Specialty Benefit Forms for Dental and Vision Plans

Advantage Plus Dental

DHMO/Prepaid Dental

Vision care

Exam Plus

Advantage Plus Dental by state

Some states may be limited in plan availability by county.

DHMO/Prepaid Dental by state

Some states may be limited in plan availability by county.

Arizona

EDS Prepaid 100N Plan – English, PDF opens new window
EDS Prepaid 100N Plan – Spanish , PDF opens new window

EDS Prepaid 700N Plan – English, PDF opens new window
EDS Prepaid 700N Plan – Spanish , PDF opens new window

California

LS100 Plan – English, PDF opens new window
LS100 Plan – Spanish, PDF opens new window

LS200 Plan – English, PDF opens new window
LS200 Plan – Spanish, PDF opens new window

LS300 Plan – English, PDF opens new window
LS300 Plan – Spanish, PDF opens new window

Colorado

Beta Health Alpha Plan – English, PDF opens new window
Beta Health Alpha Plan – Spanish, PDF opens new window

Delaware

Dominion National Select Plan 703 – English, PDF opens new window
Dominion National Select Plan 703 – Spanish, PDF opens new window

Dominion National Select Plan 705 – English, PDF opens new window
Dominion National Select Plan 705 – Spanish, PDF opens new window

Dominion National Select Plan 707 – English, PDF opens new window
Dominion National Select Plan 707 – Spanish, PDF opens new window

Dominion National Select Plan 703x – English, PDF opens new window
Dominion National Select Plan 703x – Spanish, PDF opens new window

Dominion National Select Plan 705x – English, PDF opens new window
Dominion National Select Plan 705x – Spanish, PDF opens new window

Dominion National Select Plan 705x Preventive Rewards Mid-Atlantic (MA) – English, PDF opens new window
Dominion National Select Plan 705x Preventive Rewards Mid-Atlantic (MA) – Spanish, PDF opens new window

Dominion National Select Plan 707x – English, PDF opens new window
Dominion National Select Plan 707x – Spanish, PDF opens new window

Dominion National Select Plan 703s – English, PDF opens new window
Dominion National Select Plan 703s – Spanish, PDF opens new window

Dominion National Select Plan 705s – English, PDF opens new window
Dominion National Select Plan 705s – Spanish, PDF opens new window

Dominion National Select Plan 707s – English, PDF opens new window
Dominion National Select Plan 707s – Spanish, PDF opens new window

Dominion National Select Plan 703xs – English, PDF opens new window
Dominion National Select Plan 703xs – Spanish, PDF opens new window

Dominion National Select Plan 705xs – English, PDF opens new window
Dominion National Select Plan 705xs – Spanish, PDF opens new window

Dominion National Select Plan 707xs – English, PDF opens new window
Dominion National Select Plan 707xs – Spanish, PDF opens new window

District of Columbia, Maryland, Pennsylvania, Virginia

Dominion National Select Plan 703 – English, PDF opens new window
Dominion National Select Plan 703 – Spanish, PDF opens new window

Dominion National Select Plan 705 – English, PDF opens new window
Dominion National Select Plan 705 – Spanish, PDF opens new window

Dominion National Select Plan 707 – English, PDF opens new window
Dominion National Select Plan 707 – Spanish, PDF opens new window

Dominion National Select Plan 703x – English, PDF opens new window
Dominion National Select Plan 703x – Spanish, PDF opens new window

Dominion National Select Plan 705x – English, PDF opens new window
Dominion National Select Plan 705x – Spanish, PDF opens new window

Dominion National Select Plan 707x – English, PDF opens new window
Dominion National Select Plan 707x – Spanish, PDF opens new window

Dominion National Select Plan 703s – English, PDF opens new window
Dominion National Select Plan 703s – Spanish, PDF opens new window

Dominion National Select Plan 705s – English, PDF opens new window
Dominion National Select Plan 705s – Spanish, PDF opens new window

Dominion National Select Plan 707s – English, PDF opens new window
Dominion National Select Plan 707s – Spanish, PDF opens new window

