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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.guardianlife.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

Union:

IBEW Local 18

Guardian Group Plan No.:

456998 New Application

Add Dependent(s) Remove Dependent(s)

Change Address Change Name

Drop Coverage as of: / / Employee Name

Date of hire

Employee Number

Benefit Effective

Employee Mailing Address City

State Zip

The best way to reach you: Day Phone

Evening Phone Email

Business Phone# Home Phone #

Preferred Email

Work Status/Eligibility:

Full Time Part Time

Retired Cobra/State Continuation

CHOOSE YOUR DENTAL COVERAGE: Check one box only Find dental providers online at www.guardianlife.com .

Option 1 –DHMO Option 2 – PPO Dental Guard Preferred

Employee Only

Employee + one

Employee + 2 or m

ore

ABOUT YOU AND YOUR DEPENDENTS D

ATE OF MARRIAGE __/__/____ DO YOU HAVE CHILDREN OR OTHER DEPENDENTS?

Yes No Dom

estic Partner Yes

No IF YOU HAVE A DOMESTIC PARTNER, IS YOUR PARTNERSHIP REGISTERED W

ITH THE STATE OF CALIFORNIA? Yes

No D

ental Provider Location

# - If electing the DH

MO

Add Change Drop

Em

ployee First, Middle Initial, Last N

ame

Sex M

F

Date of B

irth (mm

/dd/yyyy) S

S#

Add Change Drop

Spouse/D

P First, M

iddle Initial, Last Nam

e

Sex M

F

Date of B

irth (mm

/dd/yyyy) S

S#

Add Change Drop

Child (1):

Sex M

F

Date of B

irth (mm

/dd/yyyy) S

S#

Full-time student,

at (school): Add Change Drop

Child (2):

Sex M

F

Date of B

irth (mm

/dd/yyyy) S

S#

Full-time student,

at (school): Add Change Drop

Child (3):

Sex M

F

Date of B

irth (mm

/dd/yyyy) S

S#

Full-time student,

at (school):

Add Change Drop

Child (4):

Sex M

F

Date of B

irth (mm

/dd/yyyy)S

S#

Full-time student,

at (school): If waiving coverage, are you covered under another dental plan?

Yes No

If waiving dependent coverage, are your dependents covered under another dental plan? Yes

No

If you or your family has lost dental coverage, please explain below. Late entrant penalties m

ay apply. Reason for Loss of coverage:

Termination of Employment Divorce

Death of Spouse Termination or Expiration of coverage Date of coverage loss:

IMPORTANT NOTES: Proof of insurability does not apply to dental, but if you waive dental coverage and later decide to enroll, you may be subject to a late entrant penalty and your dental benefits may be limited for a period of time. Guardian may waive late-entrant penalties if you lose dental coverage due to termination of the plan, loss of employment, death of spouse/DP, divorce or where a court has ordered coverage be provided for an eligible spouse/DP or eligible children, provided you apply within 30 days. Late entrant penalties or proof of insurability do not apply to DHMO dental coverage. The DHMO dental plan refers to, as applicable, Managed DentalGuard dental HMO plans underwritten by Managed Dental Care. Eligibility for this coverage is only available at the open enrollment period. Signature •

I hereby apply for the group benefit(s) that I have chosen above. •

I understand that I must meet eligibility requirements for all coverage’s that I have chosen above. •

I agree that my employer may deduct premiums from my pay or add premiums to my dues; if they are required for the coverage I have chosen above. •

I attest that the information provided above is true and correct to the best of my knowledge. •

I understand that my dependent(s) cannot be enrolled for coverage if I am not enrolled for that coverage. •

Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim

containing a false or deceptive statem

ent may be guilty of insurance fraud.

SIGNATURE OF EMPLOYEE DATE

PLEASE R

ETAIN

A PH

OTO

CO

PY FOR

YOU

R R

ECO

RD

S AN

D SU

BM

IT THIS FO

RM

TO

LOC

AL 18 B

ENEFIT SER

VICE C

ENTER

, 9500 Topanga Canyon B

lvd, Chatsw

orth, CA

91311

GG

015073CA

Enrollment / C

hange Form

T

he Guardian L

ife Insurance Com

pany of Am

erica

CEF-2005 5/07 ESU

Managed D

ental Care of C

alifornia A w

holly owned subsidiary of Guardian

19

Prepared for IBEW Local 18 Guardian Group Plan Number 00456998

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

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.

