2018 Dental Benefits Summary
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2018 Dental Benefits Summary
ICUBA Dental Benefit Options from HumanaDental
The dental coverage is offered, so you and your family can receive the important dental care you need for good health. You can
choose from three different fully insured dental plans that best fit your needs. HumanaDental offers a Dental Health
Maintenance Organization (DHMO) and Preferred Provider Organization (PPO) plan. The High Option and Preventative Plus PPO
dental plans off you the convenience to see any dentist you choose, keeping in mind that using an In-Network dentist will cost
you less out of pocket. The 250CS DHMO plan requires you to stay In-Network and be assigned to a participating primary care
dentist.
High Option PPO Plan
The High Option PPO plan has an annual maximum of $2,000 per
person. For the High Option PPO Plan, adult/child orthodontia Prepaid 250CS DHMO Plan
pays 50% (no deductible) of the covered orthodontia You and each of your covered dependents must select and be
services, up to a $2,000 lifetime orthodontia maximum. The High assigned to a participating primary care dentist (PCD) who
Option PPO Plan also includes four regular preventive cleanings, participates in the HumanaDental Prepaid/DHMO network.
two preventive periodontal cleanings, availability of composite Should your PCD recommend that you see a participating
fillings and an extended annual maximum benefit which provides specialist (i.e., endodontist, oral surgeon, periodontist,
30% coinsurance on preventive, basic, and major treatments after pediatric dentist) no referral is necessary. You may select a
the annual maximum is met, per plan year. HumanaDental DHMO participating specialist of your choice.
The 250CS copayments are applicable at either a participating
Preventive Plus PPO Plan general dentist or a participating specialist. Please see the
The Preventive Plus PPO Plan has an annual maximum of schedule of benefits for a listing of procedures covered
$1,000 per person. The Preventive Plus Plan is designed for under the plan.
people that would like their preventive and basic services
covered, but not major treatment. Remember, non-
participating dentists can bill you for charges above the If a planned treatment is expected to cost more than $200, it is
amount covered by your Preventive Plus Plan. recommended that you send a dental treatment plan in prior to
beginning treatment. You and/or your dentist will be notified of
The PPO plans have a deductible which must be met before the the benefits payable based upon the dental treatment plan. This
plan coverage begins. That deductible is waived for preventive is a summary only, please refer to your schedule of benefits for a
care. For other services after your deductible is met, you pay a complete listing of covered procedures.
percentage of the allowed amount and the plan pays the rest.
High Option PPO Preventive Plus DHMO Prepaid 250CS
Plan Year
$2,000 $1,000 Unlimited
Maximum
Network
In‐Network and Out‐of‐ In‐Network and Out‐of‐
Providers Providers/Assignment
Network Providers Network Providers
Necessary
Deductible $50 Individual/$150 Family $50 Individual/$150 Family N/A
Out‐of‐ In‐Network and Out‐of‐ Patient Pays Assigned
Benefit/Service In‐Network
Network Network Network Provider
Preventive
100% 80% 100% You pay a pre‐set copay
Services
80% after 50% after
Basic Services 80% after deductible You pay a pre‐set copay
deductible deductible
50% after 30% after Discount Available for In-Network Only.
Major Services (subject to provider's discretion) You pay a pre‐set copay
deductible deductible
Orthodontia ‐ Discount Available for In-Network Only.
50% (subject to provider's discretion) You pay a pre‐set copay
Adult and/or Child
Orthodontia
Lifetime Maximum $2,000 N/A $1,800
for Each Member
Manage your plan at MyHumana
Use MyHumana to manage your plan, understand your benefits,
and take charge of your dental health.
As a Humana Dental member, you can:
• Find network dentists
• Check claims history and status
• View coverage details
• Review plan benefit details
• Order a replacement identification card
• View estimates for services
• Exchange secure messages with Humana
Registration is simple
Have your Humana Dental identification card ready and go to
Humanadental.com. Click on “Register,” then follow the instructions.
We’re here to help
Call 1-800-979-4760 for Customer Care.
Humana.com
GN67523HD 0813
What’s your dental IQ?
