Page 15 - National Door_Benefit Guide 2024

Dental Option:

Humana Dental

2 Dental options both have NO Per Pay Period Buy-Up Base

Annual Maximum. UNLIMITED Employee Only $26.61 $16.98

Coverage for Preventative, Employee + Spouse $53.22 $33.95
Employee + Child(ren) $67.86 $43.29
Basic or Major Services!
Employee + Family $94.47 $60.26

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

Preventive Services Covered at 100%; CYD Waived Covered at 100%; CYD Waived

Basic Services Covered at 90% after CYD Covered at 80% after CYD
Major Services Covered at 60% after CYD Covered at 50% after CYD

Annual Maximum UNLIMITED NO Annual Maximum UNLIMITED NO Annual Maximum
Annual Deductible (CYD) $50 Individual / $150 Family $50 Individual / $150 Family

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, endodontics (root canals),
periodontics, stainless steel crowns periodontics, stainless steel crowns
Crowns, bridges, dentures, inlays, Crowns, bridges, dentures, inlays,
onlays, dentures repair and relines / onlays, denture repair and relines /
Major Services
rebases. Implants are rebases. Implants are

Members may receive a discount on Members may receive a discount on
Orthodontia Services
non-covered services of up to 20% non-covered services of up to 20%

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

Website: www.humanadental.com or Customer Service: 1-877-877-1051

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