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|Coinsurance||Preventive-0%; Basic-60% (First Year), 45% (Second Year), 30% (Third Year); Major-80% (First Year), 70% (Second Year), 50% (Third Year).|
|Deductible||Individual $150/ Family $450 (One-time deductible for as long as you stay on the plan)|
|Annual Maximum Benefit||$1000-$1500 per individual|
|No Charge (limit 2 per plan year)|
|Teeth Cleanings||No Charge for Basic cleaning (limit 2 per year)|
|Restorative Dentistry/Fillings||30%-60% after deductible (limit 2 per plan year, composite covered on front teeth only)|
|Oral Surgery||50%-80% after deductible|
|Extractions||30%-60% after deductible (non surgical - limit 2 per person plan year)|
|X-Rays||30%-60% after deductible (Bitewing x-rays limit one set or four per plan year; Full mouth or panoramic x-rays limit one per five years)|
|Crowns||50%-80% after deductible (limit 1 tooth per 5 years)|
|Root Canals||50%-80% after deductible (limit 1 tooth per 2 years; permanent teeth only)|
|Periodontics||50%-80% after deductible (limit 2 cleanings per year) Preventive periodontal exams covered at No Charge|
|Dentures||50%-80% after deductible; Complete - limit one per arch per 5 years; Maintenance, repair, and adjustments - limit one per plan year.Removable partial dentures are covered.Fixed partial dentures are not.|
|Topical Fluoride||No Charge (limit 2 per plan year, age 14 and under)|
|Sealant||No Charge (limit one per tooth per lifetime, age 14 and under)|
|Bridges||50%-80% after deductible; Partial dentures (1 per arch per 5 years).Removable partial dentures are covered.Fixed partial dentures are not.|
|Endodontics||50%-80% after deductible (Limit one per tooth per 2 years; permanent teeth only)|
|A.M. Best Rating||A- as of 02/28/2014|
|Electronic Signature for Application Available||Yes|
|Details and documents about this plan|
|View Plan Brochure Exclusions and Limitations|
Important notices and disclaimers
- The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, dentists and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on your medical history (pursuant to state law of residence), the underwriting practices of the insurance company, the optional benefits you selected, if any, and other relevant factors, such as changes in rates which take effect before your requested effective date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
- Drug Savings amounts shown are only estimates — your costs and savings can differ. Check your plan information for accuracy. See details.
Carrier specific notices, disclaimers and fees
- Humana - Insured by Humana Insurance Company, Humana Health Plan, Inc., Humana Health Insurance Company of Florida, Inc., or Humana Health Benefit Plan of Louisiana, Inc., Or offered by Humana Medical Plan Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan of Texas, Inc. ,Humana Health Plan, Inc. , Humana Medical Plan of Michigan, In,. ,Humana Health Plan of Ohio, Inc., or Humana Medical Plan of Utah, Inc.
- Humana - For Arizona residents: Insured by Humana Insurance Company or offered by Humana Health Plan, Inc.. For Texas residents: Insured by Humana Insurance Company or offered by Humana Health Plan of Texas, Inc.
- Humana - Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, call or write your Humana insurance agent or broker.
- Humana - Insured or offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of Kentucky, Humana Health Insurance Company of Florida, Inc., Humana Insurance Company of New York, The Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., CompBenefits Direct, Inc., Humana Health Benefit Plan of Louisiana, Inc., DentiCare, Inc. (d/b/a CompBenefits), or Texas Dental Plans, Inc.