Humana Specialty dental and vision benefit forms

Advantage Plus Dental

Advantage Plus Dental by state

Some states may be limited in plan availability by county.

DHMO/Prepaid Dental

DHMO/Prepaid Dental by state

Some states may be limited in plan availability by county.

New 400 series Prepaid/DHMO plans are now available in select states.

Arizona

EDS Prepaid 100N Plan – English
EDS Prepaid 100N Plan – Spanish

EDS Prepaid 300N Plan – English
EDS Prepaid 300N Plan – Spanish

EDS Prepaid 700N Plan – English
EDS Prepaid 700N Plan – Spanish

California

LS100 Plan – English
LS100 Plan – Spanish

LS200 Plan – English
LS200 Plan – Spanish

LS300 Plan – English
LS300 Plan – Spanish

Colorado

Beta Health Alpha Plan – English
Beta Health Alpha Plan – Spanish

Delaware

Dominion National Select Plan 703 – English
Dominion National Select Plan 703 – Spanish

Dominion National Select Plan 705 – English
Dominion National Select Plan 705 – Spanish

Dominion National Select Plan 707 – English
Dominion National Select Plan 707 – Spanish

Dominion National Select Plan 703x – English
Dominion National Select Plan 703x – Spanish

Dominion National Select Plan 705x – English
Dominion National Select Plan 705x – Spanish

Dominion National Select Plan 705x Preventive Rewards Mid-Atlantic (MA) – English
Dominion National Select Plan 705x Preventive Rewards Mid-Atlantic (MA) – Spanish

Dominion National Select Plan 707x – English
Dominion National Select Plan 707x – Spanish

Dominion National Select Plan 703s – English
Dominion National Select Plan 703s – Spanish

Dominion National Select Plan 705s – English
Dominion National Select Plan 705s – Spanish

Dominion National Select Plan 707s – English
Dominion National Select Plan 707s – Spanish

Dominion National Select Plan 703xs – English
Dominion National Select Plan 703xs – Spanish

Dominion National Select Plan 705xs – English
Dominion National Select Plan 705xs – Spanish

Dominion National Select Plan 707xs – English
Dominion National Select Plan 707xs – Spanish

District of Columbia, Maryland, Pennsylvania, Virginia

Dominion National Select Plan 703 – English
Dominion National Select Plan 703 – Spanish

Dominion National Select Plan 705 – English
Dominion National Select Plan 705 – Spanish

Dominion National Select Plan 707 – English
Dominion National Select Plan 707 – Spanish

Dominion National Select Plan 703x – English
Dominion National Select Plan 703x – Spanish

Dominion National Select Plan 705x – English
Dominion National Select Plan 705x – Spanish

Dominion National Select Plan 707x – English
Dominion National Select Plan 707x – Spanish

Dominion National Select Plan 705x Preventive Rewards Mid-Atlantic (MA) – English
Dominion National Select Plan 705x Preventive Rewards Mid-Atlantic (MA) – Spanish

Dominion National Select Plan 703s – English
Dominion National Select Plan 703s – Spanish

Dominion National Select Plan 705s – English
Dominion National Select Plan 705s – Spanish

Dominion National Select Plan 707s – English
Dominion National Select Plan 707s – Spanish

Dominion National Select Plan 703xs – English
Dominion National Select Plan 703xs – Spanish

Dominion National Select Plan 705xs – English
Dominion National Select Plan 705xs – Spanish

Dominion National Select Plan 707xs – English
Dominion National Select Plan 707xs – Spanish

Florida

Prepaid HD405 Plan – English
Prepaid HD405 Plan – Spanish

Prepaid HD405 Plan with Ortho – English
Prepaid HD405 Plan with Ortho – Spanish

Prepaid HS405 Plan – English
Prepaid HS405 Plan – Spanish

Prepaid HS405 Plan with Implants – English
Prepaid HS405 Plan with Implants – Spanish

Prepaid HD410 Plan – English
Prepaid HD410 Plan – Spanish

Prepaid HD410 Plan with Ortho – English
Prepaid HD410 Plan with Ortho – Spanish

Prepaid HS410 Plan – English
Prepaid HS410 Plan – Spanish

Prepaid HS410 Plan with Implants – English
Prepaid HS410 Plan with Implants – Spanish

Prepaid HD415 Plan – English
Prepaid HD415 Plan – Spanish

Prepaid HD415 Plan with Ortho – English
Prepaid HD415 Plan with Ortho – Spanish

Prepaid HS415 Plan – English
Prepaid HS415 Plan – Spanish

Prepaid HS415 Plan with Implants – English
Prepaid HS415 Plan with Implants – Spanish

