Page 10 - NTNSC_Benefit Guide 2021
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Dental Options:
Humana
2021 Rate - Per Pay Period
Per Pay Period Humana
Dependent Information
Employee Only $21.06 North Texas Neuroscience and Sleep Centers, P.A.
offers employees the opportunity to cover their
Employee + Spouse $42.13 spouse and dependent children. Children can join
or remain on a parent’s dental plan until age 26.
Employee + Child(ren) $56.60
When a child turns 26, they will lose dental coverage
Employee + Family $78.25 on the last day of their birth month.
Type of Service (In-Network) Amount Paid
Preventive Services Covered at 100%; No Deductible
Basic Services Covered at 80% after Calendar Year Deductible
Major Services Covered at 50% after Calendar Year Deductible
Calendar Year Deductible $50 Individual / $150 Family
Orthodontic Services –Child Only Covered at 50% - Lifetime maximum $1,000 (no deductible)
NON-Network Providers Reimbursed at 90% of R&C
Annual Maximum UNLIMITED
Type of Service Benefit Description
Preventive Services Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment
Basic Services Composite Fillings, Oral Surgery, Endodontics, Periodontics
Crowns, Bridges, Inlays/Onlays, Dentures & Implant Related Services
Major Services (crowns, bridges, and dentures Coverage limited to equivalent cost of
a non-implant service. Implant placement itself is not covered.)
Orthodontic Service Children under age 19
Annual Maximum Does not apply
Please note: This is intended for general information purposes.
It is not a guarantee of benefits. Please reference the Summary of Benefits or contact the carrier for specific details.
Website: www.humana.com Customer Service: 1-800-233-4013
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