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Type of Plan
In-Network
Out-of-Network
(Subject to Usual, Reasonable and Customary)
Annual Maximum Benefit
Preventive Services
(oral exam, cleaning, x-rays)
100%
100%
Basic Services
80% after Deductible
80% after Deductible
Major Services
(crowns, dentures)
50% after Deductible
50% after Deductible
Orthodontia
(children up to age 19)
50% (Deductible Waived)
50% (Deductible Waived)
Orthodontia Lifetime Maximum Benefit
Implant Coverage Rider
Covered under Major Maximum $1500
Composite Filling Rider
Covered under Basic
$1,000
Deductible
Single: $50
Family: $150
$2,500
Dental Coverage - HUMANA #657216
PPO
Added Benefit beginning August 1, 2014
Dental Benefits
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