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Dental Plan Comparison 2018-2019

State of Texas Dental Choice PlanSM State of Texas Dental
Preferred Provider Organization (PPO)
HumanaDental DHMO1 Discount Plan
Administered by HumanaDental Insurance Company
You must select a primary care Find a list of providers for State
dentist (PCD). of Texas Dental ChoiceSM or the
Dentists NOTE: Not all participating dentists In-network/ Out-of-network/ HumanaDental DHMO at
accept new patients. Dentists are participating dentist non-participating dentist2 https://our.humana.com/ers/
not required to stay on the plan for or by calling HumanaDental at
the entire year. (877) 377-0987, TTY: 711.
Preventive-Individual-$0; Family-$0. Preventive-Individual-$50; Family-$150. There are no claim forms,
Deductibles None Combined Basic/Major-Individual-$50; Combined Basic/Major-Individual-$100; copays, deductibles,
Family-$150. Family-$300. annual maximums or limits on
Orthodontic services - no deductible. Orthodontic services - no deductible. use.
Preventive and Diagnostic Services - You
Preventive and Diagnostic Services - pay 10% coinsurance after meeting the
You pay nothing. Preventive and Diagnostic deductible.
Primary dentist - Copays vary Basic Services - You pay 10% Basic Services - You pay 30%
according to service and are coinsurance after meeting the Basic coinsurance after meeting the Basic You receive discounted prices –
listed in the “Schedule of Dental Services deductible. Services deductible.
Copays/ Benefits booklet. Major Services - You pay 50% Major Services - You pay 60% 20% to 60%
off – on most dental treatments
coinsurance Specialty dentistry - You pay coinsurance after meeting the Major coinsurance after meeting the Major and services
75% of the dentist’s usual and Services deductible. Services deductible. at participating providers.
customary fee. DHMO pays You will not be charged for anything over You may be required to pay the
nothing1. the allowed amount. difference between the allowed amount
After you reach the Maximum Calendar and billed charges.
Year Benefit you pay 60% until January 13. After you reach the Maximum Calendar
Year Benefit you pay 100% until January 13.
Maximum
calendar year Unlimited $2,000 per covered individual. $2,000 per covered individual. Unlimited
(includes orthodontic extractions)
(includes orthodontic extractions)
benefit
Maximum Unlimited $2,000 per covered individual for $2,000 per covered individual for Unlimited
lifetime benefit orthodontic services. orthodontic services.
Vary according to service and
Average cost are listed in the “Schedule of You pay nothing. 10% of the allowed amount after 20% to 60% off – on most dental
of cleaning / Dental Benefits” booklet. Up to two cleaning/oral exams deductible is met. treatments and services at
Up to two cleaning/oral exams per
oral exams Up to two cleaning/oral exams per calendar year allowed. calendar year allowed. participating providers
per calendar year allowed.
Orthodontic services
performed by a general dentist
listed in the directory with an You pay 50% of the allowed amount. 20% to 60% off – on most dental
Orthodontic “0” treatment code – You pay 50% of the allowed amount. You may be required to pay the difference treatments and services at
participating providers.
child - $1,800, adult - $2,100.
coverage Orthodontic services between the allowed amount and billed Savings on cosmetic
performed by specialist – You charges. services!
pay 75% of his/her usual fee.
DHMO pays nothing.
NOTE: The comparison chart is a summary of the benefits offered by the two dental insurance plans. See plan booklet for actual coverage and
limitations. Prior to starting treatment, discuss with your dentist the treatment plan and all charges.
1This comparison chart reflects participant responsibility for services received from participating primary care dentists only. Services from participating
specialty dentists are 25% less than the dentist’s usual charge.
2In the State of Texas Dental Choice Plan PPO, deductibles and annual maximums are per calendar year. Non-participating dentists can bill you for charges
above the amount covered by your HumanaDental plan. To ensure you do not receive additional charges, visit a participating PPO network dentist.
3Services received from in-network dental providers after the maximum calendar year benefit is reached will be paid at 40% coins urance by the plan.
There is no coverage for out-of-network dental providers after the maximum calendar year benefit is reached.

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