Dominion National Select Plan 703xs – English, PDF opens new window
DominionNational Select Plan 703xs – Spanish, PDF opens new window

Dominion National Select Plan 705xs – English, PDF opens new window
Dominion National Select Plan 705xs – Spanish, PDF opens new window

Dominion National Select Plan 707xs – English, PDF opens new window
Dominion National Select Plan 707xs – Spanish, PDF opens new window

Florida

Prepaid 150 C Plan – English, PDF opens new window
Prepaid 150 C Plan – Spanish, PDF opens new window

Prepaid 150 C Plan with Ortho – English, PDF opens new window
Prepaid 150 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 250 C Plan – English, PDF opens new window
Prepaid 250 C Plan – Spanish, PDF opens new window

Prepaid 250 C Plan with Ortho – English, PDF opens new window
Prepaid 250 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 350 C Plan – English, PDF opens new window
Prepaid 350 C Plan – Spanish, PDF opens new window

Prepaid 350 C Plan with Ortho – English, PDF opens new window
Prepaid 350 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 450 C Plan – English, PDF opens new window
Prepaid 450 C Plan – Spanish, PDF opens new window

Prepaid 450 C Plan with Ortho – English, PDF opens new window
Prepaid 450 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 150 CS Plan – English, PDF opens new window
Prepaid 150 CS Plan – Spanish, PDF opens new window

Prepaid 250 CS Plan – English, PDF opens new window
Prepaid 250 CS Plan – Spanish, PDF opens new window

Prepaid 350 CS Plan – English, PDF opens new window
Prepaid 350 CS Plan – Spanish, PDF opens new window

Prepaid 450 CS Plan – English, PDF opens new window
Prepaid 450 CS Plan – Spanish, PDF opens new window

Prepaid HD205 Plan – English, PDF opens new window
Prepaid HD205 Plan – Spanish, PDF opens new window

Prepaid HD205 Plan with Ortho – English, PDF opens new window
Prepaid HD205 Plan with Ortho – Spanish, PDF opens new window

Prepaid HS205 Plan – English, PDF opens new window
Prepaid HS205 Plan – Spanish, PDF opens new window

Prepaid HS205 Plan with Implants – English, PDF opens new window
Prepaid HS205 Plan with Implants – Spanish, PDF opens new window

Prepaid HD210 Plan – English, PDF opens new window
Prepaid HD210 Plan – Spanish, PDF opens new window

Prepaid HD210 Plan with Ortho – English, PDF opens new window
Prepaid HD210 Plan with Ortho – Spanish, PDF opens new window

Prepaid HS210 Plan – English, PDF opens new window
Prepaid HS210 Plan – Spanish, PDF opens new window

Prepaid HS210 Plan with Implants – English, PDF opens new window
Prepaid HS210 Plan with Implants – Spanish, PDF opens new window

Prepaid HD215 Plan – English, PDF opens new window
Prepaid HD215 Plan – Spanish, PDF opens new window

Prepaid HD215 Plan with Ortho – English, PDF opens new window
Prepaid HD215 Plan with Ortho – Spanish, PDF opens new window

Prepaid HS215 Plan – English, PDF opens new window
Prepaid HS215 Plan – Spanish, PDF opens new window

Prepaid HD190 Plan – English

Prepaid HD190 Plan – Spanish, PDF opens new window

Prepaid HD190 Plan with Ortho – English, PDF opens new window
Prepaid HD190 Plan with Ortho – Spanish, PDF opens new window

Prepaid HS190 Plan – English, PDF opens new window
Prepaid HS190 Plan – Spanish, PDF opens new window

Prepaid HS190 Plan with Implants – English, PDF opens new window
Prepaid HS190 Plan with Implants – Spanish, PDF opens new window

Prepaid HS195 Plan – English, PDF opens new window
Prepaid HS195 Plan – Spanish, PDF opens new window

Prepaid HS195 Plan with Implants – English, PDF opens new window
Prepaid HS195 Plan with Implants – Spanish, PDF opens new window

