Dental Plans for Individual, amilies & Self Employed Uta h 2008
Dental Plans for In d i v i d ua l s, amilies & Se l f Em p l o y e d Discount Plan Don t worry about waiting periods, deductibles, or annual maximums. You receive the services you want, when you want them. You and your family can now receive quality care at reduced prices, saving you up to 70% on most dental services. Discount Plan eatures No deductibles No waiting periods No age limits No annual maximums Includes adult and child orthodontics Includes teeth bleaching and veneers ee-for-service discount program; not an insured product Co-Pay Plans The Co-Pay Plans make dental insurance easy. There are no annual maximums to track. You know your copayment before you schedule an appointment. or quality care, excellent benefits, and affordable co-payments, choose the Co-Pay Plan. Co-Pay Plan eatures No annual maximums ixed affordable co-payments Covers preventive care at 100% (after deductible) Choose one of two networks, Gold or Platinum* Includes orthodontic discount Includes teeth bleaching and veneers Co-Insurance Plans or the ultimate freedom of choice, choose a Co-Insurance Plan. These plans allow you to receive care from any dentist you choose, either in or out of network. With Dental Select s large networks, chances are your dentist is a participating provider. Co-Insurance eatures reedom to choose any dentist Covers preventive care at 100% (after deductible/in network) Two benefit options available Choose one of two networks, Gold or Platinum* Lower co-payments when receiving care from a network dentist Includes orthodontic insured benefit plus a 20% in-network discount. (option 2) Includes implant crown benefit *How do I Choose a Network? Silver Gold Platinum Network Size Significant Substantial Dental Select s Largest Network Value Simple to Use Best Value Broadest Choice Enroll online at: DentalSelect.com ACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. This plan of insurance is underwritten by ACE American Insurance Company.
Plan Summary of Benefits Discount Plan Co-Pay Plans Co-Insurance Plans Can I go out of network? No No Yes When is my plan effective? Available the day you enroll 1st day of the following month from the date we receive your enrollment 1st day of the following month from the date we receive your enrollment Who can I include on my plan? Spouse, Children, Grandchildren, Parents & Grandparents Spouse & any unmarried children up to age 26 Spouse & any unmarried children up to age 26 Type of Plan ee-for-services discount plan In-Network discount only - Non-Insured Insured PPO In-Network only Insured PPO - Option 1 In-or-Out of Network Insured PPO - Option 2 In-or-Out of Network Preventive Cleanings (2 per year), routineexams, fluoride (14 & under) and x-rays Up to 90% ee Reduction 100% 100% 100% Basic illings and oral surgery (periodontics co-pay plans only) Up to 60% ee Reduction ajor Crowns, bridges, endodontics and dentures (periodontics co-insurance plan only) Orthodontics Deductible Per calendar year, maximum 3 per family Applies to all services Childen & Adults Children under 19 Up to 50% ee Reduction Up to 70% Coverage 70% 80% Up to 50% Coverage 50% ($500 per year ax)* 50% ($500 per year ax)* 50% Insured after 20% Discount N/A $25/$75 $75/$225 $50/$150 aximum Benefit Preventive, basic and major services Per person, per calendar year Orthodontic Lifetime aximum (Insured) Waiting Basic 6 onths 6 onths Periods: ajor Orthodontic No aximum No aximum $1,000* $1,000* 12 onths 18 onths $500 per year $1,000 lifetime maximum 6 onths 15 onths Discount - Insured - 24 months e Choose your Network Silver Gold Platinum Gold Platinum onthly Rates Enrollment ee (one time, nonrefundable) $15.00 (ee waived if you enroll online) Add Vision to any plan for only $2.00 per month Single $7 Option 1 Option 2 Option 1 Option 2 Option 1 Option 2 Two Party $10 Subscriber $19 Subscriber $24 Subscriber $20 $27 $24 $32 amily $14 Subsc. +1 $35 Subsc. +1 $44 Subscriber +1 $37 $50 $45 $60 The Discount Plan is not a dental insurance policy. This program provides discounts only from a certain network of dental providers. The member is responsible to pay for all services but will receive a discount from dental providers who are contracted on Dental Select s Silver Network. Subsc. +2 $44 Subsc. +2 $56 Subscriber +2 $48 $66 $58 $80 Subsc. +3 $53 Subsc. +3 $67 Subscriber +3 $60 $83 $72 $100 Subsc. +4 $62 Subsc. +4 $78 Subscriber +4 $70 $99 $85 $120 Subsc. +5 $71 Subsc. +5 $90 Subscriber +5 $82 $116 $99 $140 Subsc. +6 or more $80 Subsc. +6 or more $101 Subscriber +6 or more $93 $133 $112 $160 See Partial Benefits Schedule & Schedule of Co-pays for details All payments made by the plan are based on the Network ee Schedule selected. *Co-Insurance - $1,000 annual maximum, of which $500 can be used for ajor Services. **Non Insured The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are for comparison and in care of discrepancy, the plan documents apply. Please refer to the plan certificate booklet for a complete description of benefits, limitations & exclusions.
