Maximum Rollover | Guardian

Workplacebenefits

EveryonedeservesaGuardian

securitytheydeservethroughourinsuranceand wealthmanagementproductsandservices.

We’vepartneredwithyourorganizationtooffer youarangeofemployeebenefits.Insidethispack, you’llfindtheplansyouremployerthinksyoumight

Yourcoverageoptions

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Learnhowdentalinsurancecan protectyourlong-termhealth.

Dental insurance

Takingcareofyourteethisaboutmore thanjustcoveringcavitiesandcleanings. Italsomeansaccountingformoreexpensive dentalwork,andyouroverallhealth.

Withdentalinsurance,routinepreventivecarecanleadto betteroverallhealth.Andyou’llbeabletosavemoneyifany extensivedentalworkisrequired.

Who isitfor?

Everyoneshouldhaveaccesstogreatdentalcoverage,whichis whywe offercomprehensiveplansthatareavailablethroughemployersaspartof yourbenefitofferings.

What doesitcover?

Dentalinsurancehelpstoprotectyouroveralloralcare.Thatincludes serviceslikepreventivecleanings,x-rays,restorativeserviceslikefillings, andothermoreseriousformsoforalsurgeryifyoueverneedthem.

Why shouldIconsiderit?

Poororalhealthisn’tjustaesthetic,it’salsobeenlinkedtoconditions includingdiabetes,heartdisease,andstrokes.So,whilebrushingand flossingeverydaycanhelpkeepyourteethclean,nothingshouldreplace regularvisitstothedentist.

Stayinghealthy

Joevisitshisdentistforaroutine dentalcleaning,totakecareofhis teethaswellashisoverallhealth.

Oralhealthisaboutmorethanjust teethandgums.It’salsoessential forarangeofotherhealthand wellbeingreasons:

Cardiovasculardisease: Some researchsuggeststhatheart disease,cloggedarteries,and infectionsmaybelinkedto inflammationandinfections fromoralbacteria.

Osteoporosis: Weakandbrittle bonesmaybelinkedtotoothloss.

Diabetes: Researchshowsthat peoplewithgumdiseasefindit moredifficulttocontroltheir bloodsugarlevels.

Alzheimer’sdisease: Toothloss beforetheageof35maybearisk factorforAlzheimer’sdisease.

Allinformationcontainedhereis fromtheMayoClinic,OralHealth: AWindowtoYourOverallHealth, www.mayoclinic.com.2018.

Youwillreceivethesebenefitsifyoumeettheconditionslistedinthepolicy.

Yourdentalcoverage

Option1or2:LOWPLANorHIGHPLAN plan,you'llhaveaccesstooneofthelargestnetworksofdentistswithtwo reimbursementlevelsthatgiveyoumorecontroloversavings.YouwillalwayssavemoneywithanydentistinGuardian'snetwork andwhentheybelongtoatierintheTier1reimbursementlevelyouwillmaximizeyoursavings.Reimbursementforcovered servicesreceivedfromanon-contracteddentistwillbebasedonapercentileoftheprevailingfeedataforthedentist'szipcode.

YourDentalPlanOption1:LOWPLAN Tier1Tier2

Option2:HIGHPLAN Tier1Tier2

YourNetworkis DentalGuardPreferredNetwork Gold*,Silver*Non-ContractedGold*,Silver*Non-Contracted YourMonthlypremium $15.06 $26.98

YouandSpouse $31.82 $57.00 YouandChild(ren)$42.10 $75.50 You,SpouseandChild(ren)$58.86 $105.52

Calendaryeardeductible Tier1Tier2Tier1Tier2 Individual $0$0$0$50 Familylimit

(co-insurance)

GUARDIAN®isaregisteredtrademarkofTheGuardianLifeInsuranceCompanyofAmerica

Kitcreated10/20/2022

Groupnumber:00042460

Yourdentalcoverage

Option1:LOWPLANOption2:HIGHPLAN Planpays(onaverage)Planpays(onaverage) Tier1Tier2Tier1Tier2 PreventiveCareCleaning(prophylaxis)100%100%100%100% Frequency: 2in12Months(appliestoalllevels) 2in12Months(appliestoalllevels)

