records and any

appliances and related visits only. • C

omprehensive orthodontic treatm

ent, including the fixed banding

orthodontic treatment that w

as covered under this Plan.

• Retention services follow

ing a course of comprehensive

removable appliances and related visits.

• Orthodontic retention, including any and all necessary fixed and

the Participating O

rthodontic Specialist D

entist’s usual fee. the orthodontic treatm

ent. The additional charge will be based on

charges related to the orthognathic surgery and the complexity of

orthodontic benefit. The Mem

ber will be responsible for additional

surgical moving of teeth), the P

lan provides the standard orthognathic surgery (a non-covered procedure involving the

• If a Mem

ber has orthodontic treatment associated w

ith

This Plan Does N

ot Cover:

limitations, or as not covered under M

DG

. •

Any procedure listed as an exclusion, in excess of P

lan

Participating O

rthodontic Specialist D

entist. •

Orthodontic treatm

ent performed by any dentist other than a

treatment.

• Lim

ited orthodontic treatment and interceptive (P

hase I)

Specialist D

entist’s contracted fee.) m

onth of treatment, based upon the P

articipating Orthodontic

be responsible for an additional charge for each additional •

Treatment beyond tw

enty-four (24) months. (The M

ember w

ill

his or her usual fee over the remaining m

onths of treatment.

Participating O

rthodontist Specialty C

are Dentist m

ay prorate term

inates after the fixed banding appliances are inserted, the for benefits under the P

lan. If a Mem

ber’s coverage com

prehensive treatment begins before the M

ember is eligible

treatment, orthodontic services are not covered if

• E

xcept as described under treatment in progress – orthodontic

• O

rthodontic services after a Mem

ber’s coverage terminates.

optional material or linqual brackets.

appliances or those made w

ith clear, ceramic, w

hite or other •

Any increm

ental charges for non-standard orthodontic

movem

ent or (b) to correct or control harmful habits.

• P

rocedures, appliances or devices to (a) guide minor tooth

treatment necessitated by any kind of accident.

• R

e-treatment of orthodontic cases, or changes in orthodontic

due to the neglect of the Mem

ber. •

Replacem

ent or repair of orthodontic appliances damaged

treatment.

• E

xtractions performed solely to facilitate orthodontic

associated incremental charges.

• O

rthognathic surgery (moving of teeth by surgical m

eans) and

treatment.

change in Orthodontic S

pecialty Care D

entist and subsequent be responsible for any additional costs associated w

ith the orthodontic treatm

ent has started under this Plan, the M

ember w

ill S

pecialty Care D

entist after authorized comprehensive

• If a M

ember transfers to another P

articipating Orthodontic

appointment

25 ***

DH

MO

- MA

NA

GED

DEN

TAL G

UA

RD

OR

THO

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NTIC

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EFITS

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nder “

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om

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s “Fin

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form

atio

n

dow

n b

ox se

lect th

e n

um

ber o

f pro

vid

ers y

ou w

ant to

disp

lay p

er p

age

Clic

k “

Contin

ue” to

vie

w a

nd p

rint th

e list o

f netw

ork

pro

vid

ers

The d

enta

l offic

e c

ode is liste

d a

fter th

e d

enta

l offic

e n

am

e. P

lease

make n

ote

of th

e

Fin

d A

Provid

er

By v

isiting a

dentist in

Guard

ian’s n

etw

ork

, you c

an sa

ve m

oney o

n y

our d

enta

l care

and re

ceiv

e m

ore

valu

able

treatm

ents to

keep y

ou

Fin

d a

Pro

vid

er o

nlin

e se

arc

h fu

nctio

n m

akes it e

asy

to fin

d a

dentist n

ear y

ou w

ho o

ffers q

uality

, affo

rdable

care

.Just fo

llow

Locatio

n a

nd O

ffice

The d

enta

l offic

e c

ode is liste

d a

fter th

e d

enta

l offic

e n

am

e. P

lease

make n

ote

of th

e

IBE

W L

ocal 1

8 M

embers

Fo

r assistance w

ith L

ocal 1

8’s G

uard

ian D

ental B

enefits o

r for g

eneral serv

ice

issues (i.e. ad

dress ch

ang

e, dep

enden

t chan

ge an

d elig

ibility

), please co

ntact:

Local 1

8 B

enefit S

ervice C

ente

r 9

500

Top

ang

a Can

yo

n B

lvd

.,

Ch

atswo

rth, C

A 9

1311

Mon

day

– F

riday

, 8:3

0 am

– 5

:00

pm

800

-842

-66

35

818

-678

-00

40

818

-477

-14

76

(fax)

Lo

cal18

@m

yb

enefitch

oices.co

m (em

ail)

ww

w.m

yb

enefitch

oices.co

m/lo

cal18

*PHI is individually identifiable inform

ation (including demographic inform

ation) relating to your health, to the health care provided to you or to paym

ent for health care. Information acquired or m

aintained by us as a result of you having Life or D

isability coverage with G

uardian is not considered PHI.

