Plan Information

HumanaOne Preventive Plus PPO Schedule of Benefits

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

Preventive Plus
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)
No deductible
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
after deductible
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.