FluorideTreatments100%100%100%100% Limits:UnderAge19(appliestoalllevels)UnderAge19(appliestoalllevels) OralExams100%100%100%100% Sealants(pertooth)100%100%100%100% X-rays 100%100%100%100% BasicCareAnesthesia*50%50%100%80% Fillings‡ 50%50%100%80% PerioSurgery50%50%100%80% PeriodontalMaintenance50%50%100%80% Frequency:2in12months(appliestoalllevels)OnceEvery6 Months(appliestoall levels) RootCanal50%50%100%80% Scaling&RootPlaning(perquadrant)50%50%100%80% SimpleExtractions50%50%100%80% SurgicalExtractions50%50%100%80% MajorCareBridgesandDentures0%0%60%50% DentalImplantsNotCoveredNotCovered60%50% Inlays,Onlays,Veneers**0%0%60%50% Repair&Maintenanceof Crowns,Bridges&Dentures 0%0%100%80% SingleCrowns0%0%60%50% OrthodontiaOrthodontia NotCovered50%50% Limits: (appliestoalllevels)Child(ren)(appliestoalllevels)

Guardian’sPreferredProviderOrganizationconsistsofDentistsintheDentalGuardPreferred(“DGP”)network.These tiersrepresentspecific benefitlevelsasdescribedinYourScheduleofBenefits.Networkaccessvariesbygeographiclocationandzipcode.Pleasevisit www.Guardianlife.comtoconfirmyourDentist’stieredparticipation.

Thisisonlyapartiallistofdentalservices.Yourcertificateofbenefitswillshowexactlywhatiscoveredandexcluded.**ForPPOandorIndemnity members,Crowns,Inlays,OnlaysandLabialVeneersarecoveredonlywhenneededbecauseofdecayorinjuryorotherpathologywhenthetooth cannotberestoredwithamalgamorcompositefilingmaterial.WhenOrthodontiacoverageisfor"Child(ren)"only,theorthodonticappliancemust beplacedpriortotheagelimitsetbyyourplan;Iffull-time statusisrequiredbyyourplaninordertoremaininsuredafteracertainage;then orthodonticmaintenancemaycontinueaslongasfull-timestudentstatusismaintained.IfOrthodontiacoverageisfor "AdultsandChild(ren)"this limitationdoesnotapply.*GeneralAnesthesia–restrictionsapply.‡ForPPOandorIndemnitymembers,Fillings–restrictionsmayapplyto compositefillings.

Yourdentalcoverage

ManageYourBenefits:

Gotowww.Guardianlife.comtoaccesssecureinformationabout yourGuardianbenefitsincludingaccesstoanimageofyourID Card.Youron-lineaccountwillbesetupwithin30daysafteryour planeffectivedate.

FindADentist:

Visitwww.Guardianlife.com

Clickon“FindAProvider”;Youwillneedtoknowyourplan,which canbefoundonthefirstpageofyourdentalbenefitsummary.*In CO,NM,TX,DC,orNYtheprovidertiersareDentalGuard PreferredAlliance,DentalGuardPreferredElite,andDentalGuard PreferredConnect.

EXCLUSIONSANDLIMITATIONS

n ImportantInformationaboutGuardian’sDentalGuardIndemnityand DentalGuardPreferredNetworkPPOplans:Thispolicyprovides dental insuranceonly.Coverageislimitedtothosechargesthatarenecessaryto prevent,diagnoseortreatdentaldisease,defect,orinjury.Deductiblesapply. Theplandoesnotpayfor:oralhygieneservices(exceptascoveredunder preventiveservices),orthodontia(unlessexpresslyprovidedfor),cosmeticor experimentaltreatments(unlesstheyareexpresslyprovidedfor),any treatmentstotheextentbenefitsarepayablebyanyotherpayororforwhich nochargeismade,prostheticdevicesunlesscertainconditionsaremet,and servicesancillarytosurgicaltreatment.Theplanlimitsbenefitsfordiagnostic

NeedAssistance?

