Dental Select - Jordan School District
Enrollment Information
JORDAN SCHOOL DISTRICT
Utah Employee Enrollment Form
Toll Free: 800-999-9789
Toll Free Fax: 888-998-8704
DentalSelect.com
Must be completed in FULL – PLEASE PRINT – Enrollment is not valid without signature at the bottom of this page.
Last Name
Coverage Selection - Confirm available options with your employer. Check all that apply.
First Name
Dental
Street Address
City
State
Zip Code
Discount - Silver Network
PPO - Platinum Network
Co-Pay - Gold Network
Indemnity - Platinum Network
Co-Pay - Platinum Network
Home Phone
PPO - Gold Network
Date of Birth
Dual Choice :
High
Low
(MM/DD/YYYY)
Insured Vision
SSN
Marital Status
Gender
Married
Single
Effective Date
Male
Female
Date of Hire (Required)
(MM/DD/YY)
Access Choice:
Access Value
Access Classic
Vis 4
Vis 7
Vis 5
Vis 8
Vis 6
Vis 10
(MM/DD/YY)
Employer’s Full Name
AD&D - Select one
JORDAN SCHOOL DISTRICT
Employee - (complete beneficiary info on Designation Form)
Employer’s Address
Decline
Employee + Family - (complete individuals covered and sign below)
AD&D Voluntary - Amount $ _______________
Subgroup/Dept. #
Group Number
12000899
Beneficiary Designation Required: __________________________________________
Individuals Covered - List individuals for whom you are enrolling.
Dental
Vision
Enroll
Dental
Vision
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Dental
Dental
Dental
Dental
AD&D
SSN
Date of Birth - (MM/DD/YYYY)
Dependent Name - (Last, First, MI)
Gender
Male
Female
SSN
Date of Birth - (MM/DD/YYYY)
Dependent Name - (Last, First, MI)
Gender
Male
Female
SSN
Date of Birth - (MM/DD/YYYY)
Dependent Name - (Last, First, MI)
Gender
Male
Female
SSN
Date of Birth - (MM/DD/YYYY)
Dependent Name - (Last, First, MI)
Gender
Male
Female
SSN
Date of Birth - (MM/DD/YYYY)
Dependent Name - (Last, First, MI)
Gender
Male
Female
SSN
Date of Birth - (MM/DD/YYYY)
Enroll
AD&D
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AD&D
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Vision
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Gender
Male
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Vision
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AD&D
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Vision
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Spouse Name - (Last, First, MI)
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Vision
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AD&D
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AD&D
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For additional dependents include the Dependent Enrollment Form
Covered by other DENTAL Insurance?
Yes
If Yes, Name of other Dental Insurance Company
Name of Person Insured
Social Security Number
No
Confirmation
andVision
Vision &Insurance
Coverage
ConfirmationforforDental
Dental,
Basic AD&D
Insurance Coverage
Authorization
Check here to waive if no coverage is desired
Check here to waive if you have additional coverage through another policy
I understand my information is protected by privacy laws and will be released only in accordance with these laws. The only people who have access to this information are employees of the Insurance Company who service my policy
or claim and other third parties authorized by the Insurance Company. Information may be disclosed to those who have an insurance-related regulatory or legal need for the information. In other situations, We will ask you for written authorization to disclose information about you.
WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT
AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
I agree and understand that if my employer is contributing towards the cost of any of the insurance products I have chosen to decline, that I will not be entitled to any compensation for my non-participation. I further understand I
will not be eligible to enroll in this plan again until next enrollment period.
Signature (Required)
Date
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.
AH-10740-UT
2011 EEF 12/10
Page Intentionally Left Blank
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Network Access
General Dentists
Dental Select participating general dentists accept the Platinum or Gold fee schedule as payment in full.
Specialists (Include Pediatric, Endodontist, Prosthodontist, Oral Surgeon, Periodontist, Orthodontist*)
Coinsurance Plans
*Contracted Orthodontist: The member may receive a discount of up to 20% off of the contracted Orthodontist’s fee.
Contracted Specialists: The plan will pay based on a contracted fee schedule. Contracted specialist providers accept the fee schedule as payment in full with no
balance billing.
Non-Contracted Specialists:
MAC- No discount - including Orthodontists. The plan will pay from our contracted fee schedule. The Member is responsible for the difference
between the plan’s payment and the Specialist’s fee.
UCR- No discount - including Orthodontists. The plan will pay based on Reasonable & Customary fees. The Member is responsible for the
difference between the plan’s payment and the Specialist’s fee.
Co-Pay Plans - See Schedule of co-payments for member responsibility
Minnesota
Dental Select participating general dentists utilize the Premier network. Services rendered will be reimbursed according to the Premier network fee schedule as
payment in full.
Plan Notes
Silver
Discount only; no benefit will be paid.
Co-Pay Plans
COVERAGE: CO-PAYS: The member's co-payments in the Schedule of Covered Services are subject to change on January 1, of each year. Specialist Discount:
Discount only; no benefit will be paid. IN NETWORK: General Dentists: Accept a combination of fixed co-pay and plan payment as payment in full. OUT OF
NETWORK: The member will be responsible for paying the difference between what the dentist charges and the plan payment.
