Additional Plan Information For Humana Complete Insurance Plan

Annual Maximum

This is the maximum amount that the plan will pay in a calendar year

• $1,250 Year One, per individual on the plan
• $1,500 Year Two and after, per individual on the plan

Calendar Year Deductible

This is the amount you will pay out-of-pocket for services in a calendar year

• Individual - $50 (deductible waived for in-network preventive services)
• Family $150 (deductible waived for in-network preventive services)

Out of Network Coverage

Out-of-network dentists can bill you for charges above the amount covered by your Humana Dental plan. To ensure you do not receive additional charges, visit a dentist in the Humana Dental PPO Network. Waiting periods and other limitations may apply; please see your policy for coverage details.

Humana individual dental plans are insured or offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, The Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Benefit Plan of Louisiana, Inc., or DentiCare, Inc. (DBA CompBenefits). Discount plans are offered by HumanaDental Insurance Company, Humana Insurance Company, or Texas Dental Plans, Inc. Arizona residents insured by Humana Insurance Company. Texas residents insured or offered by Humana Insurance Company, HumanaDental Insurance Company, or DentiCare, Inc. (DBA CompBenefits).

Premium includes a $1 administrative fee. Association membership and fees may be required in some states. A $35 one-time, non-refundable enrollment fee applies (The fee is non-refundable as allowed by state requirements).

Dental and vision plans, excluding Dental Savings Plus, may have a minimum one-year initial contract period.

Waiting periods may apply; limitations and exclusions apply.

This site contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, the terms and conditions of the policy will govern. For more information, contact your sales agent

This is an outline of the limitations and exclusions for this Humana individual dental plan. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions. Unless specifically stated otherwise, no benefits will be provided for, or on account of, the following items:

1. Any expenses incurred while a covered person qualifies for any Worker’s Compensation or occupational disease act or law, whether or not the covered person applied for coverage.
2. Services: a. That are free or that a covered person would not be required to pay for if they did not have this insurance, unless charges are received from and reimbursable to the United States government or any of its agencies as required by law; b. Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or c. Furnished by any United States government-owned or operated hospital/institution/agency.
3. Any loss caused or contributed by: a. War or any act of war, whether declared or not (excluding acts of terrorism); b. Taking part in a riot; c. Commission of or an attempt to commit a criminal act; d. Engaging in an illegal profession or occupation; e. Any act of armed conflict; or f. Any conflict involving armed forces of any authority.
4. Any expense arising from the completion of forms.
5. Failure to keep an appointment with the provider.
6. Services we consider cosmetic dentistry unless it is required as a result of an accidental injury sustained while the covered person is covered under the policy.
7. Charges for: a. Any type of implant and all related services, including crowns or the prosthetic device attached to it; b. Precision or semi-precision attachments; c. Overdentures and any endodontic treatment associated with overdentures; d. Other customized attachments; e. 3D imaging; f. Temporary and interim dental services; g. Separate charges for materials or use of equipment, such as lasers; or h. Separate charges for treatment rendered in a clinic, dental or medical facility owned, operated, sponsored or maintained by either (i) the employer or any covered person; or (ii) by an employee of any covered person.
8. Any service related to: a. Altering vertical dimension of teeth; b. Restoration or maintenance of occlusion; c. Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth; d. Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction; or e. Bite registration or bite analysis.
9. Infection control, including but not limited to sterilization techniques.
10. 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.
11. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
12. Prescription drugs or pre-medications, whether dispensed or prescribed.
13. Services not specifically listed in the “Schedule of Policy Benefits” section.
14. Services shown as “Not Covered” in the “Schedule of Policy Benefits” section.
15. Services that we determine: a. Are not eligible for benefits based upon clinical review; b. Do not offer a favorable prognosis; c. Do not have uniform professional acceptance; or d. Are deemed to be experimental or investigational in nature.
16. Orthodontic services.
17. Any expense incurred before the covered person’s effective date or after the date the covered person’s coverage under this policy terminates.
18. Services provided by someone who ordinarily lives in the covered person’s home or is a family member.
19. Charges exceeding the reimbursement limit for the service.
20. Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, temporary dental services, study models, treatment plans 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.
21. Repair or replacement of orthodontic appliances.
22. 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 expressions and chewing functions, for symptoms including, but not limited to headaches.
23. Elective removal of non-pathologic impacted teeth.
24. Service for orthognathic surgery.
25. Services generally considered medical or covered by a medical plan.
26. Services for destruction of lesions by any method.
27. Services for tooth transplantation.
28. Services for removal of a foreign body from the oral tissue or bone.
29. Services for reconstruction of surgical, traumatic or congenital defects of the facial bones unless dental related.
30. Any separate fees for pre and post-operative care.
31. Replacement of restorations (fillings) placed less than two years ago.
32. We will not cover the replacement of any lost, stolen, damaged, misplaced or duplicate major restoration, prosthesis or appliance.