Prepaid Open Access – English, PDF opens new window
Prepaid Open Access – Spanish, PDF opens new window

Prepaid Open Access with Implants – English, PDF opens new window
Prepaid Open Access with Implants – Spanish , PDF opens new window

Georgia

DHMO HD205 Plan – English, PDF opens new window
DHMO HD205 Plan – Spanish, PDF opens new window

DHMO HD205 Plan with Ortho – English, PDF opens new window
DHMO HD205 Plan with Ortho – Spanish, PDF opens new window

DHMO HS205 Plan – English, PDF opens new window
DHMO HS205 Plan – Spanish, PDF opens new window

DHMO HS205 Plan with Implants – English, PDF opens new window
DHMO HS205 Plan with Implants – Spanish, PDF opens new window

DHMO HD210 Plan – English, PDF opens new window
DHMO HD210 Plan – Spanish, PDF opens new window

DHMO HD210 Plan with Ortho – English, PDF opens new window
DHMO HD210 Plan with Ortho – Spanish, PDF opens new window

DHMO HS210 Plan – English, PDF opens new window
DHMO HS210 Plan – Spanish, PDF opens new window

DHMO HS210 Plan with Implants – English, PDF opens new window
DHMO HS210 Plan with Implants – Spanish, PDF opens new window

DHMO HD215 Plan – English, PDF opens new window
DHMO HD215 Plan – Spanish, PDF opens new window

DHMO HD215 Plan with Ortho – English, PDF opens new window
DHMO HD215 Plan with Ortho – Spanish, PDF opens new window

DHMO HS215 Plan – English, PDF opens new window
DHMO HS215 Plan – Spanish, PDF opens new window

DHMO HS2195 Plan – English, PDF opens new window
DHMO HS195 Plan – Spanish, PDF opens new window

DHMO HS2195 Plan with Implants – English, PDF opens new window
DHMO HS195 Plan with Implants – Spanish, PDF opens new window

Illinois, Indiana, Missouri, Tennessee

Prepaid 150 C Plan – English, PDF opens new window
Prepaid 150 C Plan – Spanish, PDF opens new window

Prepaid 150 C Plan with Ortho – English, PDF opens new window
Prepaid 150 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 250 C Plan – English, PDF opens new window
Prepaid 250 C Plan – Spanish, PDF opens new window

Prepaid 250 C Plan with Ortho – English, PDF opens new window
Prepaid 250 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 350 C Plan – English, PDF opens new window
Prepaid 350 C Plan – Spanish, PDF opens new window

Prepaid 350 C Plan with Ortho – English, PDF opens new window
Prepaid 350 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 450 C Plan – English, PDF opens new window
Prepaid 450 C Plan – Spanish, PDF opens new window

Prepaid 450 C Plan with Ortho – English, PDF opens new window
Prepaid 450 C Plan with Ortho – Spanish, PDF opens new window

Prepaid 150 CS Plan – English, PDF opens new window
Prepaid 150 CS Plan – Spanish, PDF opens new window

Prepaid 250 CS Plan – English, PDF opens new window
Prepaid 250 CS Plan – Spanish, PDF opens new window

Prepaid 350 CS Plan – English, PDF opens new window
Prepaid 350 CS Plan – Spanish, PDF opens new window

Prepaid 450 CS Plan – English, PDF opens new window
Prepaid 450 CS Plan – Spanish, PDF opens new window

DHMO HD205 Plan – English, PDF opens new window
DHMO HD205 Plan – Spanish, PDF opens new window

DHMO HD205 Plan with Ortho – English, PDF opens new window
DHMO HD205 Plan with Ortho – Spanish, PDF opens new window

DHMO HS205 Plan – English, PDF opens new window
DHMO HS205 Plan – Spanish, PDF opens new window

DHMO HS205 Plan with Implants – English, PDF opens new window
DHMO HS205 Plan with Implants – Spanish, PDF opens new window

DHMO HD 210 Plan – English, PDF opens new window
DHMO HD 210 Plan – Spanish, PDF opens new window

