Humana Extend 1250 plan

Deductible: A $75 deductible per person must be satisfied each year before dental benefits are payable.

Calendar year maximum: There is a $1,250 calendar year maximum per covered person for benefits covered under this plan.

Preventive dental care

In-network and out-of-network coverage: 100% covered after deductible* and subject to calendar year maximum

Waiting period: None

Preventive dental services include:

• 2 routine oral examinations per calendar year
• 2 preventive cleanings per calendar year
• 2 topical fluoride treatments per calendar year
• Bitewing X-rays: 1 set of 2 films per calendar year for ages 10 and under and 1 set of 4 films per year for ages 11 and older
• 1 sealant per primary tooth per lifetime, for those age 14 and under only^†
• $100 whitening allowance per calendar year when performed in a dentist office (not subject to deductible or calendar year maximum)

* Deductible does not apply to preventive services in Kansas.

^† 1 sealant per primary tooth per lifetime, for those under age 19 in Illinois.

Basic dental care

In-network and out-of-network coverage: 60% covered after deductible, subject to calendar year maximum

Waiting period: 6 months*

Basic dental services include:

• 1 filling per tooth every 2 calendar years^†
• Initial placement for space maintainers for ages 14 and under^‡ when primary tooth is prematurely lost
• Anesthesia in conjunction with covered oral surgery

* Waiting period is 30 days in Pennsylvania.

^† Composite restorations allowed on anterior teeth only. Alternate benefit of amalgam for composite allowed on pre-molar and molar teeth. The covered person will be responsible for the cost difference between the amalgam and composite filling for composite restorations on posterior teeth.

^‡ Initial placement for space maintainers until age 19 in Illinois when primary tooth is prematurely lost.

Major dental services

In-network and out-of-network coverage: 30% covered* after deductible and subject to calendar year maximum

Waiting period: 12 months

Major dental services include:

• Root canal treatment for permanent teeth once per tooth per lifetime
• Surgical extractions (excluding elective removal of non-pathologic impacted teeth)
• Complete and partial dentures once every 5 calendar years
• Crowns, onlays and inlays, 1 per tooth per 5 calendar years
• Periodontal maintenance twice per year and periodontal scaling and root planing once per quadrant every 3 calendar years (waiting periods do not apply)

* Major services are 50% covered after deductible in Illinois, Connecticut and New York.

In-network and out-of-network coverage: $0 copay

Waiting period: None

Vision services include:

• 1 routine vision exam every 12 months from the last date of service

In-network coverage: $0 copays except for hearing aids

Waiting period: None

Hearing services include:*

• 1 routine hearing exam per year from an in-network provider^†
• Subject to the applicable copay, up to 2 hearing aids (1 per ear) each year from the following in-network provider options^‡
  • Advanced level hearing aid ($699 copay per ear)
    • Various styles and colors
    • Disposable battery-powered options only
  • Premium level hearing aid ($999 copay per ear, $50 additional copay for rechargeable aids)
    • Various styles and colors
    • Disposable battery-powered and rechargeable options available

* Hearing services are not available in New York.

^† Hearing exams are covered for out-of-network providers with a $45 allowance in Arizona, Georgia, Maryland, North Carolina and Texas.

^‡ Hearing aids are not covered in Arizona, Georgia, Maryland, North Carolina and Texas.