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

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.guardianlife.com Enrollment Kit 00456998, 0001, EN

Network Managed DentalGuard DentalGuard PreferredCalendar year deductible

Individual No deductible Family limit Waived for

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

3 per family Preventive Preventive

Charges covered for you (co-insurance) In - Network only Preventive Care (e.g. cleanings) You pay a copay for each Basic Care (e.g. fillings) covered procedure. See Major Care (e.g. crowns, dentures) “Plan Details”, for Orthodontia more information.

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

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

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

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

4

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

odes ++C

overed Dental Services

PatientC

hargesD

0999O

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

EvaluationsD

0120P

eriodic oral examination – established patient

0D

0140Lim

ited oral evaluation – problem focused

0D

0145O

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

ary caregiver0

D0150

Com

prehensive oral evaluation – new or established patient

0D

0170R

e-evaluation – limited, problem

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

D0180

Com

prehensive periodontal evaluation – new or established patient

0R

adiographs/Diagnostic Im

aging (Including Interpretation)D

0210Intraoral – com

plete series (including bitewings)

0D

0220Intraoral – periapical first film

0D

0230Intraoral – periapical each additional film

0D

0240Intraoral – occlusal film

0D

0270B

itewing – single film

0D

0272B

itewings – tw

o films

0D

0273B

itewings – three film

s0

D0274

Bitew

ings – four films

0D

0277V

ertical bitewings – 7 to 8 film

s0

D0330

Panoram

ic film0

Tests and Examinations

D0431

Adjunctive pre-diagnostic test that aids in detection of m

ucosal abnormalities including prem

alignant and malignant lesions, not to include cytology or

biopsy procedures50

D0460

Pulp vitality tests

0D

0470D

iagnostic casts0

Dental Prophylaxis

D1110

Prophylaxis – adult, for the first tw

o services in any 12-month period + #

0D

1120P

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

onth period + #0

D1999

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

e 12-month period + #

60Topical Fluoride Treatm

ent (Office Procedure)

D1203

Topical application of fluoride (prophylaxis not included) – child, for the first two services in any 12-m

onth period + =0

D1204

Topical application of fluoride (prophylaxis not included) – adult, for the first two services in any 12-m

onth period + =0

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

2999Topical fluoride (adult or child), each additional service in the sam

e 12-month period + =

20O

ther Preventive ServicesD

1310N

utritional counseling for control of dental disease0

D1330

Oral hygiene instructions

0D

1351S

ealant – per tooth (molars) ^

0D

9999S

ealant – per tooth (non-molars) ^

35Space M

aintenance (Passive Appliances)

D1510

Space m

aintainer – fixed - unilateral0

D1515

Space m

aintainer – fixed - bilateral0

D1525

Space m

aintainer – removable - bilateral

0D

1550R

e-cementation of space m

aintainer0

D1555

Rem

oval of fixed space maintainer

0A

malgam

Restorations (Including Polishing)

D2140

Am

algam – one surface, prim

ary or permanent

0D

2150A

malgam

– two surfaces, prim

ary or permanent

0D

2160A

malgam

– three surfaces, primary or perm

anent0

D2161

Am

algam – four or m

ore surfaces, primary or perm

anent0

Resin-B

ased Com

posite Restorations - D

irectD

2330R

esin-based composite – one surface, anterior

0D

2331R

esin-based composite – tw

o surfaces, anterior0

D2332

Resin-based com

posite – three surfaces, anterior0

D2335

Resin-based com

posite – four or more surfaces or involving incisal angle (anterior)