Partial Schedule of Co-Pays (participating General Dentist only) Deductibles: Co-Pay Plans only (applies to all services) - $25 per person / $75 family maximum Code Procedure Silver* Gold Platinum D0999 OSHA Infection and Sterilization 10 10 0 Preventive D120 Periodic oral examination 16 0 0 D150 Comprehensive oral examination 14 0 0 D170 Re-evaluation 10 0 0 D210 Intraoral - compl ser incl bitewings 34 0 0 D272 Bitewings - two films 10 0 0 D330 Panoramic film 36 0 0 D1110 Prophylaxis - adults 36 0 0 D1120 Prophylaxis - child 24 0 0 Ba s i c D140 Limited oral examination 10 0 0 D1351 Sealant - per tooth (age 14 & under) 17 11 13 D2140 Amalgam - 1 surface primary or permanent 36 9 10 D2150 Amalgam - 2 surfaces primary or permanent 47 17 19 D2160 Amalgam - 3 surfaces primary or permanent 57 23 26 D2161 Amalgam - 4 + surfaces primary or permanent 63 32 38 D2330 Resin - 1 surface anterior 56 33 33 D2331 Resin - 2 surfaces anterior 68 36 38 D2332 Resin - 3 surfaces anterior 79 39 42 D2335 Resin - 4 + surf or involving incisal angle anterior 90 46 49 D2391 Resin - 1 surface posterior prim. or perm. 59 32 36 D2392 Resin - 2 surfaces posterior prim. or perm. 75 44 50 D2393 Resin - 3 surfaces posterior prim. or perm. 91 55 60 D2394 Resin - 4 + surfaces - posterior prim. or perm. 98 61 65 Cr o w n s D2750 Crown - porcelain fused to high noble metal (note 2) 428 282 301 D2751 Crown - porcelain fused to predom. base metal 429 285 283 D2752 Crown - porcelain fused to noble metal 430 288 300 D2790 Crown - full cast high noble metal (note 2) 390 250 269 D2791 Crown - full cast predominately base metal 340 210 229 D2792 Crown - full cast noble metal 345 210 238 D2930 Prefab. stainless steel crown - prime tooth 63 63 79 D2931 Prefab. stainless steel crown - permanent tooth 65 65 96 En d o d o n t i c s (root canals) D3220 Therapeutic pulpotomy excluding final restoration 47 49 55 D3310 Root Canal - ant. exclud. final restoration 235 165 215 D3320 Root Canal - bicuspid exclud. final restoration 290 217 251 D3330 Root Canal - molar exclud. final restoration 365 298 350 Pe r i o d o n t i c s D4341 Perio. scaling & root planing - 4 + teeth per quad 20%* 79 85 D4355 ull mouth debridement 59 54 58 D4910 Perio maintenance procedures after active therapy 67 55 59 Prosthodontics (dentures) D5110 Complete denture - upper (note 4) 502 401 613 D5120 Complete denture - lower (note 4) 502 401 613 D5130 Immediate denture - upper (note 4) 526 421 681 D5140 Immediate denture - lower (note 4) 526 421 681 D5211 axillary Partial Denture - Resin Base (note 5) 20%* 326 577 D5212 and. Partial Denture - Resin Base (note 5) 20%* 326 577 Oral Surgery D7111 Extraction of primary tooth 32 20 22 D7140 Extraction of erupted tooth or exposed tooth 43 26 29 D7210 Surgical removal of erupted tooth 77 57 67 D7220 Removal impacted tooth - soft tissue 92 76 89 D7230 Removal impacted tooth - partial bony 20%* 98 109 D7240 Removal impacted tooth - completely bony 20%* 114 135 D7510 I&d abscess - intraoral soft tissue 20%* 60 66 i s c e l l a n e o u s D9110 Palliative - emerg. treatment of pain - minor proc. 29 29 34 D2940 Sedative fillings 30 30 34 D9430 Office visit obs. - scheduled hrs - no other servs. 25 25 36 D9440 Office visit - after regular scheduled hours 36 36 45 D9972 External Bleaching per Arch 20%* 100 20%* *Discount This is not a complete list of procedures, and the benefits illustrated are in summary form only. You will receive the complete version with your plan ID card. Services not listed are available on a fee for service basis, no discount applies. These fees are valid through December 31, 2008.
