Procedure Class	Services Available	Frequency of Services
Preventive No Waiting Period	•  Oral Evaluations •  2 times per 12 months •  Bitewing X-rays •  1 time per 12 months •  Full Mouth X-Rays •  1 time per 60 months •  Simple Cleaning •  2 times per 12 months •  Fluoride Treatment •  1 time per 12 months up to age 16
Basic No Waiting Period	•  Sealants •  1 time per molar per 36 months •  Space Maintainers •  Fillings •  1 per lifetime per arch •  Simple Extractions •  1 time per tooth surface per 24 months •  Palliative Emergency Treatment •  1 time per 12 months
Major 12 Month Waiting Period	•  Anesthesia*     •  Oral Surgery     •  Endodontics     •  Periodontics •  1 time per 7 years •  Single Tooth Restorations (Crowns, Inlays, Onlays)
Prosthodontic (Dentures) 24 Month Waiting Period	•  Fixed Prosthodontics •  1 time per 7 years •  Removable Prosthodontics •  1 time per 7 years •  Prosthodontic Repairs and Adjustments
Orthodontics No Waiting Period	•  In-Network discounts only

Deductible:
Just $50 per year for each covered family member.

Maximum Benefit
$1000 per year for each covered family member.

Plan Reimbursement
100% of the scheduled amount for the service required*

Plus an Extra Vision Benefit!
You’ll also receive an annual $35 eye exam benefit. In addition, you may eligible for special pricing at over 10,000 vision providers on other vision services.

National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a.k.a. The Guardian, Guardian Life.