Utah Choice PPO for 2022
The freedom of choice
What is the Choice PPO Plan?
EMI Health's Choice PPO Plan is a rich dental benefit plan at a reasonable cost. This plan is a coinsurance plan, which means we share your costs for covered dental services and procedures. Once you've met your deductible, we'll pay a percentage of your bill.
You can choose to visit dentists in different networks based on your needs. If you use the Advantage network, you'll see more savings. If your dentist isn't in the Advantage network, see if they are in the larger Premier network here: Provider Search.
VISIT HEALTHCARE.GOV
VIEW AS PDF
| Plan Summary | Advantage Network | Premier Network | Out-of-Network |
| Services | |||
|
Preventive
Oral Exams, Cleanings, Sealants, X-rays, Fluoride
|
100% | 100% | 100% up to MAC* |
|
Basic
Fillings, Space Maintainers, Oral Surgery
|
80% | 70% | 70% up to MAC* |
|
Major
Crowns, Bridges, Prosthodontics, Endodontics, Periodontics
|
50% | 50% | 50% up to MAC* |
|
Orthodontics
Children (age 7 through 18)
|
Up to 25% Discount | Up to 25% Discount | No Coverage |
|
All Members (Discount)
|
Up to 25% Discount | Up to 25% Discount | No Discount |
| Waiting Periods | |||
| Preventive | None | ||
| Basic | 6 Month Waiting Period | ||
| Major | 18 Month Waiting Period | ||
|
Orthodontics
|
Not Applicable | ||
| Deductible (applies to Preventive, Basic and Major) | In and Out of Network Deductibles are Combined | ||
| Individual | $25 | $50 | $50 |
| Family Max | $75 | $150 | $150 |
| Maximums | |||
| Major Annual Max† | $500 | ||
| Annual Max per Person† | $1,500 | $1,000 | |
|
Orthodontic Lifetime Max
(Medically / Non Medically Necessary)
|
No Coverage (Eligible for up to 25% Discount) | ||
| Pediatric EHB Annual Max | None | ||
| Pedriatric Individual EHB Out-of-Pocket Max | $375 | ||
| Pediatric Family EHB Out-of-Pocket Max | $750 | ||
*All Services are subject to EMI Health Maximum Allowable Charge (MAC). When using a Non-participating Provider, the insured is responsible for all fees in excess of the Maximum Allowable Charge. Underwritten by Educators Health Plans Life, Accident, and Health, Inc.
†EHB Pediatric benefits do not apply to the annual maximum or major annual maximum