Page 14 - Benefit Guide_SIPS_2020_Revised 2-12-21

Dental Options:

Humana Dental

2020 Rate Information

Per Pay Period Base Plan Base Plan Buy-Up Plan Buy-Up Plan Dependent Information
SIPS Consults, Corp offers
Bi-Weekly Weekly Bi-Weekly Weekly employees the opportunity to
cover their spouse and
Employee Only $14.43 $7.21 $17.60 $8.80
dependent children. Children
Employee + Spouse $28.86 $14.43 $35.20 $17.60 can join or remain on a parent’s
dental plan until age 26. When
Employee + Child(ren) $40.45 $20.23 $48.53 $24.27 a child turns 26, they will lose
dental coverage on the last day
Employee + Family $55.91 $27.95 $67.15 $33.57

Base Plan-Amount You Pay Buy-UP Plan-Amount You Pay
Type of Service Non-Network Dentists Non-Network Dentists
Reimbursed at Network Allowable Reimbursed at 90th U&C

Calendar Year Deductible (CYD) Individual: $50 / Family: $150 Individual: $50 / Family: $150

Preventive Services Covered at 100%; Deductible Waived Covered at 100%; Deductible Waived
Basic Services Covered at 100% after Deductible Covered at 80% after Deductible

Major Services Covered at 60% after Deductible Covered at 50% after Deductible

Orthodontia - Children and Adults Covered at 50% Deductible Waived Covered at 50% Deductible Waived
Annual Maximum (Calendar Year) $1,500 Unlimited

Extended Annual Maximum Covered at 30% after Deductible N/A

Orthodontia Maximum (Lifetime) $1,500 $1,500

MAC Plan - Maximum allowable R&C Plan - pays 90% of the Usual and
charge only covers “in-network”
Out of Network Customary charge for the area
allowable amount. You will be where services are provided.
balanced billed for difference.

Type of Service Benefit Description

Routine Oral Examinations, X-rays, Complete full-mouth or panoramic
Preventive Services X-rays, Routine Cleanings, Fluoride Treatments Sealants, Palliative
Treatment
Services Include: Fillings, Simple Extractions, Endodontics (including
Root Canal Treatment) Oral Surgery, General Anesthesia, Periodontal
Basic Services Maintenance procedures following active periodontal therapy, Non-
surgical Periodontal Therapy-Scaling and Root Planning, Periodontal
Surgery

Surgical Extractions, Bridges, Full and Partial Dentures, Denture Reline
Major Services and Rebase Services, Crowns, Inlays, Onlays and most related services,
Implants and related services
Orthodontia Applies to Adults and Children

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