Prepaid 150 C Plan – English
Prepaid 150 C Plan – Spanish

Prepaid 150 C Plan with Ortho – English
Prepaid 150 C Plan with Ortho – Spanish

Prepaid 250 C Plan – English
Prepaid 250 C Plan – Spanish

Prepaid 250 C Plan with Ortho – English
Prepaid 250 C Plan with Ortho – Spanish

Prepaid 350 C Plan – English
Prepaid 350 C Plan – Spanish

Prepaid 350 C Plan with Ortho – English
Prepaid 350 C Plan with Ortho – Spanish

Prepaid 450 C Plan – English
Prepaid 450 C Plan – Spanish

Prepaid 450 C Plan with Ortho – English
Prepaid 450 C Plan with Ortho – Spanish

Prepaid 150 CS Plan – English
Prepaid 150 CS Plan – Spanish

Prepaid 250 CS Plan – English
Prepaid 250 CS Plan – Spanish

Prepaid 350 CS Plan – English
Prepaid 350 CS Plan – Spanish

Prepaid 450 CS Plan – English
Prepaid 450 CS Plan – Spanish

Prepaid HD205 Plan – English
Prepaid HD205 Plan – Spanish

Prepaid HD205 Plan with Ortho – English
Prepaid HD205 Plan with Ortho – Spanish

Prepaid HS205 Plan – English
Prepaid HS205 Plan – Spanish

Prepaid HS205 Plan with Implants – English
Prepaid HS205 Plan with Implants – Spanish

Prepaid HD210 Plan – English
Prepaid HD210 Plan – Spanish

Prepaid HD210 Plan with Ortho – English
Prepaid HD210 Plan with Ortho – Spanish

Prepaid HS210 Plan – English
Prepaid HS210 Plan – Spanish

Prepaid HS210 Plan with Implants – English
Prepaid HS210 Plan with Implants – Spanish

Prepaid HD215 Plan – English
Prepaid HD215 Plan – Spanish

Prepaid HD215 Plan with Ortho – English
Prepaid HD215 Plan with Ortho – Spanish

Prepaid HS215 Plan – English
Prepaid HS215 Plan – Spanish

Prepaid HD190 Plan – English

Prepaid HD190 Plan – Spanish

Prepaid HD190 Plan with Ortho – English
Prepaid HD190 Plan with Ortho – Spanish

Prepaid HS190 Plan – English
Prepaid HS190 Plan – Spanish

Prepaid HS190 Plan with Implants – English
Prepaid HS190 Plan with Implants – Spanish

Prepaid HS195 Plan – English
Prepaid HS195 Plan – Spanish

Prepaid HS195 Plan with Implants – English
Prepaid HS195 Plan with Implants – Spanish

Prepaid Open Access – English
Prepaid Open Access – Spanish

Prepaid Open Access with Implants – English
Prepaid Open Access with Implants – Spanish