0D

2390R

esin-based composite crow

n, anterior0

D2391

Resin-based com

posite – one surface, posterior0

D2392

Resin-based com

posite – two surfaces, posterior

0D

2393R

esin-based composite – three surfaces, posterior

0D

2394R

esin-based composite – four or m

ore surfaces, posterior0

Inlay/Onlay R

estorations ^^D

2510Inlay – m

etallic – one surface **60

D2520

Inlay – metallic – tw

o surfaces **75

D2530

Inlay – metallic – three or m

ore surfaces **75

D2542

Onlay – m

etallic – two surfaces **

80D

2543O

nlay – metallic – three surfaces **

80D

2544O

nlay – metallic – four or m

ore surfaces **80

D2610

Inlay – porcelain/ceramic – one surface

60D

2620Inlay – porcelain/ceram

ic – two surfaces

75D


ic – three or more surfaces

75D

2642O

nlay – porcelain/ceramic – tw

o surfaces80

D2643

Onlay – porcelain/ceram

ic – three surfaces80

D2644


ic – four or more surfaces

80

Page 1 of 5

V.08254

DHMO

6

Managed D


Plan U60G

CD

TC

odes ++C


PatientC

harges

Crow

ns – Single Restorations O

nly ^^D

2740C

rown – porcelain/ceram

ic substrate$100

D2750

Crow

n – porcelain fused to high noble metal **

95D

2751C

rown – porcelain fused to predom

inantly base metal

95D

2752C

rown – porcelain fused to noble m

etal95

D2780

Crow

n – ¾ cast high noble m

etal **85

D2781

Crow

n – ¾ cast predom

inantly base metal

85D

2782C

rown – ¾

cast noble metal

85D

2783C

rown – ¾

porcelain/ceramic

85D

2790C

rown – full cast high noble m

etal **95

D2791

Crow

n – full cast predominantly base m

etal95

D2792

Crow

n – full cast noble metal

95D

2794C

rown – titanium

95

Other R

estorative ServicesD

2910R

ecement inlay, onlay, or partial coverage restoration

0D

2915R

ecement cast or prefabricated post and core

0D

2920R

ecement crow

n0

D2930

Prefabricated stainless steel crow

n – primary tooth

10D

2931P

refabricated stainless steel crown – perm

anent tooth10

D2932

Prefabricated resin crow

n20

D2933

Prefabricated stainless steel crow

n with resin w

indow20

D2934

Prefabricated esthetic coated stainless steel crow

n – primary tooth

20D

2940S

edative filling0

D2950

Core buildup, including any pins

20D

2951P

in retention – per tooth, in addition to restoration0

D2952

Post and core in addition to crow

n, indirectly fabricated30

D2953

Each additional indirectly fabricated post – sam

e tooth10

D2954

Prefabricated post and core in addition to crow

n25

D2957

Each additional prefabricated post – sam

e tooth8

D2960

Labial veneer (resin laminate) – chairside

40D

2970Tem

porary crown (fractured tooth)

15D

2971A

dditional procedures to construct new crow

n under existing partial denture framew

ork125

Pulp Capping

D3110

Pulp cap – direct (excluding final restoration)

0D

3120P

ulp cap – indirect (excluding final restoration)0

Pulpotomy

D3220

Therapeutic pulpotomy (excluding final restoration) – rem

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

edicament

10D

3221P

ulpal debridement, prim

ary and permanent teeth

10D

3222P

artial pulpotomy for apexogenesis - perm

anent tooth with incom

plete root development

10D

3230P

ulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)

15D

3240P

ulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)

15Endodontic Therapy (Including Treatm

ent Plan, Clinical Procedures A

nd Follow-up C

are)D

3310R

oot canal, anterior (excluding final restoration)70

D3320

Root canal, bicuspid (excluding final restoration)

80D

3330R

oot canal, molar (excluding final restoration)

140D

3331Treatm

ent of root canal obstruction; non-surgical access0

D3332

Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

70D

3333Internal root repair of perforation defects

40Endodontic R

etreatment

D3346

Retreatm

ent of previous root canal therapy – anterior80

D3347

Retreatm

ent of previous root canal therapy – bicuspid95

D3348

Retreatm

ent of previous root canal therapy – molar

150A

picoectomy/Periradicular Services

D3410

Apicoectom

y/periradicular surgery – anterior90

D3421

Apicoectom

y/periradicular surgery – bicuspid (first root)95

D3425

Apicoectom

y/periradicular surgery – molar (first root)

100D

3426A

picoectomy/periradicular surgery (each additional root)

40D

3430R

etrograde filling – per root15

D3950

Canal preparation and fitting of preform

ed dowel or post

20Surgical Services (Including U

sual Postoperative Care)

D4210

Gingivectom

y or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant

60D

4211G

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

20D

4240G

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

105D

4241G

ingival flap procedure, including root planing – one to three contiguous teeth or bounded teeth spaces per quadrant35

D4249

Clinical crow

n lengthening – hard tissue85

D4260

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

ore contiguous teeth or bounded teeth spaces per quadrant155

D4261

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

95D

4268S

urgical revision procedure, per tooth0

D4270

Pedicle soft tissue graft procedure

100D

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

110D

4273S

ubepithelial connective tissue graft procedures, per tooth120

Page 2 of 5

V.08254

Managed D


Plan U60G

CD

TC

odes ++C


PatientC

harges

Non-Surgical Periodontal Service

D4341

Periodontal scaling and root planing – four or m

ore teeth per quadrant$25

D4342

Periodontal scaling and root planing – one to three teeth per quadrant

15D

4355Full m

outh debridement to enable com

prehensive evaluation and diagnosis15

Other Periodontal Services

D4910

Periodontal m

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

onth period + #15

D4920

Unscheduled dressing change (by som

eone other than treating dentist)0

D4999

Periodontal m

aintenance, each additional service in same 12-m

onth period + #60

Com

plete Dentures (Including R

outine Post-Delivery C

are)D

5110C

omplete denture – m

axillary110

D5120

Com

plete denture – mandibular

110D

5130Im

mediate denture – m

axillary110

D5140

Imm

ediate denture – mandibular

110Partial D

entures (Including Routine Post-D

elivery Care)