Go to MyDentalIQ.com to find out how to
Did you know that making regular improve your oral health
preventive visits to your dentist can
You brush your teeth and floss daily and have regular dental checkups. What
help detect problems throughout
more can you do to improve your dental health?
your body such as heart disease,
diabetes, and stroke?* Go to MyDentalIQ.com and take a free dental health assessment. You’ll answer
a few questions to help evaluate your family history, general health, daily
Your HumanaDental® plan focuses
routine, and eating habits. You’ll receive a score that immediately rates your
on prevention, early detection, and
dental knowledge, along with a personalized action plan and tips. You can even
education.
print a copy of your plan to discuss with your dentist.
* Perio.org
Humana.com
GN51281HD 913
HumanaDental PPO 09 (High Option)
FLORIDA ICUBA
If you use If you use
IN-NETWORK provider OUT-OF-NETWORK provider
Plan-year deductible Individual Family Individual Family
(excludes orthodontia services) $50 $150 $50 $150
Annual maximum $2,000
(excludes orthodontia services) After you reach the annual maximum amount, you will
receive 30 percent coinsurance on preventive, basic, and
major services for the rest of the plan year. (Implants and
orthodontia excluded.)
Preventive services 100% no deductible 80% no deductible
• Oral examinations of maximum allowed fee
• X-rays
• Cleanings (four per plan year)
• Topical fluoride treatment
(through age 14, one per plan year)
• Sealants (through age 14)
• Periodontal cleanings (two per plan year)
Basic services 80% after deductible 50% after deductible
• Space maintainers (through age 14) of maximum allowed fee
• Emergency care for pain relief
• Basic oral surgery services - basic
extractions of erupted tooth or root
• Fillings (amalgam or composite)
• Appliances for children (through age 14)
• Prefabricated stainless steel crowns
• Composite fillings for molars
• Periodontics
• Endodontics (root canal)
Major services 50% after deductible 30% after deductible
• Crowns of maximum allowed fee
• Inlays and onlays
• Bridgework
• Dentures
• Denture relines and rebases
• Denture repair and adjustments
• Complex surgical extractions - surgical
removal of erupted tooth, impacted
.
tooth, and tooth roots
Orthodontia Adult/child orthodontia - Plan pays 50 percent (no
deductible) of the covered orthodontia services, up to:
$2,000 lifetime orthodontia maximum.
Non-participating dentists can bill you for charges above the amount covered by your HumanaDental
plan. To ensure you do not receive additional charges, visit a participating PPO Network dentist.
1-800-233-4013 • Humana.com
SGB0077A
Extended Annual Maximum
Not every dental visit is routine.
Someday you could go into your dentist’s office for a routine cleaning and
HumanaDental’s checkup, but you find out there’s a problem. When major dental work is
Extended Annual needed, many of us don’t expect or plan for it, but putting it off might not be an
option and may cause problems to worsen.
Maximum plans give
you a valuable
benefit and dental As an example, Kevin, a 40-year-old employee, goes to the dentist regularly.
But rather unexpectedly, his dentist tells him there’s an issue. He’ll need
coverage when it’s
a root canal and a crown, which are likely to cost more than his annual
needed.
maximum benefit. With Extended Annual Maximum, Kevin has the benefits
he needs when he needs them.
As a part of HumanaDental’s PPO High Plan, Extended Annual Maximum
takes over after a plan’s annual maximum benefit is reached. It gives
employees 30 percent coinsurance on preventive, basic and major services,
and it makes those unexpected and costly dental procedures – such as root
canals and crowns – easier to afford. There is no cap on dollars that may be
paid, which means you can take advantage of the benefit whenever it’s
needed within the plan year.
Kevin has the high option PPO with a $50 deductible and has met his
$2,000 annual maximum. Now he needs a root canal and a crown. Kevin
submits a claim for $875 for the root canal and Extended Annual Maximum
picks up 30 percent of the cost, or $262.50. When Kevin later needs a
crown, Extended Annual Maximum also pays 30 percent of that cost, $240.
Dental Service Cost Humana Pays
A root canal $875 $262.50
A crown $800 $240
Example is for illustration only. Actual savings may vary. Implants and orthodontia excluded.HumanaDental Preventive Plus 09 (Low Option)
FLORIDA ICUBA
Plan-year deductible Individual Family
(excludes orthodontia services) $50 $150
Annual maximum $1,000
(excludes orthodontia services)
Preventive services 100% no deductible
• Oral examinations
• X-rays
• Cleanings
• Topical fluoride treatment
(through age 14, one per plan year)
• Sealants (through age 14)
Basic services 80% after deductible
• Emergency care for pain relief
• Basic oral surgery services - basic
extractions of erupted tooth or root
• Fillings (amalgams, composite for
.
anterior teeth)
Discount Services
These services are not covered
Basic services under this plan. Members may
• Space maintainers (through age 14)
receive a discount on non-
• Appliances for children
covered services and may contact
• Prefabricated stainless steel crowns
their participating provider to
determine if any discounts are
Major services available on non-covered
• Crowns
services.
