Topaz Dental PPO (Utah)
Members have the freedom to choose any dental provider of their choice, plus get additional cost-savings with network participation. And members have access to our vast network of 155,000 dentists.
The plans also include the BEST Life special dental accident benefit. This provides $1,000 per accident to sound and natural teeth and is not counted toward the calendar year maximum.
| In-Network | Out-of-Network | |
| Calendar Year Maximum | $2,500 | $2,000 |
| $2,000 | $1,500 | |
| $1,500 | $1,500 | |
| $1,500 | $1,000 | |
| $1,000 | $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% | 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% | 80% |
| Class III: Major Services
Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures. |
60% | 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 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 |
| Child Good Vision Benefit
Included with orthodontia. |
Covers 50% of UCR for an eye exam once every 12 months for children through age 18. |
| In-Network | Out-of-Network | |
| Calendar Year Maximum | $2,000 | $1,500 |
| $1,500 | $1,500 | |
| $1,500 | $1,000 | |
| $1,000 | $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% | 80% |
| 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% | 60% |
| Class III: Major Services
Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures. |
50% | 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 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 |
| Child Good Vision Benefit
Included with orthodontia. |
Covers 50% of UCR for an eye exam once every 12 months for children through age 18. |
| In-Network | Out-of-Network | |
| Induvidual Calendar Year Maximum | $1,500 | $1,500 |
| $1,000 | $1,000 | |
| $500 | $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% | 80% |
| 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% | 50% |
| Class III: Major Services
Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures. |
0% | 0% |
| Oral Surgery | Class II or Class III |
| Endodontics | Class II or Class III |
| Periodontics | Class II or Class III |
| Waiting Periods | 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 Orthodontic 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 |
| In-Network | Out-of-Network | |
| Induvidual Calendar Year Maximum | $1,500 | $1,500 |
| $1,000 | $1,000 | |
| $500 | $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% | 80% |
| 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% | 20% |
| Class III: Major Services
Crowns and gold fillings, inlays, onlays and pontics, fixed bridges, implants, complete and partial dentures. |
0% | 0% |
| Oral Surgery | Class II or Class III |
| Endodontics | Class II or Class III |
| Periodontics | Class II or Class III |
| Waiting Periods | 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 Orthodontic 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.