11 Dental Plan It’s important to have regular dental exams and cleanings so problems are detected before they become painful – and expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and is an important part of maintaining your overall health. We offer two dental plans through Guardian. Plan Provisions Low High In - Network Out - of - Network In - Network Out - of - Network Annual Deductible (Individual/Family) $50/$150 $50/$150 $50/$150 $50/$150 Annual Maximum (per Individual) $1,000 $1,000 $2,000 $2,000 Diagnostic and Preventive Services (e.g., X - rays, cleanings, exams) Covered at 100% Covered at 100% Covered at 100% Covered at 100% Basic and Restorative Services (e.g., fillings) 50%* 50%* 20%* 20%* Major Services (e.g., dentures, crowns, bridges) 50%* 50%* 50%* 50%* Orthodontia (children up to age 26) Not Covered 50%, up to a lifetime maximum of $2,000 per individual *After deductible Get the most from your dental plans • Stay in - network – While you have the option of choosing any provider, you save money when you use in - network dentists. When using an out - of - network dental provider, you pay more because the provider has not agreed to charge you a negotiated rate. • Free annual check - up – Use free preventive care to keep your mouth and gums healthy all year long. Your bi - weekly payroll contributions for dental benefits are shown here. Dental Low High Employee Only $0 $4.67 Employee + Spouse $7.39 $16.87 Employee + Child(ren) $10.56 $25.45 Family $19.57 $42.41