for Individual, Families & Self Employed
Dental Plans for
inDiviDUals, families & self emPloyeD
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 Features
•No deductibles •Includes teeth bleaching and
•No waiting periods veneers
•No age limits •Fee-for-service discount program;
•No annual maximums not an insured product
•Includes adult and child
The Co-Pay Plans make dental insurance easy. There are no annual maximums to track. You know your co-
payment before you schedule an appointment. For quality care, excellent benefits, and affordable co-payments,
choose the Co-Pay Plan.
Co-Pay Plan Features
•No annual maximums •Choose one of two networks,
•Fixed affordable co-payments Gold or Platinum*
•Covers preventive care at 100% •Includes orthodontic discount
(after deductible) •Includes teeth bleaching and veneers
For 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.
•Freedom to choose any dentist •Lower co-payments when receiving
•Covers preventive care at 100% care from a network dentist
(after deductible/in network) •Includes orthodontic insured
•Two benefit options available benefit plus a 20% in-network
•Choose one of two networks, discount. (option 2)
Gold or Platinum* •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
1st day of the following month from the date
When is my plan effective? Available the day you enroll
we receive your enrollment
1st day of the following month from the date we receive your enrollment
Spouse, Children, Grandchildren, Parents &
Who can I include on my plan? Grandparents
Spouse & any unmarried children up to age 26 Spouse & any unmarried children up to age 26
Type of Plan Fee-for-services discount plan Insured PPO Insured PPO - Option 1 Insured PPO - Option 2
In-Network discount only - Non-Insured ◊ In-Network only In-or-Out of Network In-or-Out of Network
Preventive Up to 90%
Cleanings (2 per year), routineexams, ﬂuoride (14 & under) and x-rays
100% 100% 100%
Basic Up to 60% Up to 70% Coverage
Fillings and oral surgery (periodontics co-pay plans only) 70% 80%
Major Up to 50% Up to 50% Coverage 50% 50%
Crowns, bridges, endodontics and dentures ($500 per year Max)* ($500 per year Max)*
(periodontics co-insurance plan only) Fee Reduction
Orthodontics 20% Discount** 20% Discount** 20% Discount** 20% Discount**
Childen & Adults (In-Network) (In-Network) (In-Network) (In-Network)
Children under 19 20% Discount** 20% Discount** 20% Discount** 50% Insured after
(In-Network) (In-Network) 20% Discount (In-Network)
Per calendar year, maximum 3 per family N/A $25/$75 $75/$225 $50/$150
Applies to all services
Preventive, basic and major services No Maximum No Maximum $1,000* $1,000*
Per person, per calendar year
Orthodontic Lifetime Maximum $500 per year
None None None $1,000 lifetime maximum
Waiting Basic None 6 Months 6 Months 6 Months
Periods: Major None 12 Months 18 Months 15 Months
Discount - None
Orthodontic None None None Insured - 24 months
Choose your Network Silver Gold Platinum Gold Platinum
Monthly Rates 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
ce Enrollment Fee
(one time, nonrefundable) Family $14 Subsc. +1 $35 Subsc. +1 $44 Subscriber +1 $37 $50 $45 $60
◊ Subsc. +2 $44 Subsc. +2 $56 Subscriber +2 $48 $66 $58 $80
The Discount Plan is not a dental insurance
$15.00 policy. This program provides discounts only Subsc. +3 $53 Subsc. +3 $67 Subscriber +3 $60 $83 $72 $100
(Fee waived if you enroll online) from a certain network of dental providers. The
member is responsible to pay for all services but Subsc. +4 $62 Subsc. +4 $78 Subscriber +4 $70 $99 $85 $120
Add Vision to any plan for will receive a discount from dental providers who Subsc. +5 $71 Subsc. +5 $90 Subscriber +5 $82 $116 $99 $140
are contracted on Dental Select’s Silver Network.
only $2.00 per month Subsc. +6 Subsc. +6 Subscriber +6
$80 $101 $93 $133 $112 $160
or more or more or more
See Partial Beneﬁts Schedule & Schedule of Co-pays for details All payments made by the plan are based on the Network Fee Schedule selected.