D5211

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

90D

5212M

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

D5213

Maxillary partial denture – cast m

etal framew

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

130D

5214M

andibular partial denture – cast metal fram

ework w

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

D5225

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

140D

5226M

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

Adjustm

ents to Dentures

D5410

Adjust com

plete denture – maxillary

5D

5411A

djust complete denture – m

andibular5

D5421

Adjust partial denture – m

axillary5

D5422

Adjust partial denture – m

andibular5

Repairs To C

omplete D

enturesD

5510R

epair broken complete denture base

0D

5520R

eplace missing or broken teeth – com

plete denture (each tooth)0

Repairs To Partial D

enturesD

5610R

epair resin denture base0

D5620

Repair cast fram

ework

0D

5630R

epair or replace broken clasp0

D5640

Replace broken teeth – per tooth

0D

5650A

dd tooth to existing partial denture0

D5660

Add clasp to existing partial denture

0D

5670R

eplace all teeth and acrylic on cast metal fram

ework (m

axillary)0

D5671

Replace all teeth and acrylic on cast m

etal framew

ork (mandibular)

0D

enture Rebase Procedures

D5710

Rebase com

plete maxillary denture

0D

5711R

ebase complete m

andibular denture0

D5720

Rebase m

axillary partial denture0

D5721

Rebase m

andibular partial denture0

Denture R

eline ProceduresD

5730R

eline complete m

axillary denture (chairside)0

D5731

Reline com

plete mandibular denture (chairside)

0D

5740R

eline maxillary partial denture (chairside)

0D

5741R

eline mandibular partial denture (chairside)

0D

5750R

eline complete m

axillary denture (laboratory)0

D5751

Reline com

plete mandibular denture (laboratory)

0D

5760R

eline maxillary partial denture (laboratory)

0D

5761R

eline mandibular partial denture (laboratory)

0Interim

ProsthesisD

5820Interim

partial denture (maxillary)

45D

5821Interim

partial denture (mandibular)

45O

ther Rem

ovable Prosthetic ServicesD

5850Tissue conditioning, m

axillary0

D5851

Tissue conditioning, mandibular

0Fixed Partial D

enture Pontics ^^D

6210P

ontic – cast high noble metal **

90D

6211P

ontic – cast predominantly base m

etal90

D6212

Pontic – cast noble m

etal90

D6214

Pontic – titanium

90

D6240

Pontic – porcelain fused to high noble m

etal **90

D6241

Pontic – porcelain fused to predom

inantly base metal

90D

6242P

ontic – porcelain fused to noble metal

90D

6245P

ontic – porcelain/ceramic

90Fixed Partial D

enture Retainers – Inlays/O

nlays ^^D


ic – two surfaces

75D


ic – three or more surfaces

75D

6602Inlay – cast high noble m

etal, two surfaces **

75D

6603Inlay – cast high noble m

etal, three or more surfaces **

75D

6604Inlay – cast predom

inantly base metal, tw

o surfaces75

Page 3 of 5

V.08254

Managed D


Plan U60G

CD

TC

odes ++C


PatientC

harges

Fixed Partial Denture R

etainers – Inlays/Onlays ^^ (continued)