• Inlays and onlays
• Bridgework
• Dentures
• Denture relines and rebases
• Denture repair and adjustments
• Complex surgical extractions - surgical
removal of erupted tooth, impacted
tooth, and tooth roots
• Periodontics (gum therapy)
• Endodontics (root canals)
Orthodontia services
• Adult and child orthodontia
Non-participating dentists can bill you for charges above the amount covered by your HumanaDental
plan. To ensure you do not receive additional charges, visit a participating PPO Network dentist. If a
member sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee.
1-800-233-4013 • Humana.com
SGB0077AHumanaDental Preventive Plus 09
Questions?
Simply call 1-800-233-4013 to speak with a friendly,
knowledgeable Customer Care specialist, or visit Humana.com.
Feel good about choosing Use your HumanaDental benefits
a HumanaDental plan
Find a dentist
Make regular dental visits a priority With HumanaDental’ s PPO plan, you can see any
Regular cleanings can help manage problems dentist. You save an average of 28 percent when
throughout the body such as heart disease, you visit a dentist in HumanaDental’ s PPO
diabetes, and stroke.* Your HumanaDental PPO Network. To find a dentist in HumanaDental’ s PPO
plan focuses on prevention and early diagnosis, Network, log on to Humana.com or call
providing four exams and cleanings every plan 1-800-233-4013.
year: two regular and two periodontal.
* www.perio.org Know what your plan covers
The other side of this page provides a summary of
Go to MyDentalIQ.com HumanaDental benefits. Your plan certificate
Take a health risk assessment that immediately describes in detail your HumanaDental benefits.
rates your dental health knowledge. You’ll receive You can find it on MyHumana, your personal page
a personalized action plan with health tips. You at Humana.com or call 1-800-233-4013.
can print a copy of your scorecard to discuss with
your dentist at your next visit. See your dentist
Your HumanaDental identification card contains all
Tips to ensure a healthy mouth the information your dentist needs to submit your
• Use a soft-bristled toothbrush claims. Be sure to share it with the office staff
• Choose toothpaste with fluoride when you arrive for your appointment. If you
• Brush for at least two minutes twice a day don’t have your card, you can print proof of
• Floss daily coverage at Humana.com.
• Watch for signs of periodontal disease such as
red, swollen, or tender gums Learn what your plan paid
• Visit a dentist regularly for exams and cleanings After HumanaDental processes your dental claim,
you will receive an explanation of benefits or
Did you know that 74 percent of adult Americans believe claims receipt. It provides detailed information on
an unattractive smile could hurt a person’s chances for covered dental services, amounts paid, plus any
career success?* HumanaDental helps you feel good about amount you may owe your dentist. You can also
your dental health so you can smile confidently. check the status of your claim on MyHumana at
* American Academy of Cosmetic Dentistry Humana.com or by calling 1-800-233-4013.
Insured or administered by HumanaDental Insurance Company
This is not a complete disclosure of plan qualifications and limitations. Your broker will provide you
with specific limitations and exclusions as contained in the Regulatory and Technical Information Guide.
Please review this information before applying for coverage. The amount of benefits provided depends
upon the plan selected. Premiums will vary according to the selection made.
Plan summary created on: 6/20/12 08:38 Policy Number: FL-70090-HD 3/08 et.al.HumanaDental DHMO 250 CS Plan
Use your
HumanaDental benefits
The HumanaDental CS Series dental plan has you covered
for any circumstance. Whether you simply need quality
routine dental care or unexpected dental treatment, you
know what to expect with HumanaDental. Check your dental
• No waiting periods
• No claims to file
IQ anytime
• No annual maximums
Log on to MyDentalIQ.com and take
Know what your plan covers the dental risk assessment that could
Attached is a summary of HumanaDental CS Series plan
benefits which are described in detail in your certificate. help trim your total healthcare costs
You can find your certificate at HumanaDental.com or call over time. Find out how you can
1-800-979-4760. Here’s what you can expect:
improve your oral and overall health.