*Co-Insurance - $1,000 annual maximum, of which $500 can be used for Major Services. 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.
**Non Insured 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
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
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
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
enDoDontics (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
D4341 Perio. scaling & root planing - 4 + teeth per quad _____20%*______ 79 ______ 85
D4355 Full mouth debridement ____________________________ 59______ 54 ______ 58
D4910 Perio maintenance procedures after active therapy ______ 67______ 55 ______ 59
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 Maxillary Partial Denture - Resin Base (note 5) ________20%*_____ 326 _____ 577
D5212 Mand. Partial Denture - Resin Base (note 5) __________20%*_____ 326 _____ 577
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
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%*
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.
- No maximums - Includes contact lenses
- No limits on number of visits - Receive a discount of 5 - 15% on laser
- No claims to submit vision correction surgery
- No limits on amount of purchase - No waiting periods
- All styles, sizes and materials are - Large nationwide Network of providers
sUmmary of vision Benefits
Vision Care Services Member Cost
$5 off routine exam
Exam with Dilation as Necessary:*
$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 $50
35% off retail price
Any frame available at provider location
UV Coating $15
Tint (Solid & Gradient) $15
Standard Scratch-Resistance $15
Standard Polycarbonate $40
Standard Anti-Reflective Coating $45
Other Add-ons & Services 20% Discount
Contact Lens Materials:
(Discount applied to materials only)
Conventional 15% off retail price
Laser Vision Correction**: 15% off retail price -or-
Lasik or PRK 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 $2.00 per month
Same flat rate regardless of how many participants
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.
how to contact Us
Toll Free 1-800-999-9789 Toll Free Fax 1-888-998-8711
5373 S. Green Street, Ste. 400 Salt Lake City, UT 84123
801-495-3000 Fax 801-290-5104
Answers to Some
What if I need to see a network specialist? Co-Pay & Co-Insurance Plans
Dental Select network specialists offer you a fee Effective Date:
reduction of 20% from the specialist’s usual fees for 1st of the following month from date we receive your
covered services. A Pedodontist and Pediatric Dentist enrollment card.
are classified as the same type of provider and are
considered a specialist. Billing Date
Enrollments received before the 15th will be drafted
Discount & Co-Pay Plans one (1) payment on the 16th of the current month
There is no payment from Dental Select for specialist for the following month.( Effective date will be the
services. 1st of the following month application is received.)
Enrollments received after the 15th of the month
Gold Network Pediatric Specialist Only - Refer to fee will be charged two (2) payments on the 16th of the
schedule for specific co-pays. following month. ( Effective date will be the 1st of
the following month application is received.) If the
Co-Insurance Plans 16th of the month falls on a weekend or a holiday,
You are is responsible for the difference between the the draft will be taken on the following business day.
plan payment and the discount specialist’s fee.
How do I cancel?
When will my plan be effective? All cancellation requests must be received in writing.
When will I be billed? Your cancellation will be effective the first day of the
month following the month your written request is
Discount Plan received.
1st of the current month or 1st of the month
requested on enrollment card. In-Network Specialist Discounts
Your monthly payment will be deducted from 20% discount on: Orthodontist,
your account on the 16th of every month. Endodontist, Oral Surgeon, Periodontist,
Prosthodontist, and Pediatric Specialist.
Dental Plan exclUsions
No benefits will be paid:
1. for services and supplies not listed in the 17. for oral hygiene instruction; plaque control;
Coverage Schedule, not recognized as acid etch; prescription or take-home
essential for the treatment of the condition fluoride; broken appointments; completion
according to accepted standards of of a claim form; OSHA/Sterilization fees
practice or considered experimental. (Occupational Safety & Health Agency);
2. for services provided by Specialists whether or diagnostic photographs (except for
Network or Non-Network. (Co-pay plans orthodontic purposes).
only) 18. for implants; myofunctional therapy;
3. for cosmetic procedures, including but not athletic mouthguards; precision or
limited to veneers and bleaching of teeth semi-precision attachments; treatment
and procedures performed primarily for of fractures, cysts, tumors, or lesions;
cosmetic reasons. maxillofacial prosthesis; orthognathic
4. for services related to, performed in surgery; TMJ dysfunction; cleft palate; or
conjunction with, or resulting from a non- anodontia.
covered procedure. 19. for orthodontia, unless included within the
5. for charges in excess of the contracted Coverage Schedule.