CalltheGuardianHelpline(888)600-1600,weekdays, 8:00AMto8:30PM,EST.RefertoyourmemberID(social securitynumber)andyourplannumber:00042460

PleasecalltheGuardianHelplineifyouneedtouse yourbenefitswithin30daysofplaneffectivedate. Pleasenote,self-serveoptionsoverthephoneor onlineatGuardianAnytimearenotavailableuntilthe caseisfullyimplemented,pleasewaittospeaktoa liveagentwhencallingtheGuardianHelpline.

consultationsandforpreventive,restorative,endodontic,periodontic,and prosthodonticservices.Theservices,exclusionsandlimitationslistedabovedo notconstituteacontractandareasummaryonly.TheGuardianplan documentsarethefinalarbiterofcoverage.Contract#GP-1-DG6etal.

n PPOandorIndemnitySpecialLimitation: Teethlostormissingbeforea coveredpersonbecomesinsuredbythisplan.Acoveredpersonmayhaveoneor morecongenitallymissingteethorhavelostoneormoreteethbeforehebecame insuredbythisplan.Wewon’tpayforaprostheticdevicewhichreplacessuchteeth unlessthedevicealsoreplacesoneormorenaturalteethlostorextractedafterthe coveredpersonbecameinsuredbythisplan.R3-DG6

DentalGuardInsuranceisunderwrittenandissuedbyTheGuardianLifeInsuranceCompanyofAmerica,NewYork,NY.Productsarenotavailableinall states.Policylimitationsandexclusionsapply.Optional ridersand/orfeaturesmayincuradditionalcosts.Plandocumentsarethefinalarbiterof coverage.ThispolicyprovidesDENTALinsuranceonly.

PolicyForm#GP-1-DG2000,etal,GP-1-DEN-16

GUARDIAN®isaregisteredtrademarkofTheGuardianLifeInsuranceCompanyofAmerica

StratosphereQualityLLC

Kitcreated10/20/22

ALLELIGIBLEEMPLOYEES Groupnumber:00042460

OralHealth Rewards Program

Regularvisitstothedentistcanhelpprevent anddetecttheearlysignsofseriousdiseases.

That’swhyGuardian’sMaximumRolloverOralHealthRewards Programencouragesandrewardsmemberswhovisitthe dentist,byrollingoverpartofyourunusedannualmaximum intoaMaximumRolloverAccount(MRA).Thiscanbeusedin futureyearsifyourplan’sannualmaximumisreached.

Howmaximumrolloverworks*

Dependingonaplan’sannualmaximum,ifclaimsmadefora certainyeardon’treachaspecifiedthreshold,thentheset maximumrolloveramountcanberolledover.

Automaticrollover

Submitaclaim(without exceedingthepaidclaims thresholdofabenefityear), andGuardianwillrollover aportionofyourunused annualdentalmaximum.

Planannual maximum**

$500 Claimsamountthat determinesrollover eligibility

$250 Additionaldollars addedtoaplan’s annualmaximum forfutureyears

$350 Additionaldollars addedifonlyin-network providerswereused duringthebenefityear

$1,000

ThresholdMaximum rolloveramount In-networkonly rolloveramount Maximumrollover accountlimit $1,000 Maximum claims reimburs ment

Thelimitthatcannot beexceededwithin themaximumrollover account

*Thisexamplehasbeencreatedforillustrativepurposesonly.

**IfaplanhasadifferentannualmaximumforPPObenefitsvs.non-PPObenefits,($1500PPO/$1000non-PPOforexample)thenon-PPOmaximum determinestheMaximumRolloverplan.Maynotbeavailableinallstates.

Guardian’sDentalInsuranceisunderwrittenandissuedbyTheGuardianLifeInsuranceCompanyofAmerica,NewYork,NY.Productsarenotavailableinall states.Policylimitationsandexclusionsapply.Optionalridersand/orfeaturesmayincuradditionalcosts.Plandocumentsarethe finalarbiterofcoverage. Informationprovidedinthiscommunicationisforinformationalpurposesonly.DentalPolicyFormNo.GP-1-DEN-16.GUARDIAN®isaregisteredservicemark ofTheGuardianLifeInsuranceCompanyofAmerica®©Copyright2019TheGuardianLifeInsuranceCompanyofAmerica.