Georgia

DHMO HD405 Plan – English
DHMO HD405 Plan – Spanish

DHMO HD405 Plan with Ortho – English
DHMO HD405 Plan with Ortho – Spanish

DHMO HS405 Plan – English
DHMO HS405 Plan – Spanish

DHMO HS405 Plan with Implants– English
DHMO HS405 Plan with Implants – Spanish

DHMO HD410 Plan – English
DHMO HD410 Plan – Spanish

DHMO HD410 Plan with Ortho – English
DHMO HD410 Plan with Ortho – Spanish

DHMO HS410 Plan – English
DHMO HS410 Plan – Spanish

DHMO HS410 Plan with Implants – English
DHMO HS410 Plan with Implants – Spanish

DHMO HD415 Plan – English
DHMO HD415 Plan – Spanish

DHMO HD415 Plan with Ortho – English
DHMO HD415 Plan with Ortho– Spanish

DHMO HS415 Plan – English
DHMO HS415 Plan – Spanish

DHMO HS415 Plan with Implants – English
DHMO HS415 Plan with Implants – Spanish

DHMO HD205 Plan – English
DHMO HD205 Plan – Spanish

DHMO HD205 Plan with Ortho – English
DHMO HD205 Plan with Ortho – Spanish

DHMO HS205 Plan – English
DHMO HS205 Plan – Spanish

DHMO HS205 Plan with Implants – English
DHMO HS205 Plan with Implants – Spanish

DHMO HD210 Plan – English
DHMO HD210 Plan – Spanish

DHMO HD210 Plan with Ortho – English
DHMO HD210 Plan with Ortho – Spanish

DHMO HS210 Plan – English
DHMO HS210 Plan – Spanish

DHMO HS210 Plan with Implants – English
DHMO HS210 Plan with Implants – Spanish

DHMO HD215 Plan – English
DHMO HD215 Plan – Spanish

DHMO HD215 Plan with Ortho – English
DHMO HD215 Plan with Ortho – Spanish

DHMO HS215 Plan – English
DHMO HS215 Plan – Spanish

DHMO HS2195 Plan – English
DHMO HS195 Plan – Spanish

DHMO HS2195 Plan with Implants – English
DHMO HS195 Plan with Implants – Spanish

Illinois, Indiana, Missouri, Tennessee

DHMO/Prepaid HD405 Plan – English
DHMO/Prepaid HD405 Plan – Spanish

DHMO/Prepaid HD405 Plan with Ortho – English
DHMO/Prepaid HD405 Plan with Ortho – Spanish

DHMO/Prepaid HS405 Plan – English
DHMO/Prepaid HS405 Plan – Spanish

DHMO/Prepaid HS405 Plan with Implants – English
DHMO/Prepaid HS405 Plan with Implants – Spanish

DHMO/Prepaid HD410 Plan – English
DHMO/Prepaid HD410 Plan – Spanish

DHMO/Prepaid HD410 Plan with Ortho – English
DHMO/Prepaid HD410 Plan with Ortho – Spanish

DHMO/Prepaid HS410 Plan – English
DHMO/Prepaid HS410 Plan – Spanish

DHMO/Prepaid HS410 Plan with Implants – English
DHMO/Prepaid HS410 Plan with Implants – Spanish

DHMO/Prepaid HD415 Plan – English
DHMO/Prepaid HD415 Plan – Spanish

DHMO/Prepaid HD415 Plan with Ortho – English
DHMO/Prepaid HD415 Plan with Ortho – Spanish

DHMO/Prepaid HS415 Plan – English
DHMO/Prepaid HS415 Plan – Spanish

DHMO/Prepaid HS415 Plan with Implants – English
DHMO/Prepaid HS415 Plan with Implants – Spanish

Prepaid 150 C Plan – English
Prepaid 150 C Plan – Spanish

Prepaid 150 C Plan with Ortho – English
Prepaid 150 C Plan with Ortho – Spanish

Prepaid 250 C Plan – English
Prepaid 250 C Plan – Spanish

Prepaid 250 C Plan with Ortho – English
Prepaid 250 C Plan with Ortho – Spanish

Prepaid 350 C Plan – English
Prepaid 350 C Plan – Spanish

Prepaid 350 C Plan with Ortho – English
Prepaid 350 C Plan with Ortho – Spanish

Prepaid 450 C Plan – English
Prepaid 450 C Plan – Spanish

Prepaid 450 C Plan with Ortho – English
Prepaid 450 C Plan with Ortho – Spanish

Prepaid 150 CS Plan – English
Prepaid 150 CS Plan – Spanish

Prepaid 250 CS Plan – English
Prepaid 250 CS Plan – Spanish

Prepaid 350 CS Plan – English
Prepaid 350 CS Plan – Spanish

Prepaid 450 CS Plan – English
Prepaid 450 CS Plan – Spanish

DHMO HD205 Plan – English
DHMO HD205 Plan – Spanish

DHMO HD205 Plan with Ortho – English
DHMO HD205 Plan with Ortho – Spanish

DHMO HS205 Plan – English
DHMO HS205 Plan – Spanish

DHMO HS205 Plan with Implants – English
DHMO HS205 Plan with Implants – Spanish

DHMO HD 210 Plan – English
DHMO HD 210 Plan – Spanish

DHMO HD 210 Plan with Ortho – English
DHMO HD 210 Plan with Ortho – Spanish

DHMO HS 210 Plan – English
DHMO HS 210 Plan – Spanish

DHMO HS 210 Plan with Implants – English
DHMO HS 210 Plan with Implants – Spanish

