b'Benefits for 2022Dental CoverageSUMMARY OF COVERAGEDHMO Dental Plan ValueDental Plan PPO Dental Plan(MI Only)Plan FeaturesNetwork First Commonwealth DentalGuard Preferred DentalGuard PreferredIN NETWORKCalendar YearDeductible (Individual / Family) $0 / $0 $25 / $75 $50 / $150Preventive Care See Plan Details 100% 100%Basic Procedures (Fillings, minor restorative, etc) See Plan Details 80%Non-Surgical 80%Major Procedures (Crowns, dentures, etc.) See Plan Details 50% Surgical 50%Child Orthodontia See Plan Details Not Covered Not CoveredCalendar Year Maximum Benefit Unlimited $1,000/ person $1,000/ personOUT OF NETWORKAnnual Deductible (Individual / Family) No Coverage $75 / $225 $75 / $225Preventive Care No Coverage 100% 80%Basic Procedures (Extractions, fillings, etc.) No Coverage50% Non-Surgical 80%Major Procedures (Crowns, dentures, etc.) No Coverage25% Surgical 50%Child Orthodontia No CoverageNot Covered Not CoveredCalendar Year Maximum Benefit No Coverage$1,000/ person $1,000/ personMaximumRolloverThreshold N/A $500 $500Rollover Amount N/A $250 $250In-network only Rollover N/A $350 $350Max Rollover Limit N/A $1,000 $1,000PPO Plan - With your PPO Plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist.All dentists in the PPO network agree to provide services for participants at a cost thats below average charges in their communities.DHMO Plan - With your DHMO Plan, you must select a primary care dentist and you must see that dentist for services.Benefits are paid on a pre-determined fee schedule located in the back of this booklet.This plan has no annual maximum benefit.There are no out-of-network benefits with the DHMO.This plan is only available to Michigan Residents.To find a PPO or DHMO dentist, visit www.guardiananytime.com.2022 Employee Benefit Guide This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance12carrier or providers contract.'