GUARDIAN®isaregisteredtrademarkofTheGuardianLifeInsuranceCompanyofAmerica guardianlife.com

©Copyright2020TheGuardianLifeInsuranceCompanyofAmerica

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Vision insurance

Visioninsurancehelpsprotectthe healthofyoureyesbyprovidingcoverage forbenefitsthatoftenaren’tcovered byregularmedicalinsurance.

Protectingyoureyesightmeansallowingforroutinevisits totheoptometristforeyeexams,aswellascoveragefor glassesandcontacts.Makesureyoureyesremainingreat shapeatanyage–nomatterhowmuchtimeyouspend staringatdigitalscreens.

Who isitfor?

Evenifyouhaveperfecteyesight,it’simportanttohaveregulareyeexams tomakesureyou’restillseeingclearly.Mostofusmayeventuallyneed visioncorrection,whichiswhyweoffervisioninsurancetocoversomeof thecosts.

What doesitcover?

Visioninsurancecoversbenefitsnottypicallyincludedinmedicalinsurance plans.Itcoversthingslikeroutineeyeexams,allowancestowardsthe purchaseofeyeglassesandcontactlenses,aswellasdiscountson correctiveLasiksurgery.

Why shouldIconsiderit?

Regulareyeexamscandetectmorethanfailingeyesight,theycan alsopick updiseaseslikeglaucomaanddiabetes.Visionproblemsareoneofthe mostprevalentdisabilitiesintheUnitedStates,makingvisioninsurance especiallyusefulforanyonewhoregularlyneedstopurchase eyeglassesor contacts,oranyonewhosimplywantstohelpprotecttheireyesight and generalhealth. Youwillreceivethesebenefitsifyoumeettheconditionslistedinthepolicy.

Howvisioninsurancecanhelp youseeclearlyasyougetolder.

20/20coverage

Davidnoticesthathisvisionis deteriorating.Hegoesinforaneye exam,andisdiagnosedwithmyopia, whichmeansheneedsglasses.

Averagecostofvisionexam: $171

Averagecostofframesand lenses: $350

Totalcost: $521

WithaVisionpolicyfromGuardian, Davidpaysjust $10 forhiseyeexam. After $25 incopay,hislensesarefully covered,andhepays $96 forhis frames.

David’stotalout-of-pocketexpense is $131,savinghim $390

Thisexampleisforillustrative purposesonly.Yourplan’scoverage mayvary.Seeyourplan’sinformation onthefollowingpagesforspecific amountsanddetails.

Kitcreated10/20/2022

Groupnumber:00042460

Yourvisioncoverage

Option1: Significantout-of-pocketsavingsavailablewithyour FullFeature planbyvisitingoneofVSP’snetworklocations, includingoneofthelargestprivatepracticeprovidernetworks,VisionworksandcontractedPearleVisionlocations.

Option2: Significantout-of-pocketsavingsavailablewithyour FullFeature planbyvisitingoneofDavisVision'snetwork locationsincludingretailcenterssuchasCostco®,Wal-Mart®,JCPenney®,Target®,Sam’sClub®,Pearle®,Visionworks®.Youcan alsouseyournetworkbenefitsonlineatVisionworks®.com,glasses®.com,WarbyParker®.com,or1800contacts®.com.

