Dental

Topaz Dental IndemnityPlus

The indemnity plan that does not rely on a network. Members receive the same benefit levels both in and out-of-network, but members receive additional savings on out-of-pocket when they see one of 155,000 dentists within the network.

Members also receive the BEST Life special dental accident benefit. That means if something happens to sound and natural teeth, they will get $1,000 per accident that is not counted toward the calendar year maximum.

Calendar Year Maximum $2,500
$2,000
$1,500
$1,000

Induvidual 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%

Class II: Basic Services

Fillings (amalgam, porcelain and plastic), anterior and posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery.

90%

Class III: Major Services

Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures.

60%

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.
Wavied for qulalifying groups.

Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth.

Out-of-Network Reimbursement UCR at 80th or 90th Percentile or MAC

Orthodontics Option 50%

Child Only Orthodontia Benefit Option

Dependent children through age 18

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

Children's Good Vision Benefit

(Included with Orthodontia)

Covers 50% of UCR for an eye exam once every 12 months for children through age 18.
Calendar Year Maximum $2,000
$1,500
$1,000

Induvidual 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%

Class II: Basic Services

Fillings (amalgam, porcelain and plastic), anterior and posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery.

80%

Class III: Major Services

Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures.

50%

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 or 90th Percentile or MAC

Orthodontics Option 50%

Child Only Orthodontia 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 age 18.
Calendar Year Maximum $1,500
$1,000
$500

Induvidual 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%

Class II: Basic Services

Fillings (amalgam, porcelain and plastic), anterior and posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery.

80%

Class III: Major Services

Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures.

0%

Oral Surgery Class II or Class III

Endodontics Class II or Class III

Periodontics Class II or Class III

Waiting Periods

Wavied for qulalifying groups.

None

Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth.

Out-of-Network Reimbursement UCR at 80th or 90th Percentile or MAC

Orthodontics Option Not Offered

Child Only Orthodontia Benefit Option

Dependent children through age 18

Not Offered

Adult/Child Orthodontia Benefit Option Not Offered

Child Good Vision Benefit

Included with Orthodontia.

Not Offered
Calendar Year Maximum $1,500
$1,000
$500

Induvidual 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%

Class II: Basic Services

Fillings (amalgam, porcelain and plastic), anterior and posterior composites, anesthesia (general or IV sedation), emergency palliative treatment, space maintainers for children, limited oral exam, pathology, oral surgery.

50%

Class III: Major Services

Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures.

0%

Oral Surgery Class II or Class III

Endodontics Class II or Class III

Periodontics Class II or Class III

Waiting Periods

Wavied for qulalifying groups.

None

Special Dental Accident Benefit $1,000 maximum per accident to sound, natural teeth.

Out-of-Network Reimbursement UCR at 80th or 90th Percentile or MAC

Orthodontics Option Not Offered

Child Only Orthodontia Benefit Option

Dependent children through age 18

Not Offered

Adult/Child Orthodontia Benefit Option Not Offered

Child Good Vision Benefit

Included with Orthodontia.

Not Offered

Available in

UT Only.