D6605

Inlay – cast predominantly base m

etal, three or more surfaces

$75D

6606Inlay – cast noble m

etal, two surfaces

75D

6607Inlay – cast noble m


75D

6608O

nlay – porcelain/ceramic, tw

o surfaces80

D6609


ic, three or more surfaces

80D

6610O

nlay – cast high noble metal, tw

o surfaces **80

D6611

Onlay – cast high noble m

etal, three or more surfaces **

80D

6612O

nlay – cast predominantly base m

etal, two surfaces

80D

6613O

nlay – cast predominantly base m


80D

6614O

nlay – cast noble metal, tw

o surfaces80

D6615

Onlay – cast noble m


80D

6624Inlay – titanium

75

D6634

Onlay – titanium

75

Fixed Partial Denture R

etainers – Crow

ns ^^D

6740C

rown – porcelain/ceram

ic100

D6750

Crow

n – porcelain fused to high noble metal **

95D

6751C

rown – porcelain fused to predom

inantly base metal

95D

6752C

rown – porcelain fused to noble m

etal95

D6780

Crow

n – ¾ cast high noble m

etal **85

D6781

Crow

n – ¾ cast predom

inantly base metal

85D

6782C

rown – ¾

cast noble metal

85D

6783C

rown – ¾

porcelain/ceramic

85D

6790C

rown – full cast high noble m

etal **95

D6791

Crow

n – full cast predominantly base m

etal95

D6792

Crow

n – full cast noble metal

95D

6794C

rown – titanium

95

Other Fixed Partial D

enture ServicesD

6930R

ecement fixed partial denture

0D

6970P

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

D6972

Prefabricated post and core in addition to fixed partial denture retainer

25D

6973C

ore build up for retainer, including any pins20

D6976

Each additional cast post – sam

e tooth10

D6977

Each additional prefabricated post – sam

e tooth8

D6999

Multiple crow

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

ore units per treatment plan ^^

125Extractions

D7111

Extraction, coronal rem

nants – deciduous tooth10

D7140

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

oval)10

Surgical Extractions (Includes Local Anesthesia, Suturing, If N

eeded, And R

outine Postoperative Care)

D7210

Surgical rem

oval of erupted tooth requiring elevation of mucoperiosteal flap and rem

oval of bone and/or section of tooth35

D7220

Rem

oval of impacted tooth – soft tissue

50D

7230R

emoval of im

pacted tooth – partially bony70

D7240

Rem

oval of impacted tooth – com

pletely bony80

D7241

Rem

oval of impacted tooth – com

pletely bony, with unusual surgical com

plications85

D7250

Surgical rem

oval of residual tooth roots (cutting procedure)40

D7261

Prim

ary closure of a sinus perforation250

Other Surgical Procedures

D7280

Surgical access of an unerupted tooth

90D

7283P

lacement of device to facilitate eruption of im

pacted tooth35

D7285

Biopsy of oral tissue – hard (bone, tooth)

45D

7286B

iopsy of oral tissue – soft40

D7288

Brush biopsy – transepithelial sam

ple collection65

Alveoloplasty – Surgical Preparation O

f Ridge For D

enturesD

7310A

lveoloplasty in conjunction with extractions – four or m

ore teeth or tooth spaces, per quadrant35

D7311

Alveoloplasty in conjunction w

ith extractions – one to three teeth or tooth spaces, per quadrant16

D7320

Alveoloplasty not in conjunction w

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

45D

7321A

lveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

30Surgical Excision O

f Intra-Osseous Lesions

D7450

Rem

oval of benign odontogenic cyst or tumor – lesion diam

eter up to 1.25 cm60

D7451

Rem

oval of benign odontogenic cyst or tumor – lesion diam

eter greater than 1.25 cm110

Excision Of B

one TissueD

7471R

emoval of lateral exostosis (m

axilla or mandible)

75D

7472R

emoval of torus palatinus

75D

7473R

emoval of torus m

andibularis75

Surgical IncisionD

7510Incision and drainage of abscess – intraoral soft tissue

25D

7511Incision and drainage of abscess – intraoral soft tissue – com

plicated (includes drainage of multiple fascial spaces)

30O

ther Repair Procedures

D7960

Frenulectomy (frenectom

y or frenotomy) – separate procedure

60D

7963Frenuloplasty

100

Page 4 of 5

V.08254

Managed D


Plan U60G

CD

TC

odes ++C


PatientC

harges

Unclassified Treatm

entD

9110P

alliative (emergency) treatm

ent of dental pain – minor procedure

$0D

9120Fixed partial denture sectioning

15D

9215Local anesthesia

0D

9220D

eep sedation/general anesthesia – first 30 minutes +++

195D

9221D

eep sedation/general anesthesia – each additional 15 minutes +++

75D

9241Intravenous conscious sedation/analgesia – first 30 m

inutes +++195

D9242

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

75Professional C

onsultationD

9310C

onsultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)

30Professional Visits

D9430

Office visit for observation (during regularly scheduled hours) – no other services perform

ed0

D9440

Office visit – after regularly scheduled hours

50D

9450C

ase presentation, detailed and extensive treatment planning

0M

iscellaneous ServicesD

9951O

cclusal adjustment – lim

ited0

D9971

Odontoplasty – one to tw

o teeth10

D9972

External bleaching – per arch

165B

roken appointment

25

Current D

ental Terminology (C

DT) ©

Am

erican Dental A

ssociation (AD

A)

+++*#=^**^^

+++

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 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

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 D

ental Care entities referenced are w

holly-owned subsidiaries of The G

uardian Life Insurance Com

pany of Am

erica. Limitations and exclusions

apply. Plan docum

ents are the final arbiter of coverage.

