BEST Life Voluntary Topaz Dental PPO Plans

Voluntary Topaz Dental PPO Plans
Benefits	Premium		Classic		Basic		Value
	In Network	Out-of-Network¹	In Network	Out-of-Network¹	In Network	Out-of-Network¹	In Network	Out-of-Network¹
Calendar Year Maximum Choose your level of benefits	$1,500	$1,500	$1,500	$1,500	$1,500	$1,500	$1,500	$1,500
	$1,500	$1,000	$1,500	$1,000	$1,000	$1,000	$1,000	$1,000
	$1,000	$1,000	$1,000	$1,000	$500	$500	$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%	80%	100%	80%	100%	80%
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%	60%	80%	50%	50%	20%
Class III: Major Services Crowns & gold fillings, inlays, onlays & pontics, implants, fixed bridges, complete & partial dentures	60%	50%	50%	50%	0%	0%	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
Child Only 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
Supplemental Dental Accident Benefit Covers injury to sound, natural teeth	Up to $1,000 per accident		Up to $1,000 per accident		Up to $1,000 per accident		Up to $1,000 per accident
Children's Good Vision Benefit²	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

Out-of-network is reimbursed at UCR or at the maximum allowable charge.
50% of usual and customary expenses for a vision exam once every 12 months for dependent children through age 18. This benefit is only available to groups that elect orthodontia.

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