Dental Plans

Plan Design Topaz Dental PPO
Benefits Premium Plan Classic Plan Basic Plan Value Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Maximum $2,500 $2,000 $2,500 $2,000 $1,500 $1,500 $1,500 $1,500
$2,000 $1,500 $2,000 $1,500 $1,000 $1,000 $1,000 $1,000
$1,500 $1,500 $1,500 $1,500 $500 $500 $500 $500
$1,500 $1,000 $1,500 $1,000        
$1,000 $1,000 $1,000 $1,000        
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% 80% 100% 80% 100% 80%
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% 60% 80% 50% 50% 20%
Class III: Major Services – Crowns & gold fillings, inlays, onlays & pontics, fixed bridges, implants, complete & partial dentures 60% 50% 50% 50% 0% 0% 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.
None
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

 

Available in UT only.
Child orthodontia is available for groups with 5 or more enrolling. Adult orthodontia is available for employer-sponsored groups with 25 or more enrolling.