The G


pany of Am

erica 7 Hanover S

quare, New

York, NY 10004-4025

NO

TIC

E O

F PRIV

AC

Y PR

AC

TIC

ES

Effective A

pril 14, 2003

TH

IS NO

TIC

E D

ESC

RIB

ES H

OW

ME

DIC

AL

INFO

RM

AT

ION

AB

OU

T Y

OU

MA

Y B

E

USE

D A

ND

DISC

LO

SED

AN

D H

OW

YO

U C

AN

GE

T A

CC

ESS T

O T

HIS

INFO

RM

AT

ION

USE

S AN

D D

ISCL

OSU

RE

S OF H

EA

LT

H IN

FOR

MA

TIO

N

Guardian uses PH

I about you for treatment, paym

ent and operational purposes. We do not require

authorization to use your PHI for these purposes. W

e may also use or disclose your PH

I without your

authorization for several other reasons. Subject to certain requirements, w

e may give out health

information w

ithout your authorization for public health reasons, for auditing purposes, for research studies and for em

ergencies. T

reatment. G

uardian may use and disclose your PH

I to assist your health care providers in your diagnosis and treatm

ent. For example, w

e may disclose your PH

I to providers to provide information about

alternative treatments.

Payment. G


I in order to pay for the services and items you m

ay receive. For exam

ple, we m

ay contact your health provider to certify that you received treatment (and for

what range of benefits), and w

e may request details regarding your treatm

ent to determine if your benefits

will cover, or pay for, your treatm

ent. We also m

ay use and disclose your PHI to obtain paym

ent from

third parties that may be responsible for such costs, such as fam

ily mem

bers. H

ealth Care O

perations. Guardian m

ay use and disclose your PHI to perform

health care operations. For exam

ple, we m

ay use your PHI for underw

riting and premium

rating purposes. In addition to the above m

entioned uses of your PHI related to treatm

ent, payment and health care

operations, Guardian m

ay also use your PHI for the follow

ing purposes: Plan Sponsors. W

e may use or disclose PH

I to the plan sponsor (usually your employer) of a group health

plan. A

ppointment R

eminders. A

lthough Guardian does not do this, w

e have the right to use and disclose your PH

I to contact you and remind you of appointm

ents.

The Guardian culture is based on an unw

avering belief in integrity and fair dealing. We take pride in

treating our customers and each other w

ith dignity and respect. Protecting your personal health inform

ation is very important to us. W

e want you to have a clear understanding of how

we use and

safeguard your protected health information.

GG

-014346WR

O 3/03

This Notice of Privacy Practices describes how

Guardian and its subsidiaries m

ay use and disclose your protected health inform

ation (PHI*) in order to carry out treatm

ent, payment and health care operations and

for other purposes permitted or required by law

. It also describes your rights to access and control your PH

I. G

uardian is required to abide by the terms of this N

otice. How

ever, we m

ay modify the term

s of this N

otice at any time, and the new

notice will be effective for all PH

I in our possession at the time of the

change, and any received thereafter. Upon request, w

e will provide you w

ith any revised Notice or you can

review the N

otice by accessing our website at http://w

ww

.GuardianA

nytime.com

.








The G


pany of Am

erica 7 Hanover S

quare, New

York, NY 10004-4025

Health R

elated Benefits and Services. G

uardian may use and disclose PH

I to inform you of health

related benefits or services that may be of interest to you.

Release of Inform

ation to Family and Friends. G

uardian may release your PH

I to a friend or family

mem

ber identified by you, that is helping you pay for your health care, or who assists in taking care of you.

Disclosures R

equired by Law

. Guardian w

ill use and disclose your PHI w

hen we are required to do so by

federal, state, or local law.

In addition to the above described uses and disclosures of your PHI, G

uardian may also use and disclose

your PHI under the follow

ing unique circumstances:

Public Health R

isks. Guardian m

ay disclose your PHI to public health authorities that are authorized by

law to collect inform

ation for the purpose of:

• M

aintaining vital records, such as births and deaths; •

Reporting child abuse or neglect;

• Preventing or controlling disease, injury or disability;

• N

otifying a person regarding potential exposure to a comm

unicable disease; •

Notifying a person regarding the potential risk for spreading or contracting a disease or condition;

• R

eporting reactions to drugs or problems w

ith products or devices; •

Notifying individuals if a product or device they m

ay be using has been recalled; •

Notifying appropriate governm

ent agencies and authorities regarding the potential abuse or neglect of an adult patient (including dom

estic violence); however, w

e will only disclose this

information if the insured agrees or w

e are required or authorized by law to disclose this

information; and

• N

otifying your employer under lim

ited circumstances related prim

arily to workplace injury or

illness or medical surveillance.