Fee-for-Service schedule or the Reasonable 20. for the replacement of a filling within 24
and Customary rate, whichever applies. months of placement, unless for specific
6. for any treatment program which began health reasons.
prior to the date the Insured is covered 21. for composite, resin, or white fillings on
under the Policy. posterior primary teeth. Benefit will be
7. for crown, inlays and onlays on teeth reduced to that of an amalgam or silver
that can be restored by direct placement filling.
materials. 22. for the replacement of retainers.
8. for the replacement of crowns, bridges, 23. for sealants not applied to permanent
inlays, onlays or prosthetic appliance within bicuspid or molar; applied at age 15 or
5 years from the date of last placement. older; applied 3 years from a previous
9. for service or supplies payable under any sealant application; applied to a decayed
medical expense, auto or no-fault plan. tooth.
10. for any condition covered under any 24. for lab fees for higher metals or porcelain
Worker’s Compensation Act or similar law. crowns, bridges, inlays or onlays.
11. for services applied without cost by any 25. for general anesthesia or IV sedation. (Co-
municipality, county or other political pay plans only)
subdivision or for which there would be no 26. for services to replace teeth that were
charge in the absence of insurance. missing (extracted or congenitally) prior
12. for services that are applied toward the to the effective date of coverage on
satisfaction of a Deductible, if any. Our Plan. This limitation ends after 36
13. for services subject to a waiting period that months of continuous coverage on the
were incurred during the waiting period. Plan. Abutment teeth will be reviewed
14. for charges resulting from changing from for eligibility of prosthetic benefits. This
one provider to another while receiving exclusion does not apply if the device
treatment, or from receiving treatment covers one or more natural teeth lost or
from more than one provider for one dental extracted while covered under the Plan, or
procedure to the extent that the total if the prosthetic device was in place when
charges billed exceed the amount incurred the policy became effective.
if one provider had performed all services. 27. during travel or activity outside the United
15. for hospital facility charges for any dental States.
procedure, including but not limited to: 28. This insurance does not apply to the
emergency room charges, surgical facility extent that trade or economic sanctions or
charges, hospital confinement. other laws or regulations prohibit us from
16. for drugs or the dispensing of drugs. 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 THE REVERSE SIDE OF THIS ENROLLMENT FORM
Utah - Individual Dental Plan Enrollment Form Enroll online at www.dentalselect.com
Social Security No. Last Name First Initial
Home Address City
State Zip Code Marital Status Requested Effective Date
Married Single 1, 200
Date of Birth Sex Home Telephone Employer’s Name & Phone Number
with your payment to:
Agent Name Agent ID Number Where did you hear about us?
Toll Free (800) 999-9789
Toll Free Fax (888) 998-8711
Do you or any family member have other dental insurance? If Yes, name other dental insurance company Person Assigned As Policy Holder Social Security No.
SALT LAKE CITY, UTAH 84123
LIST ALL DEPENDENTS TO BE COVERED
5373 S. GREEN STREET, STE. 400
First Name Date of Birth Sex First Name D.O.B. Sex
Spouse F 4. Child F
DENTAL SELECT - CORPORATE OFFICE
1. Child F 5. Child F
Please fill out and return this enrollment form
2. Child F 6. Child F
3. Child F 7. Child F
Please Complete Both Sides
Choose your Plan (Choose only one) Payment Options (Choose either Checking/Savings or Credit Card Payment)
Discount Plan Billing Period: Monthly (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 Financial 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 MASTERCARD
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