• You have the freedom to select any participating
dentist. To select a dental provider from our The dental health risk assessment at
network, simply visit HumanaDental.com. Once MyDentalIQ.com takes minutes to
there, you can also check your benefits, email us
and get a new or temporary ID card. If you prefer, complete, and immediately delivers
contact us at 1-800-979-4760. a scorecard with health tips tailored
• Life without claim forms! With HumanaDental DHMO to you.
plan you pay your dentist directly, when applicable.
• Your primary dentist will provide all of your routine
dental care and any copayment or discounted charges
will be paid at the time of service. Copayments are
applicable at either a participating general dentist or a
participating specialist.
Choose
HumanaDental benefits
Be healthy
Good oral health means more than just an attractive Questions?
smile. Research shows that oral health, preventive care
and regular visits to the dentist is integral to overall
Check out HumanaDental.com
health. For example, the Academy of General Dentistry Call 1-800-979-4760 anytime for the
says there is a link between gum disease and heart
problems, and the American Academy of Periodontology automated information line or 8 a.m. to
says severe gum disease can increase blood sugar, 6 p.m. for a Customer Care specialist.
increasing the risk among diabetics. The HumanaDental
DHMO plan enables you to take better care of your teeth,
and you’ll pay less doing so.
GCA0AWGHH 4/13HumanaDental DHMO 250 CS Plan
The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a
primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods.
CS plans copayments are applicable at either a participating general dentist or a participating specialist.
Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your
dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to
see a network specialist.
Specialists services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you
may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For CS
plans, copayment amounts are applicable when treatment is performed by participating specialists.
Summary of services
Appointments Member pays D1208 Topical application of fluoride (not including
D9310 Consultation (diagnostic service provided by prophylaxis)—child (up to 16 years of age) . . . . no charge
dentist other than practitioner D1330 Oral hygiene instruction . . . . . . . . . . . . . . . . . . . . . . no charge
providing treatment) . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00 D1351 Sealant-per tooth . . . . . . . . . . . . . . . . . . . . . . . . . .$ 15 .00
D9430 Office visit (normal hours) . . . . . . . . . . . . . . . . . . . . $ 5 .00 D1510 Space maintainer—fixed, unilateral . . . . . . . . .$ 55 .00+lab
D9440 Office visit (after regularly scheduled hours) . . . $ 35 .00 D1515 Space maintainer—fixed, bilateral . . . . . . . . . .$ 55 .00+lab
D9999 Emergency visit during regularly scheduled D1520 Space maintainer—removable, unilateral . . .$ 95 .00+lab
hours, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00 D1525 Space maintainer—removable, bilateral . . . .$ 95 .00+lab
D9999 Broken appointments (without 24 hr . notice, D1550 Recementation of space maintainer . . . . . . . .$ 15 .00
per 15 min)—maximum $40 per broken Restorative Member pays
appointment . No charge will be made due D2140 Amalgam—one surface, primary
to emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00 or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 20 .00
Diagnostic Member pays D2150 Amalgam—two surfaces, primary
D0120 Periodic oral examination . . . . . . . . . . . . . . . . . . . . . no charge or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 25 .00
D0140 Limited/comprehensive/detailed and D2160 Amalgam—three surfaces, primary
extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 30 .00
D0150 Limited/comprehensive/detailed and D2161 Amalgam—four or more surfaces, primary
extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 40 .00
D0160 Limited/comprehensive/detailed and D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 20 .00
extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge D2999 Sedative base (under fillings), by report . . . . . .no charge
D0180 Comprehensive periodontal evaluation . . . . . . . . $ 15 .00 Resin restorative Member pays
D0210 X-ray intraoral—complete series D2330 Resin based composite—one surface, anterior . .$ 40 .00
including bitewings . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge D2331 Resin based composite—two
D0220 X-ray intraoral—periapical, first radiographic surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 45 .00