Access Discount Vision If you would like a simple and carefree vision plan with savings of up to 40% at more than 40,000 independent providers and retail stores such as LensCrafters, Pearle Vision, Sears Optical, and Target Optical, this is the vision plan for you. Your entire family can be included, as long as they are also on your dental plan. VISION e at u r e s - No maximums - No limits on number of visits - No claims to submit - No limits on amount of purchase - All styles, sizes and materials are included Vision Care Services Exam with Dilation as Necessary:* - Includes contact lenses - Receive a discount of 5-15% on laser vision correction surgery - No waiting periods - Large nationwide Network of providers Summary of Vision Benefits ember Cost $5 off routine exam $10 off contact lens exam Complete Pair of Glasses Purchase*: frame, lenses and lens options must be purchased in the same transaction to receive full discount. Standard Plastic Lenses: Single Vision Bifocal Trifocal Progressive rames: Any frame available at provider location Lens Options: UV Coating Tint (Solid & Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Anti-Reflective Coating Other Add-ons & Services $50 $70 $105 $135 35% off retail price $15 $15 $15 $40 $45 20% Discount Contact Lens aterials: (Discount applied to materials only) Disposable Conventional N/A 15% off retail price Laser Vision Correction**: Lasik or PRK 15% off retail price -or- 5% off promotional price * Under contract, ACCESS Vision Providers may charge usual & customary rates for a comprehensive exam up to a contracted fee per region. Access Vision Same flat rate regardless of how many participants $2.00 per month The ACCESS Vision Plan is a fee for service discount plan, it is not an insured product. This program provides discounts only from a certain network of vision providers. The member is responsible to pay for all services but will receive a discount from vision providers who are contracted on the Access Network. Ho w To Co n ta c t Us De n ta l Se l e c t.c o m Toll ree 1-800-999-9789 Toll ree ax 1-888-998-8711 5373 S. Green Street, Ste. 400 Salt Lake City, UT 84123 801-495-3000 ax 801-290-5104
Answers to Some Common Questions What if I need to see a network specialist? Dental Select network specialists offer you a fee reduction of 20% from the specialist s usual fees for covered services. A Pedodontist and Pediatric Dentist are classified as the same type of provider and are considered a specialist. Discount & Co-Pay Plans There is no payment from Dental Select for specialist services. Gold Network Pediatric Specialist Only - Refer to fee schedule for specific co-pays. Co-Insurance Plans You are is responsible for the difference between the plan payment and the discount specialist s fee. When will my plan be effective? When will I be billed? Discount Plan Effective Date: 1st of the current month or 1st of the month requested on enrollment card. Billing Date: Your monthly payment will be deducted from your account on the 16th of every month. Dental Plan Exclusions No benefits will be paid: 1. for services and supplies not listed in the Coverage Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental. 2. for services provided by Specialists whether Network or Non-Network. (Co-pay plans only) 3. for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons. 4. for services related to, performed in conjunction with, or resulting from a noncovered procedure. 5. for charges in excess of the contracted ee-for-service schedule or the Reasonable and Customary rate, whichever applies. 6. for any treatment program which began prior to the date the Insured is covered under the Policy. 7. for crown, inlays and onlays on teeth that can be restored by direct placement materials. 8. for the replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement. 9. for service or supplies payable under any medical expense, auto or no-fault plan. 10. for any condition covered under any Worker s Compensation Act or similar law. 11. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance. 12. for services that are applied toward the satisfaction of a Deductible, if any. 13. for services subject to a waiting period that were incurred during the waiting period. 14. for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services. 15. for hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, hospital confinement. 16. for drugs or the dispensing of drugs. Co-Pay & Co-Insurance Plans Effective Date: 1st of the following month from date we receive your enrollment card. Billing Date Enrollments received before the 15th will be drafted one (1) payment on the 16th of the current month for the following month.