Topaz Dental Indemnity Chart

Topaz Dental Indemnity Plans
	Premium Plan	Classic Plan	Basic Plan	Value Plan
Calendar Year Maximum Choose your level of benefits	$1,500	$1,500	$1,500	$1,500
	$1,000	$1,000	$1,000	$1,000
			$500	$500
Individual Deductible (3 per family max) Applies to Basic and Major Services	$0, $25, $50, $75, $100 per Calendar Year or $100 Lifetime Deductible	$0, $25, $50, $75, $100 per Calendar Year or $100 Lifetime Deductible	$0, $25, $50, $75, $100 per Calendar Year or $100 Lifetime Deductible	$0, $25, $50, $75, $100 per Calendar Year or $100 Lifetime Deductible
Class I: Preventive Services Routine oral exam, cleanings, fluoride treatment for children, x-rays, sealants	100%	100%	100%	100%
Class II: Basic Services Fillings (amalgam, porcelain & plastic), anterior & posterior composites, anesthesia (general or intravenous sedation), emergency palliative treatment, space maintainers for children, pathology	90%	80%	80%	50%
Class III: Major Services Crowns & gold fillings, inlays, onlays& pontics, implants, fixed bridges, complete & partial dentures	60%	50%	0%	0%
Waiting period	12 months, unless waived	12 months, unless waived	None	None
Oral Surgery/Periodontics/Endodontics	Class II or Class III	Class II or Class III	Class II or Class III	Class II or Class III
Orthodontics (optional)	50%	50%	Not offered	Not offered
Adult and/or Child Benefit Availability (Children through age 18)	$1,500 Lifetime Maximum with a $750 Calendar Year Maximum or $1,000 Lifetime Maximum with a $500 Calendar Year Maximum	$1,500 Lifetime Maximum with a $750 Calendar Year Maximum or $1,000 Lifetime Maximum with a $500 Calendar Year Maximum
Waiting period	12 months, unless waived	12 months, unless waived
Special Dental Accident Benefit Covers injury to sound, natural teeth	$1,000 maximum per accident	$1,000 maximum per accident	$1,000 maximum per accident	$1,000 maximum per accident
Children’s Good Vision Benefit¹	Included with purchase of Orthodontia	Included with purchase of Orthodontia	Not offered	Not offered
Reimbursement Level	80th or 90th Percentile or Maximum Allowable Charge	80th or 90th Percentile or Maximum Allowable Charge	80th or 90th Percentile or Maximum Allowable Charge	80th or 90th Percentile or Maximum Allowable Charge

50% of usual and customary expenses for a vision exam once every 12 months for dependent children through age 18. This is only available to groups that elect orthodontia.

Please contact your BEST Health Plans Representative for details on waiving waiting periods, adult ortho availablility and more.