UCR
CONTRACTED: General Dentists & Specialists: All payments made by the plan are based on the Platinum contracted fee schedule. NON-CONTRACTED: Dental
Select will allow up to the reasonable and customary charge for the dental procedures and services after the required deductible amount, as shown. Charges above
the plan payment are the member's responsibility. DISCOUNT: Discount only; no benefit will be paid.
This summary of benefits is current as of 04/30/2015. To verify up to date benefits, please contact Dental Select Member Services (1-800-999-9789) or refer to your
current Certificate of Insurance.
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This summary of benefits is current as of 04/30/2015. To verify up to date benefits, please contact Dental Select Member Services (1-800-999-9789) or refer to your
current Certificate of Insurance.
4/30/2015 9:49 AM
Discount – Silver
Phone: 800-999-9789
Fax: 888-673-5328
www.dentalselect.com
Easy to Use Discount Dental Plan
•
•
•
•
•
•
•
Affordable rates
No deductibles
No waiting periods
No age limits
No annual maximums
Dental discounts available the day you enroll
Plan includes all existing dental health concerns
(excluding treatments in progress)
• Includes adult and child orthodontics
• Includes teeth bleaching and other cosmetic procedures
• Parents and Grandparents may be included on this plan
Silver
Plan Type: Fee-For-Service Discount
Download our free Mobile ID App.
• Search to find a dentist in your area
• Quick access to your dental and vision ID cards
• Instantly email a copy of your ID card for your
Provider’s records
• Subscribers and covered family members can access
Contracted Discount
Preventive
Up to 70% Fee Reduction
Cleanings, exams, fluoride and x-rays
Basic
Up to 60% Fee Reduction
Fillings and oral surgery
Major
How to Find a Provider
Visit www.dentalselect.com and click on the
link at the top right of your browser.
Crowns, bridges, Periodontics, Endodontics and
dentures
Specialists
Orthodontist, Oral Surgeon, Prosthodontist, Endodontist, Periodontist and Pediatric Specialist
20% Discount
Orthodontics
Children & Adults
Lifetime Maximum (Benefit)
Discount Vision Included with Every Dental Plan
Up to 50% Fee Reduction
Deductible
20% Discount
None
$0
Maximum Benefit
No Maximum
Waiting Periods
Basic
Major
Orthodontic
None
The Discount Plan is not a dental insurance policy. This program provides discounts only from a specific
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.
EB15S9001
Page Intentionally Left Blank
2009 Utah Silver
ADA Code
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
D0330
D0340
D0470
D1110
D1120
D1208
D1330
D1351
D1353
D1510
D1515
D1520
D1525
D1550
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2915
Procedure Description
Periodic oral examination
Limited oral examination
Comprehensive oral examination
Detailed and extensive oral evaluation
Re-evaluation
Periodontal evaluation
Intraoral - compl ser incl bitewings
Intraoral - periapical - first image
Intraoral - periapical - each add image
Intraoral - occlusal image
Extraoral - first image
Extraoral - each additional
Bitewing - single image
Bitewings - two images
Bitewing-three images
Bitewings - four images
Vertical bitewings - 7 to 8 images
Panoramic image
Cephalometric image
Diagnostic casts
Prophylaxis - adults
Prophylaxis - child
Top appl fluor excl prophy (age 14 & under)
Oral hygiene instruction
Sealant - per tooth (age 14 & under)
Sealant repair - per tooth (age 14 & under)
Space maintainer - fixed unilateral (age 14 & under)
Space maintainer - fixed bilateral (age 14 & under)
Space maintainer - rem. unilateral (age 14 & under)
Space maintainer - rem. bilateral (age 14 & under)
Recement of space maintainer (age 14 & under)
Amalgam - 1 surface primary or permanent
Amalgam - 2 surfaces primary or permanent
Amalgam - 3 surfaces primary or permanent
Amalgam - 4 + surfaces primary or permanent
Resin - 1 surface anterior
Resin - 2 surfaces anterior
Resin - 3 surfaces anterior
Resin - 4 + surf or involving incisal angle anterior
Resin based comp. crown - ant. prim. or perm.
Resin - 1 surface posterior prim. or perm.
Resin - 2 surfaces posterior prim. or perm.
Resin - 3 surfaces posterior prim. or perm.
Resin - 4 + surfaces - posterior prim. or perm.
