Dental Select Platinum (2) Co-Insurance Plan

Dental Select Insurance Choices in Utah

Dental Insurance in Utah Platinum Co-Insurance Plan (2)

dental select insurance utah

Now, the Access Discount Vision Plan is included!

Summary
of Benefits

Platinum
Co-Insurance Plan (2)

In-Network

Out-of-Network(2)

Preventative
Office visit, cleaning, oral exam and x-rays

100%

100%
of usual customary fee

Basic
Simple extractions and fillings

80%

80%
of usual customary fee

Major
Crowns, bridges, dentures, inlays, periodontics, endodontics and oral surgery

50%

50%
of usual customary fee

Orthodontics

20%
Discount

N/A

Waiting Periods

6 months basic / 12 months major

Deductible

$50 per subscriber per calendar year
for basic and major services

Annual Maximum

$1,000 per subscriber

Additional Information

Platinum PPO Network

Payment Method

Family size

Monthly

All Plans allow Monthly payments by Visa, MasterCard, Discover, American Express or automatic bank account withdrawals.

Subscriber	$33
Subscriber + 1	$61
Subscriber + 2	$80
Subscriber + 3	$99
Subscriber + 4	$118
Subscriber + 5	$137
Subscriber + 6 or more	$156

Please note: Enrollee must be the legal age of 18 or older to be enrolled on their own plan.

Dental plans are fully insured by ACE American Insurance Company. Plan is administered by Dental Select. This description is intended to highlight the benefits and features only. A more complete description of the benefits can be found in the Certificate of Insurance issued to each insured and is available for examination on request.

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

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