Page 13 - Megatel Homes LLC Benefit Guide Effective 8-1-2020_Revised 051221
P. 13
Dental Options:
Humana
Per Pay Period Buy-Up Base Dependent Information
Employee Only $16.35 $ 8.62
We offer our employees and eligible dependents dental cover-
Employee + Spouse $32.69 $17.23
age. Children can join or remain on a parent’s dental plan until
Employee + Child(ren) $46.14 $24.92 age 26. When a child turns 26, they will lose dental coverage
Employee + Family $63.44 $34.13 on the last day of their birth month. This is an automated
process.
Amount You Pay—Buy-Up Amount You Pay—Base
Type of Service Non-Network Dentists Non-Network Dentists
Reimbursed at U&C Reimbursed at Network Maximum
Preventive Services Covered at 100%; CYD Waived Covered at 100%; CYD Waived
Basic Services Covered at 80% after CYD Covered at 50% after CYD
Major Services Covered at 50% after CYD Covered at 50% after CYD
Annual Maximum UNLIMITED NO Annual Maximum $1,000
Annual Deductible (CYD) $50 Individual / $150 Family $50 Individual / $150 Family
Extended Annual Maximum Covered at 30% after CYD and after
UNLIMITED NO Annual Maximum
(Orthodontia Not Included) Annual Maximum is reached
Covered at 50% - CYD Waived Covered at 50% - CYD Waived
Orthodontia (Child Only)
Lifetime Maximum of 1,500 Lifetime Maximum of $1,000
Type of Service Benefit Description
See Summary of Benefits and Policy for the age and frequency limitations of benefits.
Routine cleanings, exams, x-rays, oral Routine cleanings, exams, x-rays, oral
Preventive Services cancer screenings. Fluoride, sealants, cancer screenings. Fluoride, sealants,
space maintainers space maintainers
Amalgam fillings, extractions, oral Amalgam fillings, extractions, oral
Basic Services surgery, endodontics (root canals), surgery, stainless steel crowns
periodontics, stainless steel crowns
Crowns, bridges, dentures, inlays, Crowns, Endodontics (root canals),
onlays, dentures repair and relines / periodontics, bridges, dentures, inlays,
rebases. Implants are onlays, denture repair and relines /
Major Services rebases. Implants are
of
of
Annual Maximum Applies January 1 to December 31 Applies January 1 to December 31
Orthodontia Children under age 19 Children under age 19
NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.
Website: www.humanadental.com or Customer Service: 800-233-4013
13