Inlay - porcelain/ceramic 1 surface
Inlay - porcelain/ceramic - 2 surfaces
Inlay - porcelain/ceramic - 3 surfaces
Onlay - porcelain/ceramic - 2 surfaces
Onlay - porcelain/ceramic - 3 surfaces
Onlay - porcelain/ceramic - 4 surfaces
Composite Inlay One Surface
Composite Inlay Two Surface
Composite Inlay Three Surface or more
Composite Onlay Two Surface
Composite Onlay Three Surface
Composite Onlay Four Surface or more
Crown-Resin (indirect)
Crown- 3/4 Resin-based (indirect)
Crown- Resin High Noble Metal
Crown Resin Base Metal
Crown Resin Noble
Crown - porcelain/ceramic substrate (note 3)
Crown - porcelain fused to high noble metal (note 2)
Crown - porcelain fused to predom. base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal (note 2)
Crown - 3/4 cast predominately base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain ceramic (note 3)
Crown - full cast high noble metal (note 2)
Crown - full cast predominately base metal
Crown - full cast noble metal
Recement cast or prefabricated post and core
Utah Silver 1, Effective January 2015
Patient Fee
15
10
17
16
13
15
35
8
6
6
4
4
6
12
13
16
17
37
20% Discount
20% Discount
37
25
4
0
19
19
86
128
92
142
18
41
51
62
71
63
74
84
94
103
63
84
102
108
308
360
408
330
372
416
220
273
297
275
299
228
118
147
426
405
420
420
460
437
442
410
410
410
410
420
357
360
25
Page 1
ADA Code
D2920
D2929
D2930
D2931
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2957
D2960
D2961
D2962
D2970
D2999
D3110
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3346
D3347
D3348
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3920
D4210
D4211
D4240
D4241
D4249
D4260
D4261
D4263
D4264
D4266
D4267
D4270
D4273
D4275
D4276
D4277
D4278
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
Procedure Description
Recement crown
Prefab. Porcelain/ceramic crown -primary
Prefab. stainless steel crown - prime tooth
Prefab. stainless steel crown - permanent tooth
Prefab. stainless steel crown w/ resin window
Prefab. coated stainless steel crown - primary
Sedative fillings
Core build-up including any pins
Pin retenion - per tooth in addition to restoration
Cast post & core in addition to crown
Each additional cast post - same tooth
Prefab. post & core in addition to crown
Each additional prefab post - same tooth
Anterior bonding per tooth
Labial veneer resin laminate (lab)
Labial veneer porcelain laminate (lab)
Temporary crown (fractured tooth)
Lab Fee (notes 2 & 3)
Pulp cap - direct excluding final restoration
Therapeutic pulpotomy excluding final restoration
Pulpal debridement primary & permanent teeth
Pulpal therapy-anterior-excluding final restoration
Pulpal therapy-posterior-excluding final restoration
Root Canal - ant. exclud. final restoration
Root Canal - bicuspid exclud. final restoration
Root Canal - molar exclud. final restoration
Retreatment of previous root canal - anterior
Retreatment of previous root canal - bicuspid
Retreatment of previous root canal - molar
Apexification/Initial Visit
Apexification/Interim
Apexfication/Final Visit
Apicoectomy/periradicular surgical - anterior
Apico/perirad surgical - bicuspid first root
Apico/perirad surgical - molar first root
Apico/perirad surgical - each additional root
Retrograde filling - per root
Root Amputation
Hemisection
Gingivectomy/gingivoplasty - 4 + teeth per quad
Gingivectomy/gingivoplasty - 1 - 3 teeth per quad
Gingival flap proc. incl. root planing - 4 + teeth
Gingival flap proc. Incl. root planing 1 - 3 teeth
Clinical crown lengthening - hard tissue
Osseous surg. & flap entry/closure - 4 + teeth
Osseous surg. & flap entry/closure - 1- 3 teeth
Bone replacement graft - first site in quad
Bone replacement graft - each additional site in quad
Guided tissue regen. - resorbable barrier, per site
Guided tis. regen. - non resorbable barrier, per site
Pedicle soft tissue graft procedure
Subepithelial connnective graft proc. (incl. donor)
Soft tissue allograft
Comb. connective tissue and double pedicle graft
Free soft tissue graft & donor site
Free soft tissue graft & donor site
Provisional splinting - intracoronal
Provisional splinting - extracoronal
Perio. scaling & root planing - 4 + teeth per quad
Perio. scaling & root planing - 1 - 3 teeth per quad
Full mouth debridement
Antimicrobial agents
Perio maintenance procedures after active therapy
Complete denture - upper (note 6)
Complete denture - lower (note 6)
Immediate denture - upper (note 6)
Immediate denture - lower (note 6)
Maxillary Partial Denture - Resin Base (note 7)
Mand. Partial Denture - Resin Base (note 7)
Max. Partial Denture w/ cast metal base (note 7)
Mand. Partial Denture w/ cast metal base (note 7)
Rem. unilateral part. denture
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Repair broken complete denture base (note 7)
Replace missing/broken tooth - ea. tooth (note 7)
Repair resin saddle or base (note 7)
Repair cast framework (note 7)
Repair or replace broken clasp (note 7)
Replace broken teeth - per tooth (note 7)
Utah Silver 1, Effective January 2015
Patient Fee
25
105
66
68
104
109
31
81
16
104
47
88
44
242
20% Discount
20% Discount
0
See notes 2 & 3
20
49
49
48
46
246
308
395
222
272
346
97
56
145
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
150
137
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
64
20% Discount
71
508
508
540
540
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
34
29
27
26
43
25
29
29
33
26
Page 2
ADA Code
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5899
D6000-6199
D6205
D6210
D6211
D6212
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6930
D6971
D6973
D6976
D6977
D6999
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7270
D7280
D7285
D7286
D7287
D7288
D7290
D7310
D7311
D7320
D7321
D7471
D7510
Procedure Description
Add tooth to existing partial denture (note 7)
Add clasp to existing partial denture (note 7)
Rebase complete maxillary denture (note 7)
Rebase complete mandibular denture (note 7)
Rebase maxillary partial denture (note 7)
Rebase mandibular partial denture (note 7)
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (lab) (note 7)
Reline complete mandibular denture (lab) (note 7)
Reline upper partial denture (lab) (note 7)
Reline mandibular partial denture (lab) (note 7)
Interim complete denture (maxillary)
Interim complete denture (mandibular)
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Tissue conditioning, maxillary - per denture unit
Tissue conditioning, mandibular
Lab Fee (notes 6 & 7)
Implants (Does not include parts)
Pontic-Indirect resin based composite
Pontic - cast high noble metal (note 2)
Pontic - cast base metal
Pontic - cast noble metal
Pontic - porcelain fused to high noble metal (note 2)
Pontic - porcelain fused to predominately base metal
Pontic - porcelain fused to noble metal
Pontic - porcelain/ceramic (note 3)
Pontic - resin with high noble metal (note 2)
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Onlay - porcelain/ceramic - 2 surf.