The Guardian Life Insurance C

ompany of A

merica, N

ew Y

ork, NY

100042008-6567

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

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

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

ctive periodontal therapy includes periodontal scaling and root planing or periodontal osseous surgery.Fluoride Treatm

ent - a total of four services in any 12-month period.

Sealants are lim

ited to permanent teeth up to the 16th birthday.

The Patient C

harge for these services is per unit.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 other covered surgical services.

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

in the same 12-m

onth period, see codes D1999, D

2999 and D4999 for the applicable P

atient Charge.

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

retrospective review). O

ther codes may be used to describe C

overed Services.

If high noble metal is used, there w

ill be an additional Patient C

harge for the actual cost of the high noble metal.

The Mem

ber will be responsible for the O

ffice Visit Fee w

hen the Plan S

chedule suffix listed on the ID C

ard and Eligibility R

eport is an "M". The P

lan will be responsible

for the Office V

isit Fee when the P

lan Schedule suffix listed on the ID

Card and E

ligibility Report is a "G

". The ID C

ard and Eligibility R

eport will indicate if the O

ffice Visit

Fee is $5 or $10.

Page 5 of 5

V.08254

Managed D

entalGuard is underw

ritten by Managed D

ental Care in C

A; First C

omm

onwealth in IL, M

O, M

I and IN; G

uardian in FL and NY

, and Managed

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 G


pany of Am

erica.

MA

NA

GED

DEN

TALG

UA

RD

OR

THO

DO

NTIC

BEN

EFITS

Managed D

entalGuard O

rthodontic Plan Schedule – Option W

CD

T C

odes C

overed Services and Patient Charges

Patient C

harges O

rthodontics In Progress

O

rthodontics

D8070

Com

prehensive orthodontic treatment of the transitional dentition **

D8080

Com

prehensive orthodontic treatment of the adolescent dentition **

D8090

Com

prehensive orthodontic treatment of the adult dentition **

Child:

$1500 A

dult: 2800

*** ***

D8660

Pre-orthodontic treatm

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

250 ***

D8670

Periodic orthodontic treatm

ent visit 0

***

D8680

Orthodontic retention

400 ***

B

roken appointment

25 ***

C

urrent Dental Term

inology (CD

T) © A

merican D

ental Association (A

DA

) v.08192

** C

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

ited to dependent children age 19 and above and em

ployee or spouse. A M

ember’s age is determ

ined on the date of banding. ***

Treatment in progress: O

rthodontic Treatment – C

omprehensive orthodontic treatm

ent is started when the teeth are banded.

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

eligibility to receive benefits under this plan may be covered if the M

ember identifies a P

articipating Orthodontic S

pecialty Care D

entist w

ho is willing to com

plete the treatment at a patient charge equal to 85%

of the Participating O

rthodontic Specialty C

are Dentist’s usual

fee. In this situation retention services would also be at 85%

of the Participating O

rthodontic Specialty C

are Dentist’s usual fee. W

hen com

prehensive orthodontic treatment is started prior to the M

ember’s eligibility to receive benefits under this plan, the P

atient Charge for

orthodontic retention is equal to 85% of the P


pecialty Care D

entist’s usual fee.. Also refer to the O

rthodontic Takeover Treatm

ent-in-Progress section.

++ 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:

• Orthodontic services as listed under C

overed Dental S

ervices and P

atient Charges, lim

ited to one (1) course of treatment per

Mem

ber. We m

ust preauthorize treatment, and it m

ust be perform

ed by a Participating O

rthodontic Specialist D

entist. • U

p to twenty-four (24) m

onths of comprehensive orthodontic

treatment.

• Treatment plan and records, including initial records and any

interim and final records.

• Com

prehensive orthodontic treatment, including the fixed banding

appliances and related visits only. • R

etention services following a course of com

prehensive orthodontic treatm

ent that was covered under this P

lan. • O

rthodontic retention, including any and all necessary fixed and rem

ovable appliances and related visits. • If a M

ember has orthodontic treatm

ent associated with

orthognathic surgery (a non-covered procedure involving the surgical m

oving of teeth), the Plan provides the standard

orthodontic benefit. The Mem

ber will be responsible for additional

charges related to the orthognathic surgery and the complexity of

the orthodontic treatment. The additional charge w

ill be based on the P


pecialist Dentist’s usual fee.