DHMO HD 215 Plan – English
DHMO HD 215 Plan – Spanish

DHMO HD 215 Plan with Ortho – English
DHMO HD 215 Plan with Ortho – Spanish

DHMO HS 215 Plan – English
DHMO HS 215 Plan – Spanish

Indiana, Mississippi, Missouri, Tennessee

DHMO 150 C Plan – English
DHMO 150 C Plan – Spanish

DHMO 150 C Plan with Ortho – English
DHMO 150 C Plan with Ortho – Spanish

DHMO 250 C Plan – English
DHMO 250 C Plan – Spanish

DHMO 250 C Plan with Ortho – English
DHMO 250 C Plan with Ortho – Spanish

DHMO 350 C Plan – English
DHMO 350 C Plan – Spanish

DHMO 350 C Plan with Ortho – English
DHMO 350 C Plan with Ortho – Spanish

DHMO 450 C Plan – English
DHMO 450 C Plan – Spanish

DHMO 450 C Plan with Ortho – English
DHMO 450 C Plan with Ortho – Spanish

DHMO 150 CS Plan – English
DHMO 150 CS Plan – Spanish

DHMO 250 CS Plan – English
DHMO 250 CS Plan – Spanish

DHMO 350 CS Plan – English
DHMO 350 CS Plan – Spanish

DHMO 450 CS Plan – English
DHMO 450 CS Plan – Spanish

Kansas, Kentucky

DHMO/Prepaid HD405 Plan – English
DHMO/Prepaid HD405 Plan – Spanish

DHMO/Prepaid HD405 Plan with Ortho – English
DHMO/Prepaid HD405 Plan with Ortho – Spanish

DHMO/Prepaid HS405 Plan – English
DHMO/Prepaid HS405 Plan – Spanish

DHMO/Prepaid HS405 Plan with Implants – English
DHMO/Prepaid HS405 Plan with Implants – Spanish

DHMO/Prepaid HD410 Plan – English
DHMO/Prepaid HD410 Plan – Spanish

DHMO/Prepaid HD410 Plan with Ortho – English
DHMO/Prepaid HD410 Plan with Ortho – Spanish

DHMO/Prepaid HS410 Plan – English
DHMO/Prepaid HS410 Plan – Spanish

DHMO/Prepaid HS410 Plan with Implants – English
DHMO/Prepaid HS410 Plan with Implants – Spanish

DHMO/Prepaid HD415 Plan – English
DHMO/Prepaid HD415 Plan – Spanish

DHMO/Prepaid HD415 Plan with Ortho – English
DHMO/Prepaid HD415 Plan with Ortho – Spanish

DHMO/Prepaid HS415 Plan – English
DHMO/Prepaid HS415 Plan – Spanish

DHMO/Prepaid HS415 Plan with Implants – English
DHMO/Prepaid HS415 Plan with Implants – Spanish

DHMO 150 C Plan – English
DHMO 150 C Plan – Spanish

DHMO 150 C Plan with Ortho – English
DHMO 150 C Plan with Ortho – Spanish

DHMO 250 C Plan – English
DHMO 250 C Plan – Spanish

DHMO 250 C Plan with Ortho – English
DHMO 250 C Plan with Ortho – Spanish

DHMO 350 C Plan – English
DHMO 350 C Plan – Spanish

DHMO 350 C Plan with Ortho – English
DHMO 350 C Plan with Ortho – Spanish

DHMO 450 C Plan – English
DHMO 450 C Plan – Spanish

DHMO 450 C Plan with Ortho – English
DHMO 450 C Plan with Ortho – Spanish

DHMO 150 CS Plan – English
DHMO 150 CS Plan – Spanish

DHMO 250 CS Plan – English
DHMO 250 CS Plan – Spanish

DHMO 350 CS Plan – English
DHMO 350 CS Plan – Spanish

DHMO 450 CS Plan – English
DHMO 450 CS Plan – Spanish

DHMO HD205 Plan – English
DHMO HD205 Plan – Spanish

DHMO HD205 Plan with Ortho – English
DHMO HD205 Plan with Ortho – Spanish

DHMO HS205 Plan – English
DHMO HS205 Plan – Spanish

DHMO HS205 Plan with Implants – English
DHMO HS205 Plan with Implants – Spanish

DHMO HD210 Plan – English
DHMO HD210 Plan – Spanish

DHMO HD210 Plan with Ortho – English
DHMO HD210 Plan with Ortho – Spanish

DHMO HS210 Plan – English
DHMO HS210 Plan – Spanish

DHMO HS210 Plan with Implants – English
DHMO HS210 Plan with Implants – Spanish

DHMO HD215 Plan – English
DHMO HD215 Plan – Spanish

DHMO HD215 Plan with Ortho – English
DHMO HD215 Plan with Ortho – Spanish

DHMO HS215 Plan – English
DHMO HS215 Plan – Spanish

New Jersey

Dominion Select Plan 703x – English
Dominion Select Plan 703x – Spanish

Dominion Select Plan 705x – English
Dominion Select Plan 705x – Spanish

Dominion Select Plan 707x – English
Dominion Select Plan 707x – Spanish

Dominion Select Plan 705x Preventive Rewards – English
Dominion Select Plan 705x Preventive Rewards – Spanish