DHMO HD 210 Plan with Ortho – English, PDF opens new window
DHMO HD 210 Plan with Ortho – Spanish, PDF opens new window

DHMO HS 210 Plan – English, PDF opens new window
DHMO HS 210 Plan – Spanish, PDF opens new window

DHMO HS 210 Plan with Implants – English, PDF opens new window
DHMO HS 210 Plan with Implants – Spanish, PDF opens new window

DHMO HD 215 Plan – English, PDF opens new window
DHMO HD 215 Plan – Spanish, PDF opens new window

DHMO HD 215 Plan with Ortho – English, PDF opens new window
DHMO HD 215 Plan with Ortho – Spanish, PDF opens new window

DHMO HS 215 Plan – English, PDF opens new window
DHMO HS 215 Plan – Spanish, PDF opens new window

Indiana, Mississippi, Missouri, Tennessee

DHMO 150 C Plan – English, PDF opens new window
DHMO 150 C Plan – Spanish, PDF opens new window

DHMO 150 C Plan with Ortho – English, PDF opens new window
DHMO 150 C Plan with Ortho – Spanish, PDF opens new window

DHMO 250 C Plan – English, PDF opens new window
DHMO 250 C Plan – Spanish, PDF opens new window

DHMO 250 C Plan with Ortho – English, PDF opens new window
DHMO 250 C Plan with Ortho – Spanish, PDF opens new window

DHMO 350 C Plan – English, PDF opens new window
DHMO 350 C Plan – Spanish, PDF opens new window

DHMO 350 C Plan with Ortho – English, PDF opens new window
DHMO 350 C Plan with Ortho – Spanish, PDF opens new window

DHMO 450 C Plan – English, PDF opens new window
DHMO 450 C Plan – Spanish, PDF opens new window

DHMO 450 C Plan with Ortho – English, PDF opens new window
DHMO 450 C Plan with Ortho – Spanish, PDF opens new window

DHMO 150 CS Plan – English, PDF opens new window
DHMO 150 CS Plan – Spanish, PDF opens new window

DHMO 250 CS Plan – English, PDF opens new window
DHMO 250 CS Plan – Spanish, PDF opens new window

DHMO 350 CS Plan – English, PDF opens new window
DHMO 350 CS Plan – Spanish, PDF opens new window

DHMO 450 CS Plan – English, PDF opens new window
DHMO 450 CS Plan – Spanish, PDF opens new window

Kansas, Kentucky

DHMO 150 C Plan – English, PDF opens new window
DHMO 150 C Plan – Spanish, PDF opens new window

DHMO 150 C Plan with Ortho – English, PDF opens new window
DHMO 150 C Plan with Ortho – Spanish, PDF opens new window

DHMO 250 C Plan – English, PDF opens new window
DHMO 250 C Plan – Spanish, PDF opens new window

DHMO 250 C Plan with Ortho – English, PDF opens new window
DHMO 250 C Plan with Ortho – Spanish, PDF opens new window

DHMO 350 C Plan – English, PDF opens new window
DHMO 350 C Plan – Spanish, PDF opens new window

DHMO 350 C Plan with Ortho – English, PDF opens new window
DHMO 350 C Plan with Ortho – Spanish, PDF opens new window

DHMO 450 C Plan – English, PDF opens new window
DHMO 450 C Plan – Spanish, PDF opens new window

DHMO 450 C Plan with Ortho – English, PDF opens new window
DHMO 450 C Plan with Ortho – Spanish, PDF opens new window

DHMO 150 CS Plan – English, PDF opens new window
DHMO 150 CS Plan – Spanish, PDF opens new window

DHMO 250 CS Plan – English, PDF opens new window
DHMO 250 CS Plan – Spanish, PDF opens new window

DHMO 350 CS Plan – English, PDF opens new window
DHMO 350 CS Plan – Spanish, PDF opens new window

DHMO 450 CS Plan – English, PDF opens new window
DHMO 450 CS Plan – Spanish, PDF opens new window

DHMO HD205 Plan – English, PDF opens new window
DHMO HD205 Plan – Spanish, PDF opens new window

