Utah Exchange Certified Dental Plans
Pediatric Dental EHB Comparison PPO Plan 85% AV
Toll Free Phone: 800-999-9789
Pediatric Dental EHB Only
PPO MAC-85-Plat-Child Only
Plan ID: 10753UT0040001
Contracted
EHB Preventive (Up to age 19)
Routine exams, cleanings (2 per year),
topical fluoride, x-rays, sealants
Preventive (Age 19+)
Routine exams, cleanings (2 per year),
topical fluoride, x-rays
Basic
Fillings, extractions, oral surgery
Major
Crowns, bridges, dentures,
endodontics, periodontics
Non-Contracted
Pediatric Dental EHB Child Expanded
PPO MAC-85HI-Plat-Child
Combined
PPO MAC-85LO-Plat-Adult/
Child Combined
PPO MAC-85HI-Plat-Adult/
Child Combined
Contracted
Contracted
Contracted
Contracted
Plan ID: 10753UT0040005
85%
85%
85%
of Fee Schedule
No Coverage
No Coverage
No Coverage
No Benefit
No Benefit
70%
No Benefit
No Benefit
No Coverage
70%
of Fee Schedule
50%
50%
of Fee Schedule
12 Month Waiting Period
Waiting Periods
Non-Contracted
85%
85%
of Fee Schedule
No Coverage
No Coverage
80%
80%
of Fee Schedule
50%
50%
of Fee Schedule
12 Month Waiting Period
50%
20% Discount
Non-Contracted
85%
85%
90%
90%
70%
20% Discount
100%
of Fee Schedule
80%
80%
of Fee Schedule
50%
50%
85%
of Fee Schedule
100%
of Fee Schedule
70%
of Fee Schedule
50%
50%
of Fee Schedule
12 Month Waiting Period
of Fee Schedule
12 Month Waiting Period
50%
No Discount
20% Discount
Non-Contracted
85%
of Fee Schedule
50%
No Discount
Plan ID: 10753UT0040012
50%
No Discount
20% Discount
No Discount
12 Month Waiting Period
12 Month Waiting Period
12 Month Waiting Period
12 Month Waiting Period
$1,000.00
$1,000.00
$1,000.00
$1,000.00
Annual Maximum
$500.00
$500.00
$500.00
$500.00
OOP Max (Up to age 19)
Applies to EHB Preventive
Services
Applies to Basic & Major
Services
No Benefit
Plan ID: 10753UT0040014
Lifetime Maximum
Maximum Benefit
Specialists
Plan ID: 10753UT0040003
Non-Contracted
85%
of Fee Schedule
All Members
Adult and Child Supplemental
PPO MAC-85LO-Plat-Child
Combined
Children up to age 19
Deductible
DentalSelect.com
Pediatric Dental Essential Health Benefits (EHB) Comparison PPO Plan – Platinum Network – 85% AV
Plan Type
Ortho
Toll Free Fax: 888-998-8703
No Maximum
$1,000.00
Basic & Major Services - Calendar or Plan Year
$1,000.00 - Applies to Preventive (Age 19+),
Basic & Major Services - Calendar or Plan Year
Per Child
$700.00
$700.00
$700.00
$700.00
$700.00
Children
$1,400.00
$1,400.00
$1,400.00
$1,400.00
$1,400.00
$0.00
$75.00
$50.00
$0.00
$225.00
$150.00
$75 / $225
Per Person / Per Family
$50 / $150
Per Person / Per Family
See Note 1
See Note 1
See Note 1
See Note 1
See Note 1
Per Child
Children
Endodontists, Oral Surgeons, Pediatric,
Periodontists, Prosthodontists
1. Contracted Specialists: You receive a 20% discount off the Specialist fee. Plan pays according to the General Dentist Schedule of Fees for Preventive Services. Member pays the difference between plan payment and discount Specialist fee.
Non-contracted Specialist payment: Paid same as non-contracted dentists.
Why Choose
Who Will Be Covered?
Dental Select?
PEDIATRIC DENTAL
EHB PLAN ONLY
Covers pediatric EHB
services only
Covers pediatric EHB services plus
traditional Basic & Major Services
Coverage for employees, spouses,
dependents; includes pediatric EHB
• A Utah headquartered company for nearly 25 years
CHILDREN UP TO 19
CHILDREN UP TO 19
CHILDREN UP TO 19
CHILDREN UP TO 19
CHILDREN UP TO 19
CHILDREN UP TO 19
CHILDREN 19-26
CHILDREN 19-26
CHILDREN 19-26
ADULTS
ADULTS
ADULTS
• Hold the largest privately-owned networks in Utah
• Locally owned and operated networks since 1989
• Consistently rated A++ by A.M. Best
• Access Discount Vision is available with every
dental plan
(EHB)
(Non EHB)
PEDIATRIC DENTAL EHB
CHILD EXPANDED
(EHB)
(non EHB)
ADULT & CHILD
SUPPLEMENTAL PLAN
(EHB)
(non EHB)
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 Property & Casualty Insurance Company.
© Copyright Select Benefits Group 2014