image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge D2332 Resin based composite—three
D0230 X-ray intraoral—periapical, each additional surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 55 .00
radiographic image . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge D2391 Resin based composite—one
D0270 X-ray bitewing—single radiographic image . . . no charge surface, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 70 .00
D0272 X-ray bitewings—two radiographic images . . . no charge D2392 Resin based composite—two
D0274 Bitewings—four radiographic images . . . . . . . . . no charge surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 90 .00
D0330 Panoramic radiographic image . . . . . . . . . . . . . . . no charge D2393 Resin based composite—three
D0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 110 .00
D0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge D2394 Resin based composite—four or more
Preventive Member pays surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 130 .00
D1110 Prophylaxis—adult, routine D2510 Inlay—metallic, one surface . . . . . . . . . . . . . . . .$ 115 .00
(once every 6 months) . . . . . . . . . . . . . . . . . . . . . . . . no charge D2520 Inlay—metallic, two surfaces . . . . . . . . . . . . . . .$ 125 .00
D1120 Prophylaxis—child, routine D2530 Inlay—metallic, three or more surfaces . . . . .$ 150 .00
(once every 6 months) . . . . . . . . . . . . . . . . . . . . . . . . no charge Crown and bridge Member pays
D1110 Prophylaxis—adult/child, (additional) . . . . . . . . . $ 25 .00 D2740 Crown—porcelain/ceramic substrate . . . . . . .$ 310 .00+lab
D1120 Prophylaxis—adult/child, (additional) . . . . . . . . . $ 25 .00 D2750* Crown—porcelain fused to high noble metal . .$ 310 .00
D1206 Topical application of fluoride varnish (for child D2751 Crown—porcelain fused to predominantlyD2752* Crown—porcelain fused to noble metal . . . . . . $ 310 .00 D4381 Localized delivery of chemotherapeutic
D2790* Crown—full cast high noble metal . . . . . . . . . . . $ 310 .00 agents (per tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00
D2791 Crown—full cast predominantly base metal . $ 310 .00 D4910 Periodontal maintenance . . . . . . . . . . . . . . . . . . . . $ 55 .00
D2792* Crown—full cast noble metal . . . . . . . . . . . . . . . . $ 310 .00 Prosthodontics Member pays
D2910 Recement inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00
D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00 D5110 Complete denture—maxillary . . . . . . . . . . . . . . . $ 325 .00+lab
D2929 Crown—prefabricated porcelain/ceramic crown D5120 Complete denture—mandibular . . . . . . . . . . . . . $ 325 .00+lab
- primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00 D5130 Immediate denture—maxillary . . . . . . . . . . . . . $ 325 .00+lab
D2930 Prefabricated stainless steel crown— D5140 Immediate denture—mandibular . . . . . . . . . . . $ 325 .00+lab
primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00 D5211 Maxillary partial denture—resin base . . . . . . . . $ 325 .00+lab
D2950 Core buildup, including any pins . . . . . . . . . . . . . $ 50 .00 D5212 Mandibular partial denture—resin base . . . . . . $ 325 .00+lab
D2951 Pin retention—per tooth, in addition D5213 Maxillary partial denture—cast metal
to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00 framework, resin denture bases . . . . . . . . . . . . . . $ 325 .00+lab
D2952 Cast post and core in addition to crown . . . . . . $ 100 .00+lab D5214 Mandibular partial denture—cast metal
D2953 Each additional cast post—same tooth . . . . . . $ 100 .00+lab framework, resin denture bases . . . . . . . . . . . . . . $ 325 .00+lab
D2954 Prefabricated post and core in addition to crown . $ 100 .00 D5410 Adjust complete denture—maxillary . . . . . . . . $ 20 .00
D2962 Labial veneer (porcelain D5411 Adjust complete denture—mandibular . . . . . . $ 20 .00
laminate)—laboratory . . . . . . . . . . . . . . . . . . . . . . $ 310 .00+lab D5421 Adjust partial denture—maxillary . . . . . . . . . . . $ 20 .00
D5422 Adjust partial denture—mandibular . . . . . . . . . $ 20 .00
Prosthodontics (fixed) Member pays
Repairs to prosthetics Member pays
D6210* Pontic—cast high noble metal . . . . . . . . . . . . . . . $310 .00
D6211 Pontic—cast predominantly base metal . . . . . $ 310 .00 D5510 Repair broken complete denture base . . . . . . . . $ 20 .00+lab
D6212* Pontic—cast noble metal . . . . . . . . . . . . . . . . . . . $ 310 .00 D5520 Replace missing or broken teeth—complete
D6240* Pontic—porcelain fused to high noble metal . $ 310 .00 denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00+lab