Onlay - porcelain/ceramic - 3 + surf.
Onlay - cast high noble metal - 2 surf. (note 2)
Onlay - cast high noble metal - 3 +surf. (note 2)
Onlay - cast predom. base metal - 2 surf
Onlay - cast predom. base metal - 3 + surf.
Onlay - cast noble metal - 2 surf.
Onlay - cast noble metal - 3 + surf.
Crown - resin with high noble metal (note 2)
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic (note 3)
Crown - porc fused to high noble metal (note 2)
Crown - porcelain fused to predom. base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal (note 2)
Crown - 3/4 cast base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic (note 3)
Crown - full cast high noble metal (note 2)
Crown - full cast predominantly base metal
Crown - full cast noble metal
Recement bridge
Cast post as part of fixed partial denture retainer
Core build up for retainer, including pins
Each additional cast post - same tooth
Each additional prefab post - same tooth
Lab Fee (notes 2 & 3)
Extraction of primary tooth
Extraction of erupted tooth or exposed tooth
Surgical removal of erupted tooth
Removal impacted tooth - soft tissue
Removal impacted tooth - partial bony
Removal impacted tooth - completely bony
Removal impacted tooth
Surgical removal residual tooth roots
Tooth reimplantation/stabilization
Surgical access of an unerupted tooth
Biopsy of oral tissue-hard (bone, tooth)
Biopsy of oral tissue-soft (all others)
Cytology sample
Brush biopsy - transepithelial sample collection
Surgical repositioning of teeth
Alveoloplasty in conj. w/ extraction - per quad
Alveolaplasty in conj. w/ extractions - 1 - 3 teeth
Alveoloplasty, no extraction - per quad
Alveolaplasty not in conj. w/ exts. -1 - 3 teeth
Excision of exostosis
I&D abscess - intraoral soft tissue
Utah Silver 1, Effective January 2015
Patient Fee
31
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
See notes 6 & 7
20% Discount
204
433
391
397
446
441
441
416
440
417
417
292
351
227
237
227
239
228
238
434
430
430
422
460
447
447
429
410
410
418
437
290
290
44
67
20% Discount
20% Discount
20% Discount
See notes 2 & 3
39
47
82
101
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
185
20% Discount
Page 3
ADA Code
D7511
D7810-7899
D7960
D7971
D9110
D9210
D9220
D9221
D9241
D9242
D9248
D9430
D9440
D9940
D9951
D9972
D9973
D8010-8680
Procedure Description
I&D abscess - intraoral soft tissue, complicated
TMJ Treatment
Frenulectomy - separate procedure
Excision of pericoronal gingiva
Palliative - emerg. treatment of pain - minor proc.
Local anesthetic
General Anesthesia, first 30 minutes
General Anesthesia, additional 15 minutes
Intravenous sedation, first 30 minutes
Intravenous sedation, each add 15 minutes
Non-intraven. conscious sedation (age 7 & under)
Office visit obs. - scheduled hrs - no other servs.
Office visit - after regular scheduled hours
Occlusal guards by report (note 5)
Occlusal adjustment - limited
External Bleaching per Arch
External Bleaching per Tooth
Orthodontics (note 8)
Contracted fees are subject to change during or at the end of each plan year.
Utah Silver 1, Effective January 2015
Patient Fee
73
20% Discount
95
20% Discount
26
0
N/C
N/C
N/C
N/C
N/C
26
37
20% Discount
30
20% Discount
20% Discount
20% Discount
FSC.02.9000058 UT Silver 1 2015 12/14
Page 4
Co-Pay – Gold
Phone: 800-999-9789
www.dentalselect.com
Fax: 888-673-5328
Simple Co-Pay Dental Plan
• No waiting periods
• No annual maximums
• Large panel of Gold Providers
• Fixed affordable co-payments
• Includes non-contracted provider benefit
Enjoy these great features from any contracted provider
• Covers preventive care at 100%
• Includes implant crown discount
• Includes discount on teeth bleaching and veneers
All Specialist Types Available
Download our free Mobile ID App.
