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Utah EHB Pediatric Premier for 2021

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What is the EHB Pediatric Premier Plan?

EMI Health's EHB Pediatric Premier Plan is built to protect your young children and covers the essential exams, cleanings, x-rays, fluoride, and sealants. This plan is a coinsurance plan,which means we share your costs for covered dental services and procedures.
The Premier network gives you the opportunity to save with a broad network of providers. Search Premier network providers using our provider search here: Provider Search.
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Plan Summary EHB Pediatric
Network
 Premier Network Only
Routine cleanings, exams, fluoride, x-rays and sealants
 70%
Out of Pocket Max
 $350 Individual / $700 Family
Pediatric Annual Maximum
 No Maximum
Oral Examinations
 Periodic oral exam fees are allowed twice in a plan year. A re-evaluation is considered included in the primary procedure and is not payable separately.
Diagnostic x-rays/services

Complete mouth x-rays (posterior bitewing films and 14 periapical films plus bitewings) are allowed once during any three-year period for members age 13 through the last day of the month in which the Insured turns 19 years of age, in lieu of panorex x-ray.

Full series bitewing x-rays (4) are allowed only twice in a plan year.

A panorex is allowable once during any three-year period in lieu of complete mouth x-ray.

Vertical bitewings are payable up to eight films.
Preventive

Prophylaxis (cleaning) is allowed twice in a plan year. A child Prophylaxis will be allowed through age 13. An adult Prophylaxis will be allowed for age 14 through the last day of the month in which the Insured turns 19 years of age.

Application of fluoride in conjunction with cleaning, 2 times in a plan year.

Sealants on permanent molars are allowed once during any five-year period. Permanent molars include teeth numbers 1, 2, 3, 14, 15, 16, 17, 18, 19, 30, 31, and 32. (Permanent molars with occlusal restoration are ineligible.)

Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. All Services are subject to EMI Health Maximum Allowable Charge (MAC). Unless otherwise noted, coverage is effective through the last day of the month in which the insured turns 19 years of age. Underwritten by Educators Health Plans Life, Accident, and Health, Inc.