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Health

State PPO

HMO

Life Insurance

Dental

Vision

Supplemental

   

Dental PPO Plan

With the PPO Dental plan, you may choose to receive care from any dentist; your cost is lower when you use network dentists. You generally have an annual deductible to meet before the plan starts paying benefits, and then you pay a percentage of the cost for the care you receive.

Use the chart below to see costs for basic services for the PPO dental plan. The rows show the monthly premium and the amount or percentage you pay for the common dental services listed. The columns list the costs by plan.

 

 

Humana
(CompBenefits)
Preferred Plus
4054
   
Monthly Premiums
        Employee Only
      Employee + Spouse
      Employee + Child(ren)
      Employee + Spouse + Child(ren)

$31.76
$58.76
$65.66
$95.32

  
 

      Calendar Year Deductible

Out-of-Network
Employee $50
Family $100

 

      Calendar Year Maximum

$1,200/person

    In Network Out-of-Network
ADA Code Exams You Pay You Pay

D0120

      Periodic Checkup

$01

20%1

D0140

      Limited

$01

20%1

D0150

      Comprehensive Initial

$0

20%

  X-Rays

 

 

D0230

      Additional Intraoral

$0

20%

D0272

      2 Bite Wings

$0

20%

D0330

      Panoramic

$0

20%

  Preventive Services

 

 

D1110

      Prophy (adult cleaning)

$01

20%1

D1120

      Prophy (child cleaning)

$01

20%1

D1203

      Fluoride, child

$02

20%2

D1351

      Sealant

$02

20%2

  Silver Fillings

 

 

D2140

      Amalgam, 1 surface

20%

50%

D2150

      Amalgam, 2 surfaces

20%

50%

  White Fillings, Front Teeth

 

 

D2330

      Anterior Composite, 1 surface

20%

50%

D2331

      Anterior Composite, 2 surfaces

20%

50%

  White Fillings, Back Teeth

 

 

D2391

      Posterior Composite, 1 surface

20%

50%

D2392

      Posterior Composite, 2 surfaces

20%

50%

  Onlays and Crowns

 

 

D2740

      Crown, All Porcelain

50%

70%

D2750

      Crown, Porcelain fused to High Noble

50%

70%

D2950

      Core Build Up

50%

70%

  Periodontal Care (for gums)

 

 

D4341

      Periodontal Therapy, 4+ teeth/quadrant

20%

50%

D4910

      Periodontal Maintenance

20%

50%

  Extractions

 

 

D7140

      Extraction, Erupted Tooth or Exposed Root

20%

50%

D7210

      Extraction, Surgical

20%

50%

  Orthodontia Care6

 

 

D8080

Comprehensive orthodontic treatment of adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances)

50%; $1,500 lifetime max benefit

Not Covered

D8090

Comprehensive orthodontic treatment of adult dentition (full treatment case up to 24 months - including fixed/removable appliances)

50%; $1,500 lifetime max benefit

Not Covered

None

Bracketing (for above procedures D8080 or D8090)

Included

Not Covered

D8660

Pre-orthodontic treatment visit (consult/records/exam)

50%; $1,500 lifetime max benefit

Not Covered

D8680

Orthodontic retention (removal of applicances, construction and placement of retainer(s))

50%; $1,500 lifetime max benefit

Not Covered

D8999

Unspecified Orthodontic Procedure - By Report (Orthodontic Treatment Plan and Records)

Included

Not Covered

1Limited to once every six months
2Only for children under age 16
3Only for children under age 14
4Only for children under age 13
5Services require separate payment for laboratory charges
6Copays do not include pre-exam and retention
775% during first year; 50% for 2nd and subsequent years of continuous coverage
8Plan payments for covered preventive procedures are not deducted from your annual maximum benefit.
9Copayment for General Dentist or Specialist is the same