Schedule of Benefits
Good health starts with a healthy mouth. Regular dental exams and cleanings can lower the risk of gum disease, which is linked to heart disease, diabetes, stroke, and other serious conditions. The HumanaOne Dental Loyalty Plus plan offers loyal members increasing benefits from plan years one to three. These increasing benefits include paying less out-of-pocket for services like fillings, root canals, crowns, and other services; an increase in plan year annual maximums; a one-time deductible for as long as you’re on the plan; and no copayments or waiting periods. Most preventive services are covered at 100 percent. Also, the plan pays the same percentage no matter which dentist you visit. You can save even more by choosing one of the more than 200,000 dentist locations in the HumanaOne Dental Loyalty Plus network.
|Schedule of Benefits|
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 HumanaOne Dental Loyalty Plus network. Limitations and exclusions may apply; please see your policy 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.
|Year One||Year Two||Year Three|
|Preventive services||• Routine oral examinations (limit two per year)
• Periodontal examinations (limit two per year)
• Cleanings (limit two per year)
• Topical fluoride treatment (limit two per year, age 14 and under)
• Sealants (limit one per tooth per lifetime, age 14 and under)
|Plan Pays 100%||Plan Pays 100%||Plan Pays 100%|
|Diagnostic & Basic services||• Emergency care for pain relief (limit two per year)
• Fillings (limit two per year, composite covered on front teeth only*)
• Extractions and root removal (limit two per year)
• Miscellaneous x-rays (limit one per year)
• Bitewing x-rays (limit one set per year)
• Full mouth or panoramic x-rays (limit one per five years)
|Plan Pays 40% after deductible||Plan Pays 55% after deductible||Plan Pays 70% after deductible|
• Root canals (limit one per tooth per two years, permanent teeth only)
|Plan Pays 20% after deductible||Plan Pays 30% after deductible||Plan Pays 50% after deductible|
|Orthodontia services||Adult and child orthodontia:
Member may receive a discount on these non-covered services. You may contact your participating provider to determine if any discounts are available on non-covered services.
|One-time deductible||• Individual $150
• Individual + One $300
• Family $450
|Plan year annual maximum (Annual maximum is the most the plan will pay toward services in a plan year.)||• First year $1000 per individual on the plan
• Second year $1250 per individual on the plan
• Subsequent years $1500 per individual on the plan