Page 10 - Tritrax 2023 Benefit Guide FINAL TEST

Dental Options:

Humana

2023 Rate Information
Dependent Information
Per Pay Period Bi-Weekly
TriTrax Rehabilitation offers employees the
Employee Only $19.56 opportunity to cover their spouse and

Employee + Spouse $39.13 dependent children. Children can join or re-
Employee + Child(ren) $54.42 main on a parent’s dental plan until age 26.
When a child turns 26, they will lose dental
Employee + Family $72.68 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 -
Covered at 50% - Lifetime Maximum of $1,000 (No Deductible)
Adults & Children under 19

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

Services Include: Fillings, Simple Extractions, Endodontics (including
Root Canal Treatment) Oral Surgery, 4 annual Periodontal Cleanings,
Basic Services
Non-surgical Periodontal Therapy-Scaling and Root Planning, Periodon-
tal Surgery
Crowns, Inlays, Onlays and most related services, Bridges, Full and
Major Services Partial Dentures, Denture Reline and Rebase Services, Implants and
related services

Orthodontia Applies only to adults and children under age 19

Please note: This summary 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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