• Specialists include:
• Pediatric Specialists
• Search to find a dentist in your area
• Quick access to your dental and vision ID cards
• Instantly email a copy of your ID card for your
Provider’s records
• Subscribers and covered family members can access
• Oral Surgeons
• Endodontists
• Periodontists
• Prosthodontists
• Orthodontists
Gold Network
How to Find a Provider
Plan Type: Co-Pay Plan
Visit www.dentalselect.com and click on the
link at the top right of your browser.
Contracted
Non-Contracted
Preventive
Discount Vision Included with Every Dental Plan
Cleanings (2 per Year), exams,
fluoride and x-rays
100%
Basic
Fillings, Periodontics and Oral
Surgery
Major
See Sample Payment Schedule
Fixed Co-Pays
(See Sample Payment Schedule)
Crowns, bridges, Endodontics
and dentures
Specialists
Orthodontist, Oral Surgeon,
Prosthodontist, Endodontist,
Periodontist and Pediatric
Specialist
20% Discount
(Discount Only - No benefit will
be paid)
Orthodontics
Children & Adults
20% Discount
(Discount Only - No benefit will
be paid)
Deductible
$0 for 6 or more enrolled (2-5 enrolled $25/$75)
Maximum Benefit
No Benefit
No Maximum
Waiting Periods
Basic
Major
Orthodontic
None
This contains general plan information. Review your group specific summary of
benefits for plan details.
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.
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 plan certificate booklet for a complete description of benefits, limitations and
exclusions.
EB15G9002
Page Intentionally Left Blank
2009 Utah PPO Gold Network CoPay
ADA Code
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
D0330
D0340
D0470
D1110
D1120
D1208
D1330
D1351
D1353
D1510
D1515
D1520
D1525
D1550
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
Procedure Description
Periodic oral examination
Limited oral examination
Comprehensive oral examination
Detailed and extensive oral evaluation
Re-evaluation
Periodontal evaluation
Intraoral - compl ser incl bitewings
Intraoral - periapical - first image
Intraoral - periapical - each add image
Intraoral - occlusal image
Extraoral - first image
Extraoral - each additional
Bitewing - single image
Bitewings - two images
Bitewing-three images
Bitewings - four images
Vertical bitewings - 7 to 8 images
Panoramic image
Cephalometric image
Diagnostic casts
Prophylaxis - adults
Prophylaxis - child
Top appl fluor excl prophy (age 14 & under)
Oral hygiene instruction
Sealant - per tooth (age 14 & under)
Sealant repair - per tooth (age 14 & under)
Space maintainer - fixed unilateral (age 14 & under)
Space maintainer - fixed bilateral (age 14 & under)
Space maintainer - rem. unilateral (age 14 & under)
Space maintainer - rem. bilateral (age 14 & under)
Recement of space maintainer (age 14 & under)
Amalgam - 1 surface primary or permanent
Amalgam - 2 surfaces primary or permanent
Amalgam - 3 surfaces primary or permanent
Amalgam - 4 + surfaces primary or permanent
Resin - 1 surface anterior
Resin - 2 surfaces anterior
Resin - 3 surfaces anterior
Resin - 4 + surf or involving incisal angle anterior
Resin based comp. crown - ant. prim. or perm.
Resin - 1 surface posterior prim. or perm.
Resin - 2 surfaces posterior prim. or perm.
Resin - 3 surfaces posterior prim. or perm.
Resin - 4 + surfaces - posterior prim. or perm.
Inlay - porcelain/ceramic 1 surface
Inlay - porcelain/ceramic - 2 surfaces
Inlay - porcelain/ceramic - 3 surfaces
Onlay - porcelain/ceramic - 2 surfaces
Onlay - porcelain/ceramic - 3 surfaces
Onlay - porcelain/ceramic - 4 surfaces
Composite Inlay One Surface
Composite Inlay Two Surface
Composite Inlay Three Surface or more
Composite Onlay Two Surface
Composite Onlay Three Surface
Composite Onlay Four Surface or more
Crown-Resin (indirect)
Crown- 3/4 Resin-based (indirect)
Crown- Resin High Noble Metal
Crown Resin Base Metal
Crown Resin Noble
Crown - porcelain/ceramic substrate (note 3)
Crown - porcelain fused to high noble metal (note 2)
Crown - porcelain fused to predom. base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal (note 2)
Crown - 3/4 cast predominately base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain ceramic (note 3)
Crown - full cast high noble metal (note 2)
Crown - full cast predominately base metal
Crown - full cast noble metal
Utah CoPay Gold 1, Effective January 2015
General Dentist
In-Network
Patient Co-Pay
General Dentist
In & Out-of-Network
Plan Payment
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
17
12
19
20
16
17
37
8
6
6
4
4
6
14
14
17
17
37
0
0
37
25
4
0
8
8
0
0
0
0
0
32
34
38
39
32
40
44
52
0
32
39
45
48
107
132
168
129
142
155
65
96
105
92
105
126
0
0
165
155
163
162
192
158
160
156
156
156
156
159
146
152
20% Discount
20% Discount
0
0
0
0
13
13
87
132
95
148
19
17
23
31
38
37
41
48
54
108
36
54
65
75
210
239
253
210
250
280
160
182
197
183
205
207
120
150
280
270
277
300
320
305
308
275
270
270
275
285
250
240
Pediatric Specialist
In-Network Patient
Co-Pay or Discount
Pediatric Specialist
In & Out-of-Network
Plan Payment
0
17
0
19
0
0
0
37
8
6
6
4
4
6
14
14
17
17
37
0
0
37
25
14
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20% Discount
0
20% Discount
20% Discount
20% Discount
0
0
0
0
0
0
0
0
0
0
0
0
20% Discount
20% Discount
0
0
0
0
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
Page 1
ADA Code
D2915
D2920
D2929
D2930
D2931
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2957
D2960
D2961
D2962
D2970
D2999
D3110
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3346
D3347
D3348
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3920
D4210
D4211
D4240
D4241
D4249
D4260
D4261
D4263
D4264
D4266
D4267
D4270
D4273
D4275
D4276
D4277
D4278
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