DHMO HD205 Plan with Ortho – English, PDF opens new window
DHMO HD205 Plan with Ortho – Spanish, PDF opens new window

DHMO HS205 Plan – English, PDF opens new window
DHMO HS205 Plan – Spanish, PDF opens new window

DHMO HS205 Plan with Implants – English, PDF opens new window
DHMO HS205 Plan with Implants – Spanish, PDF opens new window

DHMO HD210 Plan – English, PDF opens new window
DHMO HD210 Plan – Spanish, PDF opens new window

DHMO HD210 Plan with Ortho – English, PDF opens new window
DHMO HD210 Plan with Ortho – Spanish, PDF opens new window

DHMO HS210 Plan – English, PDF opens new window
DHMO HS210 Plan – Spanish, PDF opens new window

DHMO HS210 Plan with Implants – English, PDF opens new window
DHMO HS210 Plan with Implants – Spanish, PDF opens new window

DHMO HD215 Plan – English, PDF opens new window
DHMO HD215 Plan – Spanish, PDF opens new window

DHMO HD215 Plan with Ortho – English, PDF opens new window
DHMO HD215 Plan with Ortho – Spanish, PDF opens new window

DHMO HS215 Plan – English, PDF opens new window
DHMO HS215 Plan – Spanish, PDF opens new window

New Jersey

Dominion Select Plan 703x – English, PDF opens new window
Dominion Select Plan 703x – Spanish, PDF opens new window

Dominion Select Plan 705x – English, PDF opens new window
Dominion Select Plan 705x – Spanish, PDF opens new window

Dominion Select Plan 707x – English, PDF opens new window
Dominion Select Plan 707x – Spanish, PDF opens new window

Dominion Select Plan 705x Preventive Rewards – English, PDF opens new window
Dominion Select Plan 705x Preventive Rewards – Spanish, PDF opens new window

Texas

DHMO 150 C Plan – English, PDF opens new window
DHMO 150 C Plan, no ortho – Spanish, PDF opens new window

DHMO 150 C Plan with Ortho – English, PDF opens new window
DHMO 150 C Plan with Ortho – Spanish, PDF opens new window

DHMO 250 C Plan – English, PDF opens new window
DHMO 250 C Plan – Spanish, PDF opens new window

DHMO 250 C Plan with Ortho – English, PDF opens new window
DHMO 250 C Plan with Ortho – Spanish, PDF opens new window

DHMO 350 C Plan – English, PDF opens new window
DHMO 350 C Plan – Spanish, PDF opens new window

DHMO 350 C Plan with Ortho – English, PDF opens new window
DHMO 350 C Plan with Ortho – Spanish, PDF opens new window

DHMO 450 C Plan – English, PDF opens new window
DHMO 450 C Plan – Spanish, PDF opens new window

DHMO 450 C Plan with Ortho – English, PDF opens new window
DHMO 450 C Plan with Ortho – Spanish, PDF opens new window

DHMO 150 CS Plan – English, PDF opens new window
DHMO 150 CS Plan – Spanish, PDF opens new window

DHMO 250 CS Plan – English, PDF opens new window
DHMO 250 CS Plan – Spanish, PDF opens new window

DHMO 350 CS Plan – English, PDF opens new window
DHMO 350 CS Plan – Spanish, PDF opens new window

DHMO 450 CS Plan – English, PDF opens new window
DHMO 450 CS Plan – Spanish, PDF opens new window

DHMO 600 CS Plan – English, PDF opens new window
DHMO 600 CS Plan – Spanish, PDF opens new window

DHMO HD205 Plan – English, PDF opens new window
DHMO HD205 Plan- Spanish, PDF opens new window

DHMO HD205 with Ortho – English, PDF opens new window
DHMO HD205 with Ortho – Spanish, PDF opens new window

DHMO HS205 Plan – English, PDF opens new window
DHMO HS205 Plan – Spanish, PDF opens new window

DHMO HS205 Plan with Implants – English, PDF opens new window
DHMO HS205 Plan with Implants – Spanish, PDF opens new window