Health O

versight Activities . G

uardian may disclose your PH

I to a health oversight agency for activities authorized by law

. Oversight activities can include, for exam

ple, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, adm

inistrative, and criminal procedures or actions; or

other activities necessary for the government to m

onitor government program

s, compliance w

ith civil rights law

s and the health care system in general.

Law

suits and Similar Proceedings. G


I in response to a court or adm

inistrative order, if you are involved in a lawsuit or sim

ilar proceeding. We also m

ay disclose your PH

I in response to a discovery request, subpoena, or other lawful process by another party involved in the

dispute, but only if we have m

ade an effort to inform you of the request or to obtain an order protecting the

information the party has requested.

Law

Enforcem

ent. We m

ay release PHI if asked to do so by a law

enforcement official:

•

Regarding a crim

e victim in certain situations, if w

e are unable to obtain the person’s agreement;

• C

oncerning a death we believe m

ight have resulted from crim

inal conduct; •

Regarding crim

inal conduct at our offices; •

In response to a warrant, sum

mons court order, subpoena or sim

ilar legal process; •

To identify and/or locate a suspect, material w

itness, fugitive or missing person; and

• In an em

ergency, to report a crime (including the location or victim

(s) of the crime, or the

description, identity or location of the perpetrator). Serious T

hreats to Health or Safety . G


I when necessary to reduce

or prevent a serious threat to your health and safety or the health and safety of another individual or the public. U

nder these circumstances, w

e will only m

ake disclosures to a person or organization able to help prevent the threat.








The G


pany of Am

erica 7 Hanover S

quare, New

York, NY 10004-4025

Military. G


I if you are a mem

ber of United States or foreign

military forces (including veterans) and if required by the appropriate m

ilitary comm

and authorities. N

ational Security. Guardian m

ay use and disclose your PHI to federal officials for intelligence and

national security activities authorized by law. W

e also may disclose your PH

I to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. Inm

ates. Guardian m

ay disclose your PHI to correctional institutions or law

enforcement officials if you

are an inmate or under the custody of a law

enforcement official. D

isclosure for these purposes would be

necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/ or (c) to protect your health and safety or the health and safety of other individuals. W

orkers’ Com

pensation. Guardian m

ay release your PHI for w

orkers’ compensation and sim

ilar program

s.

YO

UR

RIG

HT

S T

he Right to Inspect and C

opy. You have the right to inspect and obtain a copy of your PH

I that we

maintain and have in our possession, including m

edical records (if we m

aintain any) and billing records, but not including psychotherapy notes. If you request copies, w

e will charge you a fee for the costs of

copying, mailing, labor and supplies associated w

ith your request. To inspect and copy your PHI, you m

ust subm

it your request in writing.

Under certain circum

stances we m

ay deny your request to inspect and copy your PHI. If you are denied

access to medical inform

ation, you have a right to have that determination review

ed. A licensed health care

professional chosen by Guardian w

ill review your request and the denial. The person conducting the

review w

ill not be the person who denied your request. G

uardian promises to com

ply with the outcom

e of the review

. T

he Right to A

mend Y

our PHI. If you feel that any PH

I we have about you is not correct or incom

plete, you m

ay ask us to amend the inform

ation. You have the right to request an am

endment for as long as the

information is kept by G

uardian. To request an amendm

ent, your request must be m

ade in writing.

Additionally, you m

ust provide a reason that supports your request. G

uardian reserves the right to deny your request for an amendm

ent if it is not in writing or does not include

a reason to support the request. In addition, we m

ay deny your request if you ask us to amend inform

ation that:

• W

as not created by Guardian, unless the person or entity that created the inform

ation is no longer available to m

ake the amendm

ent; •

Is not part of the medical inform

ation kept by or for Guardian;

• Is not part of the inform

ation which you w

ould be permitted to inspect and copy; or

• Is accurate and com

plete. T

he Right to an A

ccounting of Disclosures . A

n accounting of disclosures is a list of the disclosures we

have made, if any, of your PH

I. Y

ou have the right to request an accounting of disclosures. This right applies to disclosures for purposes other than those m

ade to carry out treatment, paym

ent and health care operations as described in this notice. It excludes disclosures m

ade to you, or those made for notification purposes.

