Page 11 - UPDATED - 8-1-24 Heritage School Benefit Guide
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Dental Options:



          Humana




                      2024 Rate Information
          Per Monthly Pay Period                                        Dependent Information

                                                                        Heritage  School  of  Texas  offers
          Employee Only                             $  52.06            employees  the  opportunity  to  cover
          Employee + Spouse                         $104.13             their  spouse  and  dependent  children.
                                                                        Children  can  join  or  remain  on  a
          Employee + Child(ren)                     $139.01             parent’s  dental  plan  until  age  26.
                                                                        When  a  child  turns  26,  they  will  lose
          Employee + Family                         $192.33             dental coverage on the last day of their
                                                                        birth month.

                                                            Humana Dental Traditional Plus 14
         Type of Service
                                                    Non-Network Dentists - Reimbursed at 90th U&C

         Calendar Year Deductible                                 Individual $50 / Family $150

         Preventive Services                                    Covered at 100%; No Deductible

         Basic Services                                    Subject to $50 Deductible; Covered at 80%

         Major Services                                    Subject to $50 Deductible; Covered at 50%
         Annual Maximum                                                    UNLIMITED

                                              R&C Plan - pays 90% of the Usual and Customary charge for the  area
         Out of Network
                                                                  where services are provided.
         Orthodontia - Children under 19         Covered at 50% - Lifetime Maximum of $1,000 (No Deductible)
         only

         Type of Service                                             Benefit Description

                                            Routine Oral Examinations, Bitewing X-rays, 2 annual Routine cleanings,
         Preventive Services                Routine Cleanings, Fluoride Treatments Sealants to age 14. Oral Cancer
                                            Screening (1 per year, ages 40 and older)
                                            Services Include: Fillings, Simple Extractions, Endodontics (including Root
         Basic Services                     Canal  Treatment)  Oral  Surgery,  4  annual  Periodontal  Cleanings,  Non-
                                            surgical Periodontal Therapy-Scaling, Root Planning, Periodontal Surgery

                                            Crowns, Inlays, Onlays and most related services, Bridges, Full and Partial
                                            Dentures, Denture Reline and Rebase Services, Implant Related Services
         Major Services                     (crowns,  bridges,  and  dentures  each  limited  to  1  per  tooth  every  five
                                            years.  Implant  coverage  limited  to  equivalent  cost  of  a  non-implant
                                            service. Implant placement itself is not covered.)

         Orthodontia                        Applies only to children under age 19

                                   Please note:  This is intended for general information purposes.
                   It is not a guarantee of benefits.  Please reference the SBC or contact the carrier for specific details.

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