D6241 Pontic—porcelain fused to predominantly D5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . $ 20 .00+lab
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 310 .00 D5630 Repair or replace broken clasp . . . . . . . . . . . . . . . $ 20 .00+lab
D6242* Pontic—porcelain fused to noble metal . . . . . . $ 310 .00 D5640 Replace broken teeth—per tooth . . . . . . . . . . . . $ 20 .00+lab
D6750* Crown—porcelain fused to high noble metal . $ 310 .00 D5650 Add tooth to existing partial denture . . . . . . . . . $ 35 .00+lab
D6751 Crown—porcelain fused to predominantly D5730 Reline complete maxillary denture (chairside) . . $ 55 .00
base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 310 .00 D5731 Reline complete mandibular
D6752* Crown—porcelain fused to noble metal . . . . . . $ 310 .00 denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00
D6790* Crown—full cast high noble metal . . . . . . . . . . . $ 310 .00 D5740 Reline maxillary partial denture (chairside) . . . $ 55 .00
D6791 Crown—full cast predominantly base metal . $ 310 .00 D5741 Reline mandibular partial denture (chairside) . . $ 55 .00
D6792* Crown—full cast noble metal . . . . . . . . . . . . . . . . $ 310 .00 D5750 Reline complete maxillary denture (laboratory) . . $ 40 .00+lab
D6930 Recement fixed partial denture (per unit) . . . . . $ 15 .00 D5751 Reline complete mandibular
denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . $ 40 .00+lab
Endodontics Member pays D5760 Reline maxillary partial denture (laboratory) . . $ 40 .00+lab
D3220 Therapeutic pulpotomy . . . . . . . . . . . . . . . . . . . . . $ 40 .00 D5761 Reline mandibular partial denture (laboratory) . . $ 40 .00+lab
D3221 Pulpal debridement, primary and D5850 Tissue conditioning—maxillary . . . . . . . . . . . . . . $ 35 .00
permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 110 .00 D5851 Tissue conditioning—mandibular . . . . . . . . . . . . $ 35 .00
D3310 Root canal therapy—anterior Extractions/oral and maxillofacial surgery Member pays
(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 150 .00
D3320 Root canal therapy—bicuspid D7111 Coronal remnants, deciduous tooth . . . . . . . . . . $ 25 .00
(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 250 .00 D7140 Extraction, erupted tooth or exposed tooth . . $ 25 .00
D3330 Root canal therapy—molar D7210 Surgical removal of erupted tooth . . . . . . . . . . . . $ 45 .00
(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 300 .00 D7220 Removal of impacted tooth—soft tissue . . . . . $ 60 .00
D3410 Apicoectomy/periradicular surgery—anterior . . $ 150 .00 D7230 Removal of impacted tooth—partially bony . . $ 80 .00
D7240 Removal of impacted tooth—completely bony . . $ 100 .00
Periodontics (gum treatment) Member pays D7250 Surgical removal of residual tooth roots . . . . . . $ 45 .00
D4210 Gingivectomy/gingivoplasty per quadrant . . . $ 150 .00 D7310 Alveoloplasty in conjunction with
D4211 Gingivectomy/gingivoplasty per tooth . . . . . . . . $ 45 .00 extractions—per quadrant . . . . . . . . . . . . . . . . . . . $ 45 .00
D4260 Osseous surgery, per quadrant . . . . . . . . . . . . . . . $ 375 .00 D7311 Alveoplasty in conjunction with extractions—
D4261 Osseous surgery—1 to 3 teeth, per quadrant . $ 375 .00 one to three teeth or tooth spaces,
D4277 Free soft tissue graft procedure (including donor per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 45 .00
site surgery) - first tooth . . . . . . . . . . . . . . . . . . . . . $250 .00 D7320 Alveoloplasty not in conjunction with
D4278 Free soft tissue graft procedure (including donor extractions—per quadrant . . . . . . . . . . . . . . . . . . . $ 80 .00
site surgery), ea add’l . . . . . . . . . . . . . . . . . . . . . . . . $ 188 .00 D7321 Alveoplasty not in conjunction with
D4341 Periodontal scaling and root planing, extractions—one to three teeth or tooth
per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00 spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . $ 80 .00
D4342 Periodontal scaling and root planing D7510 Incision and drainage of abscess—intraoral . . $ 30 .00
1 to 3 teeth per quadrant . . . . . . . . . . . . . . . . . . . . $ 55 .00 Anesthesia Member pays
D4355 Full mouth debridement to enable
comprehensive evaluation and diagnosis . . . . $ 50 .00 D9215 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge
D9230 Analgesia (nitrous oxide), per 15 minutes . . . . $ 20 .00
GCA0AWGHH 4/13Adjunctive general services Member pays D8080 Comprehensive orthodontic treatment of the
D9450 Case presentation, detailed and extensive transitional/adolescent dentition; Children up
treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . no charge to 19 years of age; Up to 24 months of routine
