Humana Dental PPO Standard

The Humana Dental PPO Standard Plan allows members to visit any licensed dentist, while generally offering the greatest cost savings when using an in-network dentist. In-network dentists have agreed to contracted fees and covered in-network services are provided based on the plan’s copayment schedule. Members may also use an out-of-network dentist; however, out-of-network costs are typically higher.

PPO Comparison Chart

Under this plan, in-network benefits are based on fixed copayments for covered services, as shown in the PPO Standard summary of benefits.

For out-of-network services, benefits are subject to the plan deductible and are paid as a percentage of the plan’s maximum allowable charge, referred to by Humana as in network fee schedule (INFS). Because out-of-network dentists do not have contracted fees with Humana, they may bill the member for charges above the amount covered by the plan.

The plan includes a $50 individual deductible and $150 family deductible. The deductible applies to all services except preventive services. The plan also includes a $1,000 annual maximum per member.

For out-of-network services, preventive services are covered at 90% after deductible, basic services are covered at 60% after deductible, and major services are covered at 30% after deductible, based on the plan’s allowable amount. Members should review the benefit schedule for covered services, copayments, frequency limits, limitations, exclusions, and other plan details.

To search for a participating provider:

Go to www.Humana.com/findadentist and search as a guest by entering the desired zip code

  • Under coverage type select PPO
  • Under Network Select: PPO/Traditional Preferred
  • Then you can search by the dentist’s name, specialty, or all. Verify the Dentist is accepting new patients and participating.

Summary of Benefits

** Non - PPO Network: Member pays balance in addition to the remaining balance of claim. Balance equals the difference between total claim and PPO fee.

If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern.

Plan Documents & Resources

Exclusions & Limitations

    In addition to the limitations and exclusions listed in Your plan benefits section, this policy does not provide benefits for the following:

    1. Any expenses arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which benefits are paid under any Workers’ Compensation or Occupational Disease Act or Law.
    2. Services:
    • That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law;
    • Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or
    • Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected with sickness or bodily injury.
    1. Any loss caused or contributed by:
    • War or any act of war, whether declared or not, excluding terrorism;
    • Any act of international armed conflict; or
    • Any conflict involving armed forces of any international authority.
    1. Any expense arising from the completion of forms.
    2. Your failure to keep an appointment with the dentist.
    3. Any service we consider cosmetic unless it is necessary as a result of an accidental injury sustained while you are covered under this policy. We consider the following cosmetic procedures to include, but are not limited to:
    • Facings on crowns or pontics (the portion of a fixed bridge between the abutments) posterior to the second bicuspid.
    • Any service to correct congenital malformation;
    • Any service performed primarily to improve appearance;
    • Characterizations and personalization of prosthetic devices; or
    • Any procedure to change the spacing and/or shape of the teeth.
    1. Charges for:
    • Any type of implant and all related services;
    • Precision or semi-precision attachments;
    • Overdentures and any endodontic treatment associated with overdentures;
    • Other customized attachments;
    • Any service for 3D imaging (cone beam images);
    • Temporary and interim dental services;
    • Additional charges related to material or equipment used in the delivery of dental care.
    • Charges rendered for treatment in a clinical or dental facility sponsored or maintained by the employer policyholder;
    • The removal of any implants unless specified in the Summary of Your Benefits section of this certificate.
    1. Any service related to:
    • Altering vertical dimension of teeth;
    • Restoration or maintenance of occlusion;
    • Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth;
    • Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction; or
    • Bite registration or bite analysis.
    1. Infection control, including but not limited to sterilization techniques.
    2. Fees for treatment performed by someone other than a dentist except for scaling and teeth cleaning, and the topical application of fluoride that can be performed by a licensed dental hygienist. The treatment must be rendered under the supervision and guidance of the dentist in accordance with generally accepted dental standards.
    3. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
    4. Prescription drugs or pre-medications, whether dispensed or prescribed.
    5. Any service not specifically listed in Your plan benefits.
    6. Any service that:
    • Is not eligible for benefits based upon clinical review;
    • Does not offer a favorable prognosis;
    • Does not have uniform professional acceptance; or
    • Is deemed to be experimental or investigational in nature.
    1. Orthodontic services unless specified in your Summary of your benefits. Only the services specified in the orthodontic rider will be covered orthodontic benefits under this plan.
    2. Any expense incurred before your effective date or after the date your coverage under this policy terminates (unless the service is eligible under Extension of benefits).
    3. Services provided by someone who ordinarily lives in your home or who is a family member.
    4. Charges exceeding the reimbursement limit for the service.
    5. Treatment resulting from any intentionally self-inflicted injury or bodily illness.
    6. Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, study models, treatment plans, occlusal adjustments, or tissue preparation associated with the impression or placement of a restoration when charged as a separate service. These services are considered an integral part of the entire dental service.
    7. Temporary dental services.
    8. Repair and replacement of orthodontic appliances.
    9. Any surgical or nonsurgical treatment for any jaw joint problems, including any temporomandibular joint disorder, craniomaxillary, craniomandibular disorder or other conditions of the joint linking the jaw bone and skull; or treatment of the facial muscles used in expression and chewing functions, for symptoms including, but not limited to, headaches.
    10. The oral surgery benefits under this plan does not include:
    11. Any services for orthognathic surgery;
    12. Any services for destruction of lesions by any method;
    13. Any services for tooth transplantation;
    14. Any services for removal of a foreign body from the oral tissue or bone;
    15. Any services for reconstruction of surgical, traumatic, or congenital defects of the facial bones;
    16. Any separate fees for pre and post-operative care.
    17. General anesthesia or conscious sedation is not a covered service unless it is based on clinical review of documentation provided and administered by a dentist or health care practitioner in conjunction with covered oral surgical procedures, periodontal and osseous surgical procedures, or periradicular surgical procedures for covered services.

    General anesthesia or conscious sedation administered due, but not limited to, the following reasons are not covered:

    1. Pain control unless a documented allergy to local anesthetic is provided.
    2. Anxiety.
    3. Fear of pain.
    4. Pain management.
    5. Emotional inability to undergo surgery.
    6. Preventive control programs including, but not limited to, oral hygiene instructions, plaque control, take-home items, prescriptions and dietary planning.
    7. Replacement of any lost, stolen, damaged, misplaced or duplicate major restoration, prosthesis or appliance.
    8. Any caries susceptibility testing, laboratory tests, saliva samples, anaerobic cultures, sensitivity testing or charges for oral pathology procedures.
    9. Separate fees for pre- and post-operative care and re-evaluation within 12 months are not considered covered services under the surgical periodontic services in this plan.
    10. We do not cover services that generally are considered to be medical services except those specifically noted as covered in this certificate.

    Missing tooth clause: See plan document for more details

    Insured by Humana Insurance Company.

    This is not a complete disclosure of plan qualifications and limitations. Your agents 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.

    Customer Service Hotline (prior to your effective date):

    1-855-811-0409
    Monday to Friday, 8 AM to 6 PM

    Member Services (after to your effective date):

    1-800-233-4013
    Monday to Friday, 8 AM to 6 PM

    Website:

    www.humana.com (prior to your effective date)
    www.myhumana.com (after your effective date)

    Service Hours (EST):

    M-F: 8:00am – 6:00pm