|
|
 |
Humana Dental Plan – PPO Silver Plan (Perio/Endo )
| Benefits Summary |
| |
|
|
| |
Participating Dentists: |
Non-participating Dentists: |
| Preventive Services |
100% |
80% after deductible (option to waive deductible available)
|
| Oral examinations |
|
|
| Cleaning |
|
|
| Topical flouride treatment (through age 14) |
| Sealants (through age 14) |
| X-rays |
|
|
| |
|
|
| Basic Services |
90% after deductible |
80% after deductible |
| Space maintainers (through age 14) |
|
|
| Emergency exams and palliative care for pain relief |
|
|
| Thumb sucking and harmful habit appliances (through age
14) |
|
|
| Non-cast prefabricated stainless steel crowns |
|
|
| Partial or complete denture repairs/adjustments |
|
|
| Amalgam, composite fillings |
|
|
| Endodontics (root canals) |
|
|
| Periodontics |
|
|
| Oral Surgery |
|
|
| Extractions (routine) |
|
|
| |
|
|
| Major Services |
50% after deductible |
50% after deductible |
| Inlays and onlays |
|
|
| Removable or fixed bridgework |
|
|
| Partial or complete dentures |
|
|
| Denture relines/rebases |
|
|
| Crowns |
|
|
| Calendar-year Deductible Options |
Individual / Family |
Individual / Family |
| (select one of the three options) |
$25 / $75 |
$50 / $150 |
| |
$50 / $150 |
$50 / $150 |
| |
$50 / $150 |
$100 / $300 |
| Annual Maximum Options (excludes orthodontic services) |
$1,000 or $1,500 or $2,000 or $2,500 |
|
| |
|
|
| Orthodontic Option |
50% no deductible |
|
| 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. |
| |
|
|
| Lifetime Orthodontic Maximum |
$1,000 or $1,500 or $2,000 |
|
| |
|
|
| Note: Waiting periods may apply. |
|
|
| Insured by HumanaDental Insurance Company |
| This is not a complete disclosure of the plan.
The plan certificate contains specific qualifications, limitations
and exclusions. |
|
