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Humana Dental Plan – PPO Bronze Plan (Perio/Endo
Basic)
| Benefits Summary |
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Participating Dentists: |
Non-participating Dentists: |
| Preventive Services |
100% |
80% after deductible (option to waive deductible available)
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| Oral examinations |
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| Cleaning |
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| Topical flouride treatment (through age 14) |
| Sealants (through age 14) |
| X-rays |
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| Basic Services |
80% after deductible |
50% after deductible |
| Space maintainers (through age 14) |
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| Emergency exams and palliative care for pain relief |
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| Thumb sucking and harmful habit appliances (through age
14) |
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| Non-cast prefabricated stainless steel crowns |
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| Partial or complete denture repairs/adjustments |
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| Amalgam, composite fillings |
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| Endodontics (root canals) |
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| Periodontics |
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| Oral Surgery |
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| Extractions (routine) |
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| Major Services |
50% after deductible |
30% after deductible |
| Inlays and onlays |
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| Removable or fixed bridgework |
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| Partial or complete dentures |
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| Denture relines/rebases |
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| Crowns |
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| Calendar-year Deductible Options |
Individual / Family |
Individual / Family |
| (select one of the three options) |
$25 / $75 |
$50 / $150 |
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$50 / $150 |
$50 / $150 |
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$50 / $150 |
$100 / $300 |
| Annual Maximum Options (excludes orthodontic services) |
$1,000 or $1,500 or $2,000 or $2,500 |
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| Orthodontic Option |
50% no deductible |
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| Child Orthodontia-covers children through age
18. Available for 10+ groups at an additional cost. |
| Adult/Child Orthodontia-covers adults and children.
Available for 25+ groups at an additional cost. |
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| Lifetime Orthodontic Maximum |
$1,000 or $1,500 or $2,000 |
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| Note: Waiting periods may apply. |
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| Insured by HumanaDental Insurance Company |
| Benefits under this plan are substantially limited
when you see non-participating providers. The benefits in
this plan are designed to allow you to realize lower out-of-pocket
amounts when you receive your services from a participating
provider. |
| When your treatment is provided by a non-participating
provider you will have substantially higher out-of-pocket
amounts. Review your schedule of benefits carefully to understand
this difference in benefits. |
| This is not a complete disclosure of the plan.
The plan certificate contains specific qualifications, limitations
and exclusions. |
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