Procedure Description
Recement cast or prefabricated post and core
Recement crown
Prefab. Porcelain/ceramic crown -primary
Prefab. stainless steel crown - prime tooth
Prefab. stainless steel crown - permanent tooth
Prefab. stainless steel crown w/ resin window
Prefab. coated stainless steel crown - primary
Sedative fillings
Core build-up including any pins
Pin retenion - per tooth in addition to restoration
Cast post & core in addition to crown
Each additional cast post - same tooth
Prefab. post & core in addition to crown
Each additional prefab post - same tooth
Anterior bonding per tooth
Labial veneer resin laminate (lab)
Labial veneer porcelain laminate (lab)
Temporary crown (fractured tooth)
Lab Fee (notes 2 & 3)
Pulp cap - direct excluding final restoration
Therapeutic pulpotomy excluding final restoration
Pulpal debridement primary & permanent teeth
Pulpal therapy-anterior-excluding final restoration
Pulpal therapy-posterior-excluding final restoration
Root Canal - ant. exclud. final restoration
Root Canal - bicuspid exclud. final restoration
Root Canal - molar exclud. final restoration
Retreatment of previous root canal - anterior
Retreatment of previous root canal - bicuspid
Retreatment of previous root canal - molar
Apexification/Initial Visit
Apexification/Interim
Apexfication/Final Visit
Apicoectomy/periradicular surgical - anterior
Apico/perirad surgical - bicuspid first root
Apico/perirad surgical - molar first root
Apico/perirad surgical - each additional root
Retrograde filling - per root
Root Amputation
Hemisection
Gingivectomy/gingivoplasty - 4 + teeth per quad
Gingivectomy/gingivoplasty - 1 - 3 teeth per quad
Gingival flap proc. incl. root planing - 4 + teeth
Gingival flap proc. Incl. root planing 1 - 3 teeth
Clinical crown lengthening - hard tissue
Osseous surg. & flap entry/closure - 4 + teeth
Osseous surg. & flap entry/closure - 1- 3 teeth
Bone replacement graft - first site in quad
Bone replacement graft - each additional site in quad
Guided tissue regen. - resorbable barrier, per site
Guided tis. regen. - non resorbable barrier, per site
Pedicle soft tissue graft procedure
Subepithelial connnective graft proc. (incl. donor)
Soft tissue allograft
Comb. connective tissue and double pedicle graft
Free soft tissue graft & donor site
Free soft tissue graft & donor site
Provisional splinting - intracoronal
Provisional splinting - extracoronal
Perio. scaling & root planing - 4 + teeth per quad
Perio. scaling & root planing - 1 - 3 teeth per quad
Full mouth debridement
Antimicrobial agents
Perio maintenance procedures after active therapy
Complete denture - upper (note 6)
Complete denture - lower (note 6)
Immediate denture - upper (note 6)
Immediate denture - lower (note 6)
Maxillary Partial Denture - Resin Base (note 7)
Mand. Partial Denture - Resin Base (note 7)
Max. Partial Denture w/ cast metal base (note 7)
Mand. Partial Denture w/ cast metal base (note 7)
Rem. unilateral part. denture
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Repair broken complete denture base (note 7)
Replace missing/broken tooth - ea. tooth (note 7)
Repair resin saddle or base (note 7)
Repair cast framework (note 7)
Repair or replace broken clasp (note 7)
Replace broken teeth - per tooth (note 7)
Utah CoPay Gold 1, Effective January 2015
General Dentist
In-Network
Patient Co-Pay
General Dentist
In & Out-of-Network
Plan Payment
Pediatric Specialist
In-Network Patient
Co-Pay or Discount
Pediatric Specialist
In & Out-of-Network
Plan Payment
25
27
130
75
80
110
113
31
87
18
107
50
90
44
247
20% Discount
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
See notes 2 & 3
See notes 2 & 3
See notes 2 & 3
See notes 2 & 3
26
55
55
56
55
185
240
325
174
209
266
100
60
150
0
0
0
0
0
83
91
98
53
69
86
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
19
18
9
0
17
117
117
112
112
94
94
104
104
0
0
0
0
0
0
0
0
0
0
0
20% Discount
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
154
140
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
86
60
58
20% Discount
59
415
415
438
438
343
343
422
422
20% Discount
35
35
32
32
60
80
35
40
40
33
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
Page 2
ADA Code
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5899
D6000-6199
D6205
D6210
D6211
D6212
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6930
D6971
D6973
D6976
D6977
D6999
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7270
D7280
D7285
D7286
D7287
D7288
D7290
D7310
D7311
D7320
D7321
D7471
D7510
D7511
Procedure Description
Add tooth to existing partial denture (note 7)
Add clasp to existing partial denture (note 7)
Rebase complete maxillary denture (note 7)
Rebase complete mandibular denture (note 7)
Rebase maxillary partial denture (note 7)
Rebase mandibular partial denture (note 7)
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (lab) (note 7)
Reline complete mandibular denture (lab) (note 7)
Reline upper partial denture (lab) (note 7)
Reline mandibular partial denture (lab) (note 7)
Interim complete denture (maxillary)
Interim complete denture (mandibular)
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Tissue conditioning, maxillary - per denture unit
Tissue conditioning, mandibular
Lab Fee (notes 6 & 7)
Implants (Does not include parts)
Pontic-Indirect resin based composite
Pontic - cast high noble metal (note 2)
Pontic - cast base metal
Pontic - cast noble metal
Pontic - porcelain fused to high noble metal (note 2)
Pontic - porcelain fused to predominately base metal
Pontic - porcelain fused to noble metal
Pontic - porcelain/ceramic (note 3)
Pontic - resin with high noble metal (note 2)
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Onlay - porcelain/ceramic - 2 surf.