( Effective date will be the 1st of the following month application is received.) Enrollments received after the 15th of the month will be charged two (2) payments on the 16th of the following month. ( Effective date will be the 1st of the following month application is received.) If the 16th of the month falls on a weekend or a holiday, the draft will be taken on the following business day. How do I cancel? All cancellation requests must be received in writing. Your cancellation will be effective the first day of the month following the month your written request is received. In-Network Specialist Discounts All Plans 20% discount on: Orthodontist, Endodontist, Oral Surgeon, Periodontist, Prosthodontist, and Pediatric Specialist. 17. for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes). 18. for implants; myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TJ dysfunction; cleft palate; or anodontia. 19. for orthodontia, unless included within the Coverage Schedule. 20. for the replacement of a filling within 24 months of placement, unless for specific health reasons. 21. for composite, resin, or white fillings on posterior primary teeth. Benefit will be reduced to that of an amalgam or silver filling. 22. for the replacement of retainers. 23. for sealants not applied to permanent bicuspid or molar; applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth. 24. for lab fees for higher metals or porcelain crowns, bridges, inlays or onlays. 25. for general anesthesia or IV sedation. (Copay plans only) 26. for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits. This exclusion does not apply if the device covers one or more natural teeth lost or extracted while covered under the Plan, or if the prosthetic device was in place when the policy became effective. 27. during travel or activity outside the United States. 28. This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are only for comparison and in the case of discrepancy the plan documents apply. Please refer to the certificate for a complete description of benefits, limitations, and exclusions. UT2008 INDIVIDUAL 08/07
Please fill out and return this enrollment form with your payment to: DENTAL SELECT - CORPORATE OICE 5373 S. GREEN STREET, STE. 400 SALT LAKE CITY, UTAH 84123 Toll ree (800) 999-9789 Toll ree ax (888) 998-8711 PLEASE ILL OUT THE REVERSE SIDE O THIS ENROLLENT OR Enroll online at www.dentalselect.com Utah - Individual Dental Plan Enrollment orm Social Security No. Last Name irst Initial Home Address City State Zip Code arital Status Requested Effective Date arried Single 1, 200 ST Date of Birth Sex Home Telephone Employer s Name & Phone Number ale emale Agent Name Agent ID Number Where did you hear about us? Do you or any family member have other dental insurance? If Yes, name other dental insurance company Yes No Person Assigned As Policy Holder Social Security No. LIST ALL DEPENDENTS TO BE COVERED irst Name Date of Birth Spouse 1. Child 2. Child 3. Child Sex irst Name D.O.B. Sex 4. Child 5. Child 6. Child 7. Child
Please Complete Both Sides Choose your Plan (Choose only one) Payment Options (Choose either Checking/Savings or Credit Card Payment) Discount Plan Billing Period: onthly (Withdrawn on the 16th) Annual (Check or Credit Card) Co-Pay Plans Checking or Savings (Include a $15.00 enrollment fee with your paymant) Option 1 - Gold Network Checking Account (Include Voided Check) Savings Account (Include Deposit Slip) Option 2 - Platinum Network inancial Institution: Co-Insurance Plans Routing Number: Gold Network Platinum Network Account Number: Option 1 Option 1 Credit Card Payment (Include your check for the $15.00 enrollment fee) Option 2 Option 2 VISA ASTERCARD Yes, include the Vision Plan for $2.00 per month Account Number: Exp. Date: I wish to enroll in the plan I have selected. I authorize and agree to account deduction of the required premium. Account Holder Name: Signature: Date: Account Holder Signature: Date: This authorization will remain in effect until the financial institution has received and has had reasonable time to act on a written request from me to terminate this agreement. I understand that I can stop a withdrawal by notifying the financial institution at least three business days before the withdrawal is made. In the event of a withdrawal error, I must promptly notify the financial institution to preserve any rights I may have. Please direct billing inquiries to Dental Select, 5373 S. Green Street., Ste. 400, Salt Lake City, UT 84123. I have read and understand the statements above pertaining to the billing option. Your cancellation will be effective the first day of the month following the month your written request is received. The 3rd returned check in any 12 month period will result in the immediate cancellation of your policy. We reserve the right to deny you the ability to be reinstated on any Individual Dental Select plan for one year. ACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. Gold and Platinum plans of insurance are underwritten by ACE American Insurance Company.