Texas

DHMO HD405 Plan – English
DHMO HD405 Plan – Spanish

DHMO HD405 Plan with Ortho – English
DHMO HD405 Plan with Ortho – Spanish

DHMO HS405 Plan – English
DHMO HS405 Plan – Spanish

DHMO HS405 Plan with Implants – English
DHMO HS405 Plan with Implants – Spanish

DHMO HD410 Plan – English
DHMO HD410 Plan – Spanish

DHMO HD410 Plan with Ortho – English
DHMO HD410 Plan with Ortho – Spanish

DHMO HS410 Plan – English
DHMO HS410 Plan – Spanish

DHMO HS410 Plan with Implants – English
DHMO HS410 Plan with Implants – Spanish

DHMO HD415 Plan – English
DHMO HD415 Plan – Spanish

DHMO HD415 Plan with Ortho – English
DHMO HD415 Plan with Ortho – Spanish

DHMO HS415 Plan – English
DHMO HS415 Plan – Spanish

DHMO HS415 Plan with Implants – English
DHMO HS415 Plan with Implants – Spanish

DHMO 150 C Plan – English
DHMO 150 C Plan, no ortho – Spanish

DHMO 150 C Plan with Ortho – English
DHMO 150 C Plan with Ortho – Spanish

DHMO 250 C Plan – English
DHMO 250 C Plan – Spanish

DHMO 250 C Plan with Ortho – English
DHMO 250 C Plan with Ortho – Spanish

DHMO 350 C Plan – English
DHMO 350 C Plan – Spanish

DHMO 350 C Plan with Ortho – English
DHMO 350 C Plan with Ortho – Spanish

DHMO 450 C Plan – English
DHMO 450 C Plan – Spanish

DHMO 450 C Plan with Ortho – English
DHMO 450 C Plan with Ortho – Spanish

DHMO 150 CS Plan – English
DHMO 150 CS Plan – Spanish

DHMO 250 CS Plan – English
DHMO 250 CS Plan – Spanish

DHMO 350 CS Plan – English
DHMO 350 CS Plan – Spanish

DHMO 450 CS Plan – English
DHMO 450 CS Plan – Spanish

DHMO 600 CS Plan – English
DHMO 600 CS Plan – Spanish

DHMO HD205 Plan – English
DHMO HD205 Plan- Spanish

DHMO HD205 with Ortho – English
DHMO HD205 with Ortho – Spanish

DHMO HS205 Plan – English
DHMO HS205 Plan – Spanish

DHMO HS205 Plan with Implants – English
DHMO HS205 Plan with Implants – Spanish

DHMO HD210 Plan – English
DHMO HD210 Plan – Spanish

DHMO HD210 Plan with Ortho – English
DHMO HD210 Plan with Ortho – Spanish

DHMO HS210 Plan – English
DHMO HS210 Plan – Spanish

DHMO HS210 Plan with Implants – English
DHMO HS210 Plan with Implants – Spanish

DHMO HD215 Plan – English
DHMO HD215 Plan – Spanish

DHMO HD215 Plan with Ortho – English
DHMO HD215 Plan with Ortho – Spanish

DHMO HS215 Plan – English
DHMO HS215 Plan – Spanish

Prepaid HD190 Plan – English
Prepaid HD190 Plan – Spanish

DHMO HD190 Plan with Ortho – English
DHMO HD190 Plan with Ortho – Spanish

DHMO HS190 Plan – English
DHMO HS190 Plan – Spanish

DHMO HS190 Plan with Implants – English
DHMO HS190 Plan with Implants – Spanish

Vision care

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
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Connecticut, Maine, Massachusetts, New Hampshire, Vermont

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Florida

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Georgia

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Kansas, Missouri

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Kentucky

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Maryland, Virginia, Washington D.C.

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Texas

Vision Care Plan – English
Vision Care Plan – English (editable)
Vision Care Plan – Spanish
Vision Care Plan – Spanish (editable)

Exam Plus

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
Exam Plus plan – Spanish

Kansas, Missouri

Exam Plus plan – English
Exam Plus plan – Spanish

Need help?

If you are not able to access the documents from this page contact us by email at accessibility@humana.com

Call a licensed Humana sales agent at 855-832-8335 (TTY: 711). We’re available Monday – Friday, 8 a.m. – 9 p.m., Eastern time.

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