Page 12 - Wesco Benefit Guide Effective 9-1-2020_Revised 9-28-2020

Dental Options:

Humana

Per Pay Period Weekly Rate Dependent Information
Employee Only $ 8.71
We offer our employees and eligible dependents dental cover-
Employee + Spouse $17.43
age. Children can join or remain on a parent’s dental plan until
Employee + Child(ren) $23.66 age 26. When a child turns 26, they will lose dental coverage
Employee + Family $32.67 on the last day of their birth month. This is an automated
process.

Amount You Pay — Traditional Plus
Type of Service
Non-Network Dentists are Reimbursed at Usual & Customary Rates

Preventive Services Covered at 100%; CYD Waived

Basic Services Covered at 80% after CYD
Major Services Covered at 50% after CYD

Annual Maximum $1,500
Annual Deductible (CYD) $50 Individual / $150 Family

Extended Annual Maximum
Covered at 30%
(Orthodontia Not Included)

Orthodontia (Child Only) Covered at 50% - CYD Waived Lifetime Maximum of 1,000

Type of Service Benefit Description

See Summary of Benefits and Policy for the age and frequency limitations of benefits.

Preventive Services Routine cleanings, exams, x-rays, oral cancer screenings. Fluoride,
sealants, space maintainers

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

Crowns, bridges, dentures, inlays, onlays, dentures repair and relines /
rebases.
Major Services Implants are

of

Annual Maximum Applies January to December
Orthodontia Children under age 19

NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.

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

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