This Plan Does N

ot Cover:

• A

ny procedure listed as an exclusion, in excess of Plan

limitations, or as not covered under M

DG

. •

Orthodontic treatm

ent performed by any dentist other than a

Participating O

rthodontic Specialist D

entist. •

Limited orthodontic treatm

ent and interceptive (Phase I)

treatment.

• Treatm

ent beyond twenty-four (24) m

onths. (The Mem

ber will

be responsible for an additional charge for each additional m

onth of treatment, based upon the P

articipating Orthodontic

Specialist D

entist’s contracted fee.) •

Except as described under treatm

ent in progress – orthodontic treatm

ent, orthodontic services are not covered if com

prehensive treatment begins before the M

ember is eligible

for benefits under the Plan. If a M

ember’s coverage

terminates after the fixed banding appliances are inserted, the

Participating O

rthodontist Specialty C

are Dentist m

ay prorate his or her usual fee over the rem

aining months of treatm

ent. •

Orthodontic services after a M

ember’s coverage term

inates. •

Any increm

ental charges for non-standard orthodontic appliances or those m

ade with clear, ceram

ic, white or other

optional material or linqual brackets.

• P

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

movem

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

• R

e-treatment of orthodontic cases, or changes in orthodontic

treatment necessitated by any kind of accident.

• R

eplacement or repair of orthodontic appliances dam

aged due to the neglect of the M

ember.

• E

xtractions performed solely to facilitate orthodontic

treatment.

• O

rthognathic surgery (moving of teeth by surgical m

eans) and associated increm

ental charges. •

If a Mem

ber transfers to another Participating O

rthodontic S

pecialty Care D

entist after authorized comprehensive

orthodontic treatment has started under this P

lan, the Mem

ber will

be responsible for any additional costs associated with the

change in Orthodontic S

pecialty Care D

entist and subsequent treatm

ent.

Finding a dentist is easy G

o online — it takes just m

inutes!

It’s easy to find dentists you can trust. Whether you’re looking for a list of dentists

that serve your plan (in-network) or trying to locate a specific dentist, it takes just

minutes through G

uardian’s Provider O

nline Search.

Guardian’s P

rovider Online S

earch is available to you 24 hours a day, 7 days a week.

Here are just a few

things you can do online: �

Custom

ize your search by specialty, languages spoken, gender and m

ore �

Get side-by-side com

parisons of dentists’ information (ie. office

status, distance) �

Create a short-list of “favorite” dentists —

for quick reference online

� G

et maps and directions to a dentist’s office location

� V

iew your results online or have them

faxed or emailed to you

� S

ave your search criteria for easy access when you revisit

Provider O

nline Search

� C

reate a customized directory of dentists

� N

ominate a dentist to be included in a netw

ork Follow

these steps to find Dental P

roviders in your area: �

Go to w

ww

.GuardianLife.com

�

Under

� S

elect Find a Dentist

� S

elect your dental plan (DH

MO

or PP

O)

� S

elect your Search Type (Location, N

ame, G

roup Nam

e, or Zip code

� S

elect your Dental N

etwork

o D

HM

O - M

anaged Dental C

are o

PP

O - D

entalGuard P

referred For questions on how

to find a provider, you can also call the G

uardian Em

ployee Benefit H

otline at 1-888-600-1600.

2007 — 7669 (10/07) The G


pany of Am

erica, New

York, NY 10004 D

ental

12"C

ontact us"(middle right) click on "Find a provider"

hecplarRectangle

15

IBEW Local 18 Members

For Questions Regarding Local 18’s Guardian Dental Benefits or for general service issues (i.e. claims or eligibility), please contact:

Local 18 Benefit Service Center 9500 Topanga Canyon Blvd., Chatsworth, CA 91311 Monday – Friday, 8:30 am – 5:00 pm

800-842-6635

818-678-0040

818-477-1476 (fax)

[email protected] (email)

www.mybenefitchoices.com/local18

*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

This N

otice of Privacy Practices describes how G

uardian and its subsidiaries may use and disclose your

protected health information (PH

I*) in order to carry out treatment, paym

ent and health care operations and for other purposes perm

itted or required by law. It also describes your rights to access and control your

PHI.