DHMO HD210 Plan – English, PDF opens new window
DHMO HD210 Plan – Spanish, PDF opens new window

DHMO HD210 Plan with Ortho – English, PDF opens new window
DHMO HD210 Plan with Ortho – Spanish, PDF opens new window

DHMO HS210 Plan – English, PDF opens new window
DHMO HS210 Plan – Spanish, PDF opens new window

DHMO HS210 Plan with Implants – English, PDF opens new window
DHMO HS210 Plan with Implants – Spanish, PDF opens new window

DHMO HD215 Plan – English, PDF opens new window
DHMO HD215 Plan – Spanish, PDF opens new window

DHMO HD215 Plan with Ortho – English, PDF opens new window
DHMO HD215 Plan with Ortho – Spanish, PDF opens new window

DHMO HS215 Plan – English, PDF opens new window
DHMO HS215 Plan – Spanish, PDF opens new window

Prepaid HD190 Plan – English, PDF opens new window
Prepaid HD190 Plan – Spanish, PDF opens new window

DHMO HD190 Plan with Ortho – English, PDF opens new window
DHMO HD190 Plan with Ortho – Spanish, PDF opens new window

DHMO HS190 Plan – English, PDF opens new window
DHMO HS190 Plan – Spanish, PDF opens new window

DHMO HS190 Plan with Implants – English, PDF opens new window
DHMO HS190 Plan with Implants – Spanish, PDF opens new window

Vision care by state

Some states may be limited in plan availability by county.

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, Idaho, Illinois, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New York, North Carolina, North Dakota, New Jersey, New Mexico, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, West Virginia, Wisconsin

Vision Care Plan – English, PDF opens new window
Vision Care Plan – English (editable), PDF opens new window
Vision Care Plan – Spanish, PDF opens new window
Vision Care Plan – Spanish (editable), PDF opens new window

Connecticut, Maine, Massachusetts, New Hampshire, Vermont

Florida

Georgia

Kansas, Missouri

Kentucky

Maryland, Virginia, Washington D.C.

Texas

Exam Plus by state

Some states may be limited in plan availability by county.

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, West Virginia, Wisconsin

Exam Plus plan – English, PDF opens new window
Exam Plus plan – Spanish, PDF opens new window

Kansas, Missouri

Exam Plus plan – English, PDF opens new window
Exam Plus plan – Spanish, PDF opens new window

Advantage Plus Dental by state

Florida, Indiana, Missouri, Tennessee

Illinois, Kansas, Kentucky

Michigan

Texas

Utah

Wisconsin

DHMO/Prepaid Dental by state

Arizona

California

Colorado

Delaware

District of Columbia, Maryland, Pennsylvania, Virginia

Florida

Georgia

Illinois, Indiana, Missouri, Tennessee

Indiana, Mississippi, Missouri, Tennessee

Kansas, Kentucky

New Jersey

Texas

Vision care by state

Connecticut, Maine, Massachusetts, New Hampshire, Vermont

Florida

Georgia

Kansas, Missouri

Kentucky

Maryland, Virginia, Washington D.C.

Texas

Exam Plus by state

Kansas, Missouri

Need help?

Need help?

Humana Specialty dental and vision benefit forms

Advantage Plus Dental by state

Florida, Indiana, Missouri, Tennessee

Illinois, Kansas, Kentucky

Michigan

Texas

Utah

Wisconsin

DHMO/Prepaid Dental by state

Arizona

California

Colorado

Delaware

District of Columbia, Maryland, Pennsylvania, Virginia

Florida

Georgia

Illinois, Indiana, Missouri, Tennessee

Indiana, Mississippi, Missouri, Tennessee

Kansas, Kentucky

New Jersey

Texas

Vision care by state

Connecticut, Maine, Massachusetts, New Hampshire, Vermont

Florida

Georgia

Kansas, Missouri

Kentucky

Maryland, Virginia, Washington D.C.

Texas

Exam Plus by state

Kansas, Missouri

Need help?

Need help?