|Coinsurance||0% for Preventive, 20% after deductible for Basic, 50% after deductible for Major|
|Deductible||Individual $50/Family $150|
|Annual Maximum Benefit||$1,250 year one; $1,500 year two and after, per individual on the plan|
|Teeth Cleanings||No Charge (limit 2 per year)|
|Restorative Dentistry/Fillings||20% after deductible (limit 1 per tooth, per 2 years, composite covered on front teeth only2)|
|Oral Surgery||50% after deductible|
|Extractions||20% after deductible|
|X-Rays||No Charge (1 set of films per year for covered persons under age 10 and up to 4 films per year for covered persons age 10 and older)|
|Crowns||50% after deductible (limit 1 per tooth per 5 years)|
|Root Canals||50% after deductible (limit 1 per lifetime, per tooth)|
|Periodontics||50% after deductible, Periodontal maintenance (limit 2 per year), Periodontal scaling and root planing (limit 1 per quadrant every 3 years)|
|Dentures||50% after deductible (limit 1 per 5 years)|
|Topical Fluoride||No Charge (limit 2 per year)|
|Sealant||No Charge (limit of 1 per tooth per lifetime, age 14 and under)|
|Endodontics||50% after deductible (limit 1 per lifetime, per tooth)|
|A.M. Best Rating||A- as of 07/10/2019|
|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.
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.