D9951 Occlusal adjustment—limited . . . . . . . . . . . . . . . $ 30 .00 orthodontic treatment for Class I and
D9952 Occlusal adjustment—complete . . . . . . . . . . . . $ 175 .00 Class II cases
Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge
Orthodontics Member pays Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00
D8070 Comprehensive orthodontic treatment of the Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00
transitional/adolescent dentition; Children up Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,800 .00
to 19 years of age; Up to 24 months of routine D8090 Comprehensive orthodontic treatment of the
orthodontic treatment for Class I and adult dentition; Adult 19 years of age and over
Class II cases Up to 24 months of routine orthodontic
Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge treatment for Class I and Class II cases
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00 Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge
Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00
Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,800 .00 Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00
Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 2,000 .00
D8680 Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 450 .00
* The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal.
The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal.
Note:
• Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to
treatment for availabilty of services.
• Unlisted procedures are available at certain participating dentists usual fee less 25%. Visit HumanaDental.com to find
a participating dentist who offers the discount on non-covered services.
• When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional
$50 per unit.
• If you break your appointment with your dentist without 24-hour advance notice, you will be subject to your dentist’s
broken appointment fee.
• Additional exclusions and limitations are listed along with full plan information in your certificate of benefits.
Insured or administered by Humana Insurance Company, The Dental Concern, Inc., CompBenefits Dental, Inc.,
CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., or CompBenefits Insurance Company.
Humana.com
GCA0AWGHH 4/13Humana Dental DHMO Members
How to Select Your Primary Care Dentist (PCD)
2017
How to Search for a PCD
Visit www.humanadental.com
Click on Find a Dentist
Select the DHMO radio button and enter your zip code
Select HD DHMO/Prepaid CS250 Network
Set your search criteria
Search for a dentist
Select a dentist and locate the Dentist ID number
Select Show Info radio button to verify that the provider
is accepting new patients
How to Select Your PCD at the Time
of Enrollment (First‐Time Only)
Log on to the ICUBA Benefits Portal website
at http://icubabenefits.org
For the dental enrollment, select the DHMO HumanaDental
Prepaid radio button
On the Dental – Primary Care Provider screen, enter the six digit Dentist ID number
In the drop down box, select if you are a new or established patient
If You Have Previously Enrolled in the DHMO, you MUST Contact
Humana Directly to Select or to Change Your Primary Care Dentist
Contact customer support center at
1‐800‐979‐4760
Hours of Operation: Monday thru Friday 8 a.m.‐ 6 p.m. EST
Effective Date of Your Change –
Any changes done prior to the 15th of the month will be effective on the first day of the
next month. (i.e. a change on July 12 will be effective August 1)
Any changes made after the 15th of the month will become effective for the first day of
the second following month. (i.e. a change on July 16 will be effective September 1)Relationships are built on trust. Respect for an individual’s privacy goes a long way toward building trust.
Humana values our relationship with you, and we take your personal privacy seriously. Humana’s Notice
of Privacy Practices outlines how Humana may use or disclose your personal and health information. It
also tells how we protect this information. The notice provides an explanation of your rights concerning
your information, including how you can access this information and how to limit access to your
information. In addition, it provides instructions on how to file a privacy complaint with Humana or to
exercise any of your rights regarding your information.
If you’d like a copy of Humana’s Notice of Privacy Practices, you can request a copy by:
• Visiting Humana.com and clicking the Privacy Practices link at the bottom of the home page
• E-mailing us at privacyoffice@humana.com
• Sending a written request to:
Humana Privacy Office
P.O. Box 1438
Louisville, KY 40202You can also read
