Humana Extend 2500 plan

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

Calendar year maximum: $2500 calendar year maximum per covered person for benefits covered under this plan

Preventive dental care

In-network coverage: 100% covered subject to calendar year maximum (deductible does not apply)

Out-of-network coverage: Deductible applies*

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
• 1 comprehensive oral examination every 3 calendar years
• 1 comprehensive periodontal evaluation every 3 calendar years
• 1 panoramic X-ray or 1 intraoral complete series X-ray every 5 calendar years
• Bitewing X-ray: 1 set of 2 films per calendar year for ages 10 and under and 1 set of 4 films per calendar year for ages 11 and older
• 1 sealant per primary tooth per lifetime, for those age 14 and under only^†
• $100 teeth whitening allowance per year when performed in a dentist office (not subject to calendar year maximum)

* Deductible is waived on non-network preventive services in Georgia, Kansas and Texas.

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

Basic dental care

In-network and out-of-network coverage: 80% covered after deductible and subject to calendar year maximum

Waiting period: 90 days*

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: 50% covered after deductible and subject to calendar year maximum

Waiting period: 12 months

Major dental services include:

• $1000 annual maximum for dental implants,* subject to 12 month waiting period, $2,000 lifetime maximum and $2,500 annual maximum for all dental benefits combined
• Surgical extractions (excluding elective removal of non-pathologic impacted teeth)
• Root canal treatment for permanent teeth once per tooth per lifetime
• Complete and partial dentures once every 5 years
• Crowns, onlays and inlays, 1 per tooth per 5 years
• Periodontal maintenance twice per calendar year and periodontal scaling and root planing once per quadrant every 3 calendar years (waiting periods do not apply)

*Implants and implant supported prostheses covered under this plan are limited to the replacement of permanent teeth extracted while insured under this plan, or for replacement of a prior prosthesis if it has been at least 5 years since the prior insertion, and is not, and cannot be made serviceable. Dental implant services do not include the following:

1. Interim abutment
2. Semi-precision attachment abutment
3. Implant/abutment supported interim fixed denture for edentulous arch—mandibular
4. Implant/abutment supported interim fixed denture for edentulous arch—maxillary
5. Provisional implant crown
6. Remove broken implant retaining screw
7. Unspecified implant procedure, by report

Eye Exam

In-network coverage: $10 copay

Out-of-network coverage: $30 allowance

Waiting period: None

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

Contact lens standard fit and follow-up

In-network coverage: $40 copay

Out-of-network coverage: Not covered

Waiting period: None

• 1 standard contact lens fit and follow-up every 12 months from the last date of service*

* Contact lens fit and follow-up is not covered in Arizona, Georgia, Maryland, North Carolina and Texas.

Eyeglass frames

In-network coverage: $100 allowance

Out-of-network coverage: $50 allowance

Waiting period: None

• 1 pair of frames every 24 months from the last date of service

Eyeglass lenses

In-network coverage for standard plastic lenses:
Single vision: $25 copay
Bifocal: $25 copay
Trifocal: $25 copay
Lenticular*: $25 copay

Out-of-network coverage for standard plastic lenses:
Single vision: $25 allowance
Bifocal: $40 allowance
Trifocal: $55 allowance
Lenticular:* not covered

Waiting period: None

• 1 pair eyeglass lenses every 12 months from the last date of service

* Lenticular lenses are not covered in Arizona, Georgia, Maryland, North Carolina and Texas.

Contact lenses (in lieu of eyeglass lenses)

In-network coverage:
Conventional: $100 allowance
Disposable: $100 allowance
Medically necessary: $0 copay

Out-of-network coverage:
Conventional: $80 allowance
Disposable: $80 allowance
Medically necessary: $200 allowance

Waiting period: None

• Contact lenses (in lieu of eyeglass lenses), 1 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 are 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.