Onlay - porcelain/ceramic - 3 + surf.
Onlay - cast high noble metal - 2 surf. (note 2)
Onlay - cast high noble metal - 3 +surf. (note 2)
Onlay - cast predom. base metal - 2 surf
Onlay - cast predom. base metal - 3 + surf.
Onlay - cast noble metal - 2 surf.
Onlay - cast noble metal - 3 + surf.
Crown - resin with high noble metal (note 2)
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic (note 3)
Crown - porc fused to high noble metal (note 2)
Crown - porcelain fused to predom. base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal (note 2)
Crown - 3/4 cast base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic (note 3)
Crown - full cast high noble metal (note 2)
Crown - full cast predominantly base metal
Crown - full cast noble metal
Recement bridge
Cast post as part of fixed partial denture retainer
Core build up for retainer, including pins
Each additional cast post - same tooth
Each additional prefab post - same tooth
Lab Fee (notes 2 & 3)
Extraction of primary tooth
Extraction of erupted tooth or exposed tooth
Surgical removal of erupted tooth
Removal impacted tooth - soft tissue
Removal impacted tooth - partial bony
Removal impacted tooth - completely bony
Removal impacted tooth
Surgical removal residual tooth roots
Tooth reimplantation/stabilization
Surgical access of an unerupted tooth
Biopsy of oral tissue-hard (bone, tooth)
Biopsy of oral tissue-soft (all others)
Cytology sample
Brush biopsy - transepithelial sample collection
Surgical repositioning of teeth
Alveoloplasty in conj. w/ extraction - per quad
Alveolaplasty in conj. w/ extractions - 1 - 3 teeth
Alveoloplasty, no extraction - per quad
Alveolaplasty not in conj. w/ exts. -1 - 3 teeth
Excision of exostosis
I&D abscess - intraoral soft tissue
I&D abscess - intraoral soft tissue, complicated
Utah CoPay Gold 1, Effective January 2015
General Dentist
In-Network
Patient Co-Pay
General Dentist
In & Out-of-Network
Plan Payment
Pediatric Specialist
In-Network Patient
Co-Pay or Discount
Pediatric Specialist
In & Out-of-Network
Plan Payment
40
42
42
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20% Discount
20% Discount
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
See notes 6 & 7
20% Discount
See notes 6 & 7
See notes 6 & 7
See notes 6 & 7
20% Discount
20% Discount
0
91
162
145
150
159
148
148
148
154
154
154
94
127
95
95
95
95
95
95
157
154
154
148
159
148
148
154
155
155
159
154
143
143
0
0
0
0
0
20% Discount
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
See notes 2 & 3
See notes 2 & 3
See notes 2 & 3
See notes 2 & 3
27
35
68
88
108
130
140
75
160
17
20
26
28
34
34
40
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20% Discount
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
90
90
85
85
155
155
140
140
20% Discount
20% Discount
20% Discount
20% Discount
120
281
251
251
291
297
297
282
291
270
270
203
229
142
155
150
152
152
155
295
290
290
290
315
312
312
290
270
270
280
293
275
275
47
77
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
210
75
85
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
Page 3
ADA Code
D7810-7899
D7960
D7971
D9110
D9210
D9220
D9221
D9241
D9242
D9248
D9430
D9440
D9940
D9951
D9972
D9973
D8010-8680
Procedure Description
TMJ Treatment
Frenulectomy - separate procedure
Excision of pericoronal gingiva
Palliative - emerg. treatment of pain - minor proc.
Local anesthetic
General Anesthesia, first 30 minutes
General Anesthesia, additional 15 minutes
Intravenous sedation, first 30 minutes
Intravenous sedation, each add 15 minutes
Non-intraven. conscious sedation (age 7 & under)
Office visit obs. - scheduled hrs - no other servs.
