Individual Dental Insurance

You can choose any dentist, but you can save up to 30% on out-of-pocket costs when you visit one of the more than 110,000 dentist locations in the PPO network. You can find a dentist by visiting Humana.com. This is not a complete disclosure of plan qualifications and limitations. Please review the specific Dental Limitations & Exclusions before applying for coverage.

Annual Maximum Benefit	$1000 per individual
Annual Deductible	$50 individual / $150 family

BENEFIT CATEGORY

NETWORK: Plan Pays

NON-NETWORK: Plan Pays

Preventive Care - No waiting period Oral Examinations • Routine Cleanings • X-Rays • Sealants • Topical Fluoride Treatment •	100% no deductible	100% no deductible
Basic Services - Six month waiting period applies Emergency Care for Pain Relief • Thumb Sucking and Harmful Habit Appliances • Space Maintainers • Amalgam, Composite Fillings (Front/Anterior Teeth Only) • Oral Surgery • Routine Extractions • Non-Cast Stainless Steel Crowns • Partial or Complete Denture Repairs/Adjustments •	50% after deductible	50% after deductible
Major Services - Twelve month waiting period applies Endodontics (Root Canals) • Periodontics • Crowns • Inlays and Onlays • Partial or Complete Dentures • Denture Relines/Rebases • Removable or Fixed Bridgework •	50% after deductible	50% after deductible
Teeth Whitening - Six month waiting period applies	$200 Lifetime Maximum Benefit
	50% after deductible	50% after deductible

Orthodontia

Orthodontia is not an insured expense eligible for reimbursement. However, members can receive up to 20% discount if they visit an orthodontist form the HumanaDental PPO Network and ask for the discount.

Dental Limitations and Exclusions

This is an outline of the limitations and exclusions for the HumanaOne Individual Dental Plan. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions.

Unless stated otherwise, no benefits are payable for expenses arising from:

The course of any occupation or employment for compensation, profit or gain, for which benefits are provided or payable under any Workers' Compensation or Occupational Disease Act or Law; or where such coverage was available, regardless of whether the coverage was actually applied for

Services and supplies for which no charge is made, or for which the covered person would not be required to pay in the absence of insurance

Services furnished by or payable under any plan or law through any Government or any political subdivision

Services furnished by any hospital or institution owned or operated by the United States Government, unless legally required to pay

War or any act of war, whether declared or not; or any act of international armed conflict or any conflict involving armed forces of any international authority

Completion of forms or failure to keep an appointment with a dentist

Cosmetic dentistry, except as stated in the policy

Any service related to altering vertical dimension; restoration or maintenance of occlusion; splinting teeth; replacing tooth structures lost as a result of abrasion, attrition or erosion; or bite registration or bite analysis

Bone grafts, regeneration, augmentation or 9. preservative procedures in edentulous sites

Implants, including any crowns or prosthetic device attached to it; precision or semi-precision attachments; overdentures and any endodontic treatment associated with it; or other customized attachments

10.

Infection control

11.

Fees for treatment by other than a dentist, except as stated in the policy

12.

Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist

13.

Prescription drugs or pre-medications, whether dispensed or prescribed

14.

Any service not listed as a covered expense

15.

Any service not considered a dental necessity, does not offer a favorable prognosis, does not have uniform professional endorsement, or is experimental or investigational in nature

16.

Expenses incurred prior to the effective date or after the date coverage is terminated, except for any extension of benefits

17.

Services provided by a person who ordinarily resides in the covered person's home or who is a family member

18.

Charges in excess of the reimbursement limit for the service or supply

19.

Treatment as a result of an intentionally self-inflicted injury or bodily illness, while sane or insane

20.

Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, temporary dental services, study models, treatment plans, occlusal adjustments, or tissue preparation associated with impression or placement of a restoration, charged as a separate service

21.

Repair and replacement of orthodontic appliances

22.

Insured by Humana Insurance Company or HumanaDental Insurance Company or The Dental Concern, Inc. Applications are subject to approval. Waiting periods, limitations and exclusions apply. The HumanaOne brand of individual products are insured by subsidiaries of Humana, Inc.

This document 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.