Page 13 - IFC Roofing Benefit Guide Jan 1 to Dec 31 2021

Dental Option:

Humana

Dependent Information

For your Pre-Taxed costs per pay
We offer our employees and eligible dependents dental
period please see rates when you coverage. Children can join or remain on a parent’s dental
plan until age 26. When a child turns 26, they will lose
enroll online. dental coverage on the last day of their birth month. This
is an automated process.

Amount You Pay—Buy-Up
Type of Service
Non-Network Dentists Reimbursed at U&C

Preventive Services Covered at 100%; CYD Waived

Basic Services Covered at 80% after CYD

Major Services Covered at 50% after CYD

Annual Maximum UNLIMITED NO Maximum

Annual Deductible (CYD) $50 Individual / $150 Family

Orthodontia (Child Only) Covered at 50% - CYD Waived Lifetime Maximum of $2,000

No Waiting Period for Preventative and Basic Services. 12 Months for
Waiting Periods Orthodontics. Waiting Periods may decrease based on the number of
months or prior coverage.

Type of Service Benefit Description

Routine cleanings, exams, x-rays, oral cancer screenings. Fluoride, seal-
Preventive Services
ants, space maintainers, up to age 15

Amalgam fillings, extractions, oral surgery, endodontics (root canals),
Basic Services
periodontics, SS crowns

Crowns, bridges, dentures, inlays, onlays, dentures, implants (see limita-
Major Services
tions)
Annual Maximum Applies January 1 to December 31

Orthodontia Children under age 19

Website: www.humanadental.com or Customer Service: 800-233-4013
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