Guardian Healthcare

Avesis administers vision, hearing, and dental benefits to members of Guardian Healthcare in South Carolina.

Below you find an image of the ID card that members will present for services along with a description of the member's covered benefits.

Guardian Healthcare Dental Benefit Design

TRIBUTE

Office Visit Co-Pay:$0.00 per office visit

Choose One per year (A or B):

	ADA Code	Description	Limitations
A	D0120	Recall Exam	One per year
B	D0150	Comprehensive Exam	One per year;limited to one every 3 years

	ADA Code	Description	Limitations
A	D1110	Cleaning	One per year

TRIBUTE ENHANCED

Office Visit Co-Pay:$0.00 per office visit

Choose One per year (A or B):

	ADA Code	Description	Limitations
A	D0120	Recall Exam	One per year
B	D0150	Comprehensive Exam	One per year; limited to one every 3 years

	ADA Code	Description	Limitations
A	D1110	Cleaning	One per year

Guardian Healthcare Hearing Benefit Design

TRIBUTE SELECT PPO

Benefits	Avesis Network	Frequency
Routine Hearing Test	Covered in full after $30 co-pay	One per year
Materials	$300 max allowance for Hearing Aid	Once every three years

Guardian Healthcare Vision Benefit Design

TRIBUTE

Benefits	Avesis Network	Frequency
Routine Eye Examination	Covered in full after $15 co-pay	One per year
Materials	$100 material allowance for Frames & Lenses OR Contact Lenses	$100 allowance every two years

TRIBUTE ENHANCED

Benefits	Avesis Network	Frequency
Routine Eye Examination	Covered in full after $10 co-pay	One per year
Materials	$200 material allowance for Frames & Lenses OR Contact Lenses	$200 allowance every two years

TRIBUTE PRIDE

Benefits	Avesis Network	Frequency
Routine Eye Examination	Covered in full after $10 co-pay	One per year
Materials	$100 material allowance for Frames & Lenses OR Contact Lenses	$200 allowance every two years