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Plan Type DPPO
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 First year $1,000, Second year $1,250, and Subsequent years $1,500 per individual on plan
Office Visit
Find Dentists 		No Charge (limit 2 per plan year)
Primary Benefits
Teeth Cleanings No Charge for Basic cleaning (limit 2 per year)
Restorative Dentistry/Fillings Member pays-First Year:60% after deductible; Second Year:45% after deductible; Subsequent Year:30% after deductible (limit 2 per plan year, composite covered on front teeth only)
Oral Surgery Member pays-First Year:80% after deductible; Second Year:70% after deductible; Subsequent Year:50% after deductible
Extractions Member pays-First Year:60% after deductible; Second Year:45% after deductible; Subsequent Year:30% after deductible(non surgical - limit 2 per person plan year)
X-Rays Member pays-First Year:60% after deductible; Second Year:45% after deductible; Subsequent Year:30% 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 Member pays-First Year:80% after deductible; Second Year:70% after deductible; Subsequent Year:50% after deductible (limit 1 tooth per 5 years)
Root Canals Member pays-First Year:80% after deductible; Second Year:70% after deductible; Subsequent Year:50% after deductible (limit 1 tooth per 2 years; permanent teeth only)
Periodontics Member pays-First Year:80% after deductible; Second Year:70% after deductible; Subsequent Year:50% after deductible (limit 2 cleanings per year) Preventive periodontal exams covered at No Charge
Dentures Member pays-First Year:80% after deductible; Second Year:70% after deductible; Subsequent Year:50% 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 Please refer to Dentures section for more details.
Endodontics Member pays-First Year:80% after deductible; Second Year:70% after deductible; Subsequent Year:50% after deductible (Limit one per tooth per 2 years; permanent teeth only)
Additional Information
A.M. Best Rating A as of 09/28/2023
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) 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.