|Plan Design||Topaz Dental IndemnityPlus|
|Benefits||Premium Plan||Classic Plan||Basic Plan||Value Plan|
|Calendar Year Maximum||$2,500||$2,000||$1,500||$1,500|
|Calendar Year Deductible
3 per family max.
|$0, $25, $50, $75 or $100
Waived on preventive services.
|Class I: Preventive Services – Routine oral exam, cleanings, fluoride treatment for children, bitewing x-rays, panoramic/full mouth x-rays, sealants||100%||100%||100%||100%|
|Class II: Basic Services – Fillings (amalgam, porcelain & plastic), anterior & posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery||90%||80%||80%||50%|
|Class III: Major Services – Crowns & gold fillings, inlays, onlays & pontics, fixed bridges, implants, complete & partial dentures||60%||50%||0%||0%|
|Oral Surgery||Class II or Class III|
|Endodontics||Class II or Class III|
|Periodontics||Class II or Class III|
|Waiting Periods||12 month waiting period applies to major and orthodontic services.
Waived for qualifying groups.
|Special Dental Accident Benefit||$1,000 maximum per accident to sound, natural teeth.|
|Out-of-Network Reimbursement||UCR at 80th, 90th Percentile or MAC|
|Orthodontics Option||50%||Not offered|
|Child Only Orthodontic Benefit Option
Dependent children through age 18.
|$1,000 Lifetime / $500 Calendar Year Maximum or $1,500 Lifetime / $750 Calendar Year Maximum|
|Adult/Child Orthodontia Benefit Option||$1,000 Lifetime / $500 Calendar Year Maximum or $1,500 Lifetime / $750 Calendar Year Maximum|
|Child Good Vision Benefit
Included with orthodontia.
|Covers 50% of UCR for an eye exam once every 12 months for children through 18.|