Guardian is required to abide by the term

s of this Notice. H

owever, w

e may m

odify the terms of this

Notice at any tim

e, and the new notice w

ill be effective for all PHI in our possession at the tim

e of the change, and any received thereafter. U

pon request, we w

ill provide you with any revised N

otice or you can review

the Notice by accessing our w

ebsite at http://ww

w.G

uardianLife.com.

U

SES A

ND

DISC

LO

SUR

ES O

F HE

AL

TH

INFO

RM

AT

ION

G

uardian uses PHI about you for treatm

ent, payment and operational purposes. W

e do not require authorization to use your PH

I for these purposes. We m

ay also use or disclose your PHI w

ithout your authorization for several other reasons. Subject to certain requirem

ents, we m

ay give out health inform

ation without your authorization for public health reasons, for auditing purposes, for research studies

and for emergencies.

Treatm

ent. Guardian m

ay use and disclose your PHI to assist your health care providers in your diagnosis

and treatment. For exam

ple, we m

ay disclose your PHI to providers to provide inform

ation about alternative treatm

ents. Paym

ent. Guardian m

ay use and disclose your PHI in order to pay for the services and item

s you may

receive. For example, w

e may contact your health provider to certify that you received treatm

ent (and for w

hat range of benefits), and we m

ay request details regarding your treatment to determ

ine if your benefits w

ill cover, or pay for, your treatment. W

e also may use and disclose your PH

I to obtain payment from

third parties that m

ay be responsible for such costs, such as family m

embers.

Health C

are Operations. G

uardian may use and disclose your PH

I to perform health care operations. For

example, w

e may use your PH

I for underwriting and prem

ium rating purposes.

In addition to the above mentioned uses of your PH

I related to treatment, paym

ent and health care operations, G

uardian may also use your PH

I for the following purposes:

Plan Sponsors. We m

ay use or disclose PHI to the plan sponsor (usually your em

ployer) 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








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

eo ;ed/ j' ns/ d;skt/}K ~ gzikph ftu ;[D ;ed/ j'.

e[M d;skt/} s[jk~ gzikph ftZu G/i/ ik ;ed/ jB. wdd bJh, s[jkv/ n

kJhvh (ID) ekov @s/ fdZs/ Bzpo @s/ iK

dzdK bJh 1-800-541-7846@s/ ;k~ \'B eo'. tX/o/ wdd b

Jh e?bh\'oBhn

k fvgkoNw+N nk\ fJBF'o+; ~ 1-

800-927-4357 @s/ \'B eo'. Punjabi Бесплатны

е услуги перевода. Вы

можете воспользоваться услугами переводчика, и ваш

и документы

прочтут для вас на русском языке. Если вам требуется помощ

ь, звоните нам по номеру, указанному на ваш

ей идентификационной карте, или 1-800-541-7846 (стоматологическая страховка). Если вам требуется дополнительная помощ

ь, звоните в Департамент страхования ш

тата Калифорния (D

epartment of Insurance) по телефону 1-800-927-4357. R

ussian W

alang Gastos na m

ga Serbisyo sa Wika. M

akakakuha ka ng interpreter o tagasalin at maipababasa m

o sa Tagalog ang m

ga dokumento. Para m

akakuha ng tulong, tawagan kam

i sa numerong nakalista sa iyong

ID card o sa 1-800-541-7846 para sa D

ental. Para sa karagdagang tulong, tawagan ang C

A D

ept. of Insurance sa 1-800-927-4357 Tagalog C

aùc Dòch V

uï Trôï Giuùp N

goân Ngöõ M

ieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc

ngöôøi khaùc ñoïc giuùp caùc taøi lieäu baèng tieáng Vieät. Ñ

eå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc goïi soá 1-800-541-7846 cho dòch vuï nha khoa. Ñ

eå ñöôïc trôï giuùp theâm

, xin goïi Sôû Baûo H

ieåm C

alifornia taïi soá 1-800-927-4357. Vietnam

ese

© 2005 The Guardian Life Insurance Company of America,

7 Hanover Square, New York 10004

Your Benefits Information … Anytime, Anywhere

www.GuardianAnytime.com

Enrolled members and their dependents can access helpful,

secure information about their Guardian benefit(s) online at

www.GuardianAnytime.com–24 hours a day, 7 days a week.

Anytime, anywhere you have an internet connection, you’ll be

able to:

• Review your benefits

• Look up coverage amounts

• Check the status of a claim

• Print forms and plan materials

• And so much more!

To register, go to www.GuardianAnytime.com

IBEW Local 18 Dental

Benefits Plan

0001

7 Hanover Square, New York 10004

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