YourMonthlypremium$7.26

Copay

(waivedforelectivecontactlenses)

Frames 80%ofamountover $130¹ Amountover$4680%ofamountover $130*² Amountover$48

Costco,WalmartandSam'sClubFrame

Allowance Amountover$70N/A

ContactLenses (Elective) Amountover$130Amountover$100N/AN/A

ContactLenses (Electiveandconventional) N/AN/A85%ofamountover $130* Amountover$105

ContactLenses (Plannedreplacementand disposable) N/AN/A85%ofamountover $130* Amountover$105

ContactLenses (MedicallyNecessary) $0Amountover$210$0Amountover$210

ContactLenses (Evaluationandfitting) 15%offUCRNodiscountsNodiscountsNodiscounts

CosmeticExtrasAvg.20-25%offretail price NodiscountsAvg.40-60%offretail price Nodiscounts

Yourvisioncoverage

YourVisionPlan

Option1:FullFeatureOption2:FullFeature-Designer Glasses (Additionalpairofframesandlenses) 20%offretailprice**Nodiscounts50%atVisionworks and30%atotherin networkproviders

LaserCorrectionSurgeryDiscountUpto15%offthe usualchargeor5% offpromotionalprice

ServiceFrequencies

NodiscountsSavingsof40-50%off nationalaverageprice thruDavislaser visionnetwork

Nodiscounts

Nodiscounts

Exams

EverycalendaryearEverycalendaryear Lenses (forglassesorcontactlenses)‡‡EverycalendaryearEverycalendaryear Frames EverycalendaryearEverycalendaryear Networkdiscounts (glassesandcontactlens professionalservice) Limitlesswithin12monthsofexam.Appliestofirstpurchase&courtesydiscount frommostprovidersonsubsequent purchases.

DependentAgeLimits 26 26

ToFindaProvider:RegisteratVSP.comtofindaparticipating provider. Visitwww.Guardianlife.comandclickon“Find aProvider”

VSP

• ‡‡Benefitincludescoverageforglassesorcontactlenses,notboth.

• **Forthediscounttoapplyyourpurchasemustbemadewithin12monthsoftheeyeexam.

• Chargesforaninitialpurchasecanbeusedtowardthematerialallowance.Anyunusedbalanceremainingaftertheinitialpurchasecannotbebankedforfutureuse. Theonlyexceptionwouldbeifamemberpurchasescontactlensesfromanoutofnetworkprovider,memberscanusethebalancetowardsadditionalcontact lenseswithinthesamebenefitperiod.

• 1Extra$20onselectbrands

• MemberscanusetheirinnetworkbenefitsonlineatEyeconic.com.

• InNetworkRoutineRetinalScreeningCoveredafternomorethana$39copay.

Davis

• ‡‡Benefitincludescoverageforglassesorcontactlenses,notboth.

• ContactlensesfromDavisVision'sCollectionareavailable atmostprivatepracticelocationswithFullFeatureandMaterialsOnlyplans.Contactsfromthecollection arecoveredinfullincludingfittingandevaluation,inexcessoftheplan'smaterialscopay.Electivecontactsthatare notpartoftheCollectionarecovereduptothe plan'selectivecontactlensallowanceandthematerialscopayiswaived.

• *Additionaldiscountsarenotavailableatallprivatepracticelocations.Costco,Walmart,Sam’sClub,glasses.com,and 1800contacts.comdonotallowadditional discounts.

• ForDavisVision,completeeyeglassesmustbepurchasedatonetimefromoneprovider.Forexample,ifamemberpurchasesonlylenses,heorshecannot purchaseframeslaterinthesamebenefitperiod.Thememberisnoteligiblefornewvisionmaterialsuntilthenextbenefitperiod.Onlychargesforaninitial purchasecanbeusedtowardthematerialallowance.Anyunusedbalanceremainingaftertheinitialpurchasecannotbebankedforfutureuse.

• 2Extra$50atVisionworksstoresandatVisionworks.com.

• InNetworkRoutineRetinalScreeningCoveredafternomorethana$39copay.

• Memberscanusetheirinnetworkbenefitsatvisionworks.com,warbyparker.com,glasses.com,and1800contacts.com.Additionaldiscountsarenotavailableat glasses.comor1800contacts.com.DiscountsmayvaryatWarbyParker.

