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HumanaOne - Preventive Plus 1

Preventive Plus 1

 

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HumanaOne Preventive Plus 1 PPO
Schedule of Benefits

Preventive Plus 1 PPO helps you meet your everyday dental needs. The plan covers services most often used, with the freedom to select any dentist.

 

Preventive Plus 1
  In-network Out-of-network
Preventive / Diagnostic (No Waiting Periods)
  • Routine oral exam (limit 2 per year)
    • Periodontal examinations (limit 2 per year)
    • X-rays (limit 1 set per year, excludes full mouth and Panoramic)
    • Cleanings (limit 2 per year)
    • Topical fluoride treatment (limit 1 per year, age 14 and under)
    • Sealants (limit of 1 per tooth per lifetime, age 14 and under)

  • 100%
    No deductible

    100%
    of  in network fee schedule
    after deductible
    Basic (6 Month Waiting Period)
    • Emergency care for pain relief
    • Extractions and root removal
    • Fillings (limit 2 per year, composite covered at front teeth only*)
    • Space maintainers (age 14 and under, initial placement only)
    • Oral surgery
    • Prefabricated stainless steel crowns
    60%
    after deductible
    60%
    of  in network fee schedule
    after deductible
    Discount Services (No Waiting Periods)
    • Periodontics
    • Endodontics (root canals)
    • Crowns
    • Implants
    • Bridgework
    • Dentures
    • Denture relines and rebases
    • Denture repair and adjustments
    • Inlays and onlays
    • Appliances for children
    • Orthodontia Services (Adult and child orthodontia)
    Receive an average discount
    of 28% by seeing
    in-network dentists**

    Not available

    Additional Information
    Calendar-Year Deductible
    (exlcudes discount services)

    $50 per individual on the plan

    Up to a maximum of $150 per family.
    Annual Maximum
    (exlcudes discount services)
    $1000 per individual on the plan.

    Out-of-network dentists can bill you for charges above the amount covered by your HumanaOne Dental plan. To ensure you do not receive additional charges, visit a dentist in the HumanaDental PPO network.

    Waiting periods and other limitations may apply, please see your policy certificate for coverage details.

    * Composite (white) fillings are only covered on anterior (front) teeth. An alternate benefit is allowed for composite fillings on posterior (back) teeth where the plan will cover the cost of an amalgam (silver) filling and the member is responsible for any cost over the covered amount.

    ** Dentists in the HumanaDental PPO network provide a discount for services not covered by the plan, with an average savings of 28% on out-of-pocket costs. Some services will have lower than average discounts. Check with in-network providers for specific discounts.

    Dental Insurance

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