Your request m

ust be made in w

riting and state a time period that cannot be longer than six years and

cannot include any dates before April 13, 2003. Y

our request should indicate in what form

you want the

list (e.g. paper, electronically). We m

ay charge you for the costs of providing the list. We w

ill notify you of the cost involved and you m

ay choose to withdraw

or modify your request at that tim

e before any costs are incurred.








The G


pany of Am

erica 7 Hanover S

quare, New

York, NY 10004-4025

The R

ight to Receive C

omm

unications of PHI by A

lternative Means or at A

lternative Locations.

You have the right to request that G

uardian comm

unicate with you about your health and related issues in a

particular manner or at a certain location. For exam

ple, you may ask that w

e contact you at work rather

than at home. W

e will accom

modate all reasonable requests m

ade in writing. Y

our request to receive PHI

by alternative means or at an alternative location m

ust clearly state that your life could be endangered by the disclosure of all or part of your PH

I. T

he Right to R

equest Restrictions. Y

ou have the right to request a restriction or limitation on the PH

I we

use or disclose about you for treatment, paym

ent or health care operations as described in this notice. You

also have the right to request a limit on the m

edical information w

e disclose about you to someone w

ho is involved in your care or the paym

ent for your care (like a family m

ember or friend), or for notification

purposes as described in this notice. G

uardian is not required to agree to your request, however, if w

e do agree, we w

ill comply w

ith your request until w

e receive notice from you that you no longer w

ant the restriction to apply (except as required by law

or in emergency situations).

Any R

equest for a restriction on our use and disclosure of your PHI m

ust be made in w

riting. Your request

must describe in a clear and concise m

anner: (a) the information you w

ish restricted; (b) whether you are

requesting to limit G

uardian’s use, disclosure or both; and (c) to whom

you want the lim

its to apply. T

he Right to Provide an A

uthorization for Other U

ses and Disclosures. G

uardian will obtain your

written authorization for uses and disclosures that are not identified by this notice or perm

itted by applicable law

. Any authorization you provide to us regarding the use and disclosure of your PH

I may be

revoked at any time in w

riting. After you revoke your authorization, w

e will no longer use or disclose your

PHI for the purposes described in the authorization, except under the follow

ing circumstances:

•

We have taken action in reliance upon your authorization before w

e received your written

revocation; •

You w

ere required to give us your authorization as a condition of obtaining coverage; or •

If state law gives us the right to contest a claim

under your policy. T

he Right to O

btain a Paper Copy of T

his Notice . U

pon request, you have a right to a paper copy of this notice, even if you have agreed to accept this notice electronically. T

he Right to File a C

omplaint. If you believe your privacy rights have been violated, you m

ay file a com

plaint with the U

.S. Secretary of Health and H

uman Services. If you w

ish to file a complaint w

ith G

uardian you may do so using the contact inform

ation below. Y

ou will not be penalized for filing a

complaint.

How

to Contact U

s If you have any com

plaints or questions about this Notice or you w

ant to submit a w

ritten request to G

uardian as required in any of the previous sections of this Notice, please call the toll-free num

ber on the back of your G

uardian ID card, or w

rite to us at the address below:

Attention:

Guardian C

orporate Privacy Officer

N

ational Operations

Address:

The Guardian Life Insurance C

ompany of A

merica

G

roup Quality A

ssurance - WR

O

P.O

. Box 2457

Spokane, W

A 99210-2457

No C

ost Language Services. Y

ou can get an interpreter. You can get docum

ents read to you and some sent

to you in your language. For help, call us at the number listed on your ID

card or 1-800-541-7846 for D

ental. For more help call the C

A D

ept. of Insurance at 1-800-927-4357. English Servicios de idiom

as sin costo. Puede obtener un intérprete. Le pueden leer los documentos y puede que le

envíen algunos en español. Para obtener ayuda, llámenos al núm

ero que figura en su tarjeta de identificación o al 1-800-541-7846 para servicios odontológicos. Para obtener m

ás ayuda, llame al

Departam

ento de Seguros de CA

al 1-800-927-4357. Spanish N

o Cost L

anguage Services. You can get an interpreter and get docum

ents read to you in your language. For help, call us at the num

ber listed on your ID card or 1-800-541-7846 for D

ental. For more help call the

CA

Dept. of Insurance at 1-800-927-4357. English

Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los docum

entos en español. Para obtener ayuda, llám

enos al número que figura en su tarjeta de identificación o al 1-800-541-7846 para

servicios odontológicos. Para obtener más ayuda, llam

e al Departam

ento de Seguros de CA

al 1-800-927-4357. Spanish

خدمات ترجمة بدون تكلفة .