Office visit - after regular scheduled hours
Occlusal guards by report (note 5)
Occlusal adjustment - limited
External Bleaching per Arch
External Bleaching per Tooth
Orthodontics (note 8)
General Dentist
In-Network
Patient Co-Pay
General Dentist
In & Out-of-Network
Plan Payment
Pediatric Specialist
In-Network Patient
Co-Pay or Discount
Pediatric Specialist
In & Out-of-Network
Plan Payment
20% Discount
20% Discount
38
0
0
0
0
0
0
0
0
0
0
0
0
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
26
38
157
30
0
0
0
0
0
0
0
20% Discount
0
0
0
0
0
0
0
110
20% Discount
20% Discount
20% Discount
20% Discount
Contracted fees are subject to change during or at the end of each plan year.
Utah CoPay Gold 1, Effective January 2015
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
FSC.02.9000059 UT Gold 1 2015 12/14
Page 4
PPO – Platinum
Phone: 800-999-9789
Fax: 888-673-5328
www.dentalselect.com
Flexible PPO Dental Plan
Enjoy these great features from any contracted provider
• Covers preventive care at 100%
• Lower out-of-pocket costs
• Includes cosmetic discounts
• Includes adult and child orthodontic discount
All Specialist Types Available
• Specialists include:
• Pediatric
• Oral Surgeons
• Endodontists
• Periodontists
• Prosthodontists
• Orthodontists*
*Contracted Orthodontist: The member will receive a 20% discount off of the
contracted Orthodontist’s fee.
Download our free Mobile ID App.
• Search to find a dentist in your area
• Quick access to your dental and vision ID cards
• Instantly email a copy of your ID card for your
Provider’s records
• Subscribers and covered family members can access
Contracted Specialists: The plan will pay based on a contracted fee schedule.
Contracted specialist providers accept the fee schedule as payment in full with
no balance billing.
Non-Contracted Specialists: No discount - including Orthodontists. The plan will
pay based on Reasonable & Customary fees. The Member is responsible for the
difference between the plan’s payment and the Specialist’s fee.
How to Find a Provider
Visit www.dentalselect.com and click on the
link at the top right of your browser.
Discount Vision Included with Every Dental Plan
This contains general plan information. Review your group specific summary of benefits
for plan details.
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.
EB15P9005RC
Page Intentionally Left Blank
EyeMed Access Discount Vision Plan
Phone: 801-495-3000
Toll Free: 800-999-9789
DentalSelect.com
Easy to Use for the Whole Family - No Waiting!
Included with every dental plan. Simply present your Dental Select
ID Card to a participating vision provider and receive immediate
savings. Preferred providers under the Access Discount plan charge
a discounted amount for a comprehensive examination.
Access Discount Features
-
No maximums
- Discount on laser vision
No limits on number of visits
correction surgery
No claims to submit
- No waiting periods
No limits on amount of
- Large nation-wide panel of
purchase
providers
EyeMed Access Discount Vision Plan Summary
Vision Care Services
Exam with Dilation as Necessary*:
Member Cost
$5 off routine exam
$10 off contact lens exam
Complete Pair of Glasses (frame, lenses and lens options) must be purchased in the same transaction to receive full discount. Items purchased separately will be discounted
20% off of the retail price.
Standard Plastic Lenses:
Single Vision
Bifocal
Trifocal
Progressive
Frames:
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 Materials:
(Discount applied to materials only)
Conventional
15% off retail price
Laser Vision Correction:
Lasik or PRK
15% off retail price -or5% off promotional price
To find an EyeMed Access Vision Care Network provider near you, visit www.dentalselect.com, or call Member Services at (801) 495-3000 or toll free (800) 999-9789.
*Optimap is not a covered service
The EyeMed Access Discount Vision plan is a fee-for-service discount plan; it is not an insured product.
This vision plan is only available when added to a dental plan.
VIS10001 02/12
Find A Provider
Toll Free: 800-999-9789
Toll Free Fax: 888-998-8704
DentalSelect.com
Locate a Dentist Near You
How to search for a dentist on our website.
Go to www.dentalselect.com and select the
“Find a Provider” button at the top of the
home page. Enter your desired search options and select the “Search” button at the
bottom of the page. A list of dentists that
match your search criteria will be displayed.
You can print the list of dentists by selecting
the “Print All” button.
Download the Mobile ID Card App
ID card and provider search information can be accessed anytime through Dental Select’s mobile app. Members can search for a provider or save or email a virtual ID card to share with their dentist’s office. Dental
Select’s mobile app is available for Android and iOS device and downloads are free for all members. Visit
your Apple or Google Play app store and search “Dental Select mobile app” to download today. You will need
your member ID the first time you login.
Contracted Dentist Verification
When calling to verify if a dentist accepts Dental Select insurance, be sure to ask if they are a “Contracted
Dental Select Dentist”.
Most dentists will file an insurance claim to Dental Select, but only contracted dentists accept our fee schedule as payment in full.
Dentists that are not contracted with Dental Select will balance bill the member.
2014 FAP 08/14
7031
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