Dental Plans for Individual, Families Self Employed

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Dental Plans for Individual, Families Self Employed Powered By Docstoc
					Dental Plans
for Individual, Families & Self Employed

                                 Utah 2008
Dental Plans for
inDiviDUals, families & self emPloyeD
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 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

co-Pay Plans
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

co-insUrance Plans
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.

      Co-Insurance Features
      •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:

         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
                                                                                                        Fee Reduction
                                                                                                                                                                     100%                                                       100%                                                     100%

            Basic                                                                                     Up to 60%                                     Up to 70% Coverage
            Fillings and oral surgery (periodontics co-pay plans only)                                                                                                                                                           70%                                                      80%
                                                                                                        Fee Reduction

            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

            Maximum Benefit
            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

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    Maxillary Partial Denture - Resin Base (note 5) ________20%*_____ 326 _____ 577
D5212    Mand. 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

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.

vision featUres
-   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
        Bifocal                                                                  $70
        Trifocal                                                                $105
        Progressive                                                             $135
                                                                        35% off retail price
        Any frame available at provider location
    Lens Options:
         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)
          Disposable                                                           N/A
          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
                           Common Questions
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.
Effective Date:
 1st of the current month or 1st of the month
 requested on enrollment card.                                    In-Network Specialist Discounts
                                                                             All Plans
Billing Date:
 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
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
                                      Male    Female
                                                                                                                                                                                                                           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

                            Yes       No

                                                                                                                                                                                        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

                                                                                        M                                                                                           M
1. Child                                                                                F   5. Child                                                                                F
                                                                                        M                                                                                           M
                                                                                                                                                                                                                           Please fill out and return this enrollment form

2. Child                                                                                F   6. Child                                                                                F
                                                                                        M                                                                                           M
3. Child                                                                                F   7. Child                                                                                F
                                                                                        M                                                                                           M
                              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
Insurance Company.