صول على مترجم وقراءةيمكنك الح

الوثائق باللغة العربية .

صول على المساعدة، للح

ضويتك أو على الرقم صل بنا على الرقم المبين على بطاقة ع

ات1-800-541-7846

ب األسنانت ط

لخدما .

صول للح

صل بإدارة التأمين لوالية آاليفورنيا على الرقم ت، ات

على المزيد من المعلوما1-800-927-4357.

Arabic

Անվճա

ր Լեզվակա

ն Ծառա

յություններ: Դուք կա

րող եք թարգմա

ն ձեռք բերել և փաստ

աթղթերը ընթերցել տ

ալ ձեզ հա

մար հա

յերեն լեզվով: Օգնությա

ն համա

ր մեզ զա

նգահա

րեք ձեր ինքնության (ID

) տոմսի վրա

նշված կա

մ 1-800-541-7846 համա

րով Ատամնա

բուժության հա

մար: Լրա

ցուցիչ օգնության հա

մար 1-800-927-4357 հա

մարով

զանգա

հարեք Կ

ալիֆորնիա

յի Ապահովա

գրության Բ

աժա

նմունք: Arm

enian 免

費語

言服

務。

您可

獲得

口譯

員服

務，

用中

文把

文件

唸給

您聽

。欲

取得

協助

，請

致電

您的

保險

卡所

列的

電話

號碼

，牙

科協

助請

致電

1-800-541-7846 與

我們

聯絡

。欲

取得

其他

協助

，請

致電

1-800-927-4357

與加

州保

險部

聯絡

。Traditional C

hinese C

ov Kev Pab T

xhais Lus T

sis them N

qi. Koj yuav thov tau kom

muaj neeg los txhais lus rau koj thiab

kom neeg nyeem

cov ntawv ua lus H

moob. Y

og xav tau kev pab, hu rau peb ntawm

tus xov tooj nyob hauv koj daim

yuaj ID los sis 1-800-541-7846 rau K

ev Kho H

niav. Yog xav tau kev pab ntxiv hu rau C

a lub Caij

Meem

Fai Muab K

ev Tuav Pov Hw

m ntaw

m 1-800-927-4357. H

mong

無料

の言

語サ

ービ

ス

日本

語で

通訳

をご

提供

し、

書類

をお

読み

しま

す。

サー

ビス

をご

希望

の方

は、

IDカ

ード

記載

の番

号ま

たは

1-800-541-7846（歯

科用

）ま

でお

問い

合わ

せくだ

さい

。更

なる

お問

い合

わせ

は、

カ

リフ

ォル

ニア

州保

険庁

、1-800-927-4357

まで

ご連

絡くだ

さい

。Japanese

esvakmμPasa\tKitéfø. GñkGacTTYl)anGñkbkERbPasa nigGanÉksarCUnGñkCaPasaExμr . sRmab;CMnYy sUmTUrs½BÞmkeyIg´tamelxEdlman bgðajelIb½NÑsMKal;xøÜnrbs;Gñk b¤elx 1-800-541-7846 sRmab;xageFμj

. sRmab;CMnYybEnßmeTot sUmTUrs½BÞeTARksYgFanara:b;rgrdækalIhV½rj:atamelx 1-800-927-4357 Khm

er

무료

통역

서비스

. 귀하는

통역

서비스를

받으실

수 있으며

한국어로

서류를

낭독해주는

서비스를

받으실

수 있습니다

. 도움이

필요하신

분은

귀하의

ID 카드에

나와있는

치과

서비스

1-800-541-7846

번으로

문의해주십시오

. 보다

자세한

사항을

문의하실

분은

캘리포니아

주 보험국

, 안내전화

1-800-927-4357

번으로

연락해

주십시오

. Korean

خدمات مجاني مربوط به زبان.

ت يك مترجم شفاهي است شما ميتوانيد از خدما

فاده آنيد و بگوئيد مدارك به ز با

فارسي برايتان خوانده شوند .

ت آمكبراي درياف

،ت شناسائي شما قيد شده

با ما از طريق شماره تلفني آه روي آارت و يا شماره

اس1-800-541-7846

براي دندانپزشكيس بگيريد

تما .

ت آمك بيشتر بهبراي درياف

CA

Dep. of

Insurance)

اداره بيمه آاليفرنيا (

به شماره 1-800-927-4357

تلفن آنيد .

Persian

w[\s GkFk ;/tktKI L s[;hI d[GkFhJ/ dhnK ;/tktK jk;b

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Transcript of Dental Coverage · Guardian is a leading provider of employee benefits and individual insurance...