GUARDIAN®isaregisteredtrademarkofTheGuardianLifeInsuranceCompanyofAmerica StratosphereQualityLLC Kitcreated10/20/2022

Groupnumber:00042460

Yourvisioncoverage

EXCLUSIONSANDLIMITATIONS

ImportantInformation: Thispolicyprovidesvisioncarelimitedbenefitshealth insuranceonly.Itdoesnotprovidebasichospital,basicmedicalormajor medicalinsuranceasdefinedbytheNewYorkStateInsuranceDepartment. Coverageislimitedtothosechargesthatarenecessaryfora routinevision examination.Co-paysapply.Theplandoesnotpayfor:orthopticsorvision trainingandanyassociatedsupplementaltesting;medicalorsurgicaltreatment oftheeye;andeyeexaminationorcorrectiveeyewearrequiredbyan employerasaconditionofemployment;replacementoflenses andframes thatarefurnishedunderthisplan,whicharelostorbroken(exceptatnormal intervalswhenservicesareotherwiseavailableorawarrantyexists).Theplan limitsbenefitsforblendedlenses,oversizedlenses,photochromiclenses, tintedlenses,progressivemultifocallenses,coatedorlaminatedlenses,a framethatexceedsplanallowance,cosmeticlenses;U-Vprotectedlensesand optionalcosmeticprocesses.

Theservices,exclusionsandlimitationslistedabovedonot constituteacontract andareasummaryonly.TheGuardianplandocumentsarethefinalarbiterof coverage.Contract#GP-1-DAVIS-05-VISetal.Contract#GP-1-VSN-96-VISet al.

LaserCorrectionSurgery:

Lasersurgeryisnotaninsuredbenefit.Thesurgeryisavailableatadiscounted fee.Thecoveredpersonmustpaytheentirediscountedfee.In addition,the lasersurgerydiscountmaynotbeavailableinallstates.

Guardian’sVisionInsuranceisunderwrittenandissuedbyTheGuardianLifeInsuranceCompanyofAmerica,NewYork,NY.Productsarenotavailableinall states.Policylimitationsandexclusionsapply.Optionalridersand/orfeaturesmayincuradditionalcosts.Thispolicyprovidesvisioncarelimitedbenefitshealth insuranceonly.ItdoesNOTprovidebasichospital,basicmedicalormajormedicalinsuranceasdefinedbytheNewYorkState DepartmentofFinancial Services.Plandocumentsarethefinalarbiterofcoverage.

PolicyForm#GP-1-GVSN-17

GUARDIAN®isaregisteredtrademarkofTheGuardianLifeInsuranceCompanyofAmerica

StratosphereQualityLLC

Kitcreated10/20/2022

Groupnumber:00042460

Ourcommitmenttoyou

Pleasereadthedocumentationreferencedbelowcarefully. Thenoticesareintendedtoprovideyou importantinformationaboutourinsuranceofferingsandto protectyourinterests.Certainonesare requiredbylaw.

Importantinformation

NoticeInformingIndividualsaboutNondiscriminationand AccessibilityRequirements

GuardiannoticestatingthatitcomplieswithapplicableFederalcivilrightslawsanddoesnotdiscriminatebasedonrace, color,nationalorigin,age,disability,sex,oractualorperceivedgenderidentity.Thenoticeprovidescontactinformationfor filinganondiscriminationgrievance.Italsoprovidescontactinformationforaccesstofreeaidsandservicesbydisabled peopletoassistincommunicationswithGuardian.

Visit https://www.guardiananytime.com/notice48 toreadmore.

NoCostLanguageServices

Guardianprovideslanguageassistanceinmultiplelanguages formemberswhohavelimitedEnglishproficiency.

Visit https://www.guardiananytime.com/notice46 toreadmore.

Visioninsurance

Guardian'sHIPAANoticeofPrivacyPractices

Thenoticedescribeshowhealthinformationaboutyoumaybeusedanddisclosedandhowyoucanaccessthisinformation.

Visit https://www.guardiananytime.com/notice50 toreadmore.

GUARDIAN®isaregisteredtrademarkofTheGuardianLifeInsuranceCompanyofAmerica

StratosphereQualityLLC Kitcreated10/20/2022

Groupnumber:00042460