Dental Benefits Summary

The dental coverage is offered, so you and your family can receive the important dental care you need for good health. You can choose from three different fully insured dental plans that best fit your needs. HumanaDental offers a Dental Health Maintenance Organization (DHMO) and Preferred Provider Organization (PPO) plan. The High Option and Preventative Plus PPO dental plans off you the convenience to see any dentist you choose, keeping in mind that using an In-Network dentist will cost you less out of pocket. The 250CS DHMO plan requires you to stay In-Network and be assigned to a participating primary care dentist.

High Option PPO PlanThe High Option PPO plan has an annual maximum of $2,000 per person. For the High Option PPO Plan, adult/child orthodontia pays 50% (no deductible) of the covered orthodontia services, up to a $2,000 lifetime orthodontia maximum.  The  High  Option PPO Plan also includes four regular preventive  cleanings, two preventive periodontal cleanings, availability of  composite  fillings and an extended annual maximum benefit  which provides 30% coinsurance on preventive, basic, and major treatments after the annual maximum is met, per plan year. 

The Preventive Plus PPO Plan has an annual maximum of $1,000 per person. The Preventive Plus Plan is designed for people that would like their preventive and basic services covered, but not major treatment. Remember, non-participating dentists can bill you for charges above the amount covered by your Preventive Plus Plan.

Prepaid 250CS DHMO PlanYou and each of your covered dependents must select and be assigned to a participating primary care dentist (PCD) who participates in the HumanaDental Prepaid/DHMO network. Should  your PCD recommend that you see a participating  specialist  (i.e., endodontist, oral surgeon, periodontist, pediatric dentist)  no referral is necessary. You may select a  HumanaDental  DHMO participating specialist of your choice. The 250CS copayments are applicable at either a participating general dentist  or a participating specialist. Please see the  schedule of benefits  for a listing of procedures covered under the plan. 

If a planned treatment is expected to cost more than $200, it is recommended that you send a dental treatment plan in prior to beginning treatment. You and/or your dentist will be notified of the benefits payable based upon the dental treatment plan. This is a summary only, please refer to your schedule of benefits for a complete listing of covered procedures.

High Option PPO  Preventive Plus  DHMO Prepaid 250CS 

Plan Year Maximum  $2,000   $1,000   Unlimited 

Providers  In‐Network and Out‐of‐Network Providers 

In‐Network and Out‐of‐Network Providers 

Network Providers/Assignment 

Necessary 

Deductible  $50 Individual/$150 Family  $50 Individual/$150 Family  N/A 

Benefit/Service  In‐Network  Out‐of‐Network 

In‐Network and Out‐of‐Network 

Patient Pays Assigned Network Provider 

Preventive Services  100%  80%  100%  You pay a pre‐set copay 

Basic Services  80% after deductible 

50% after deductible  80% after deductible  You pay a pre‐set copay 

Major Services  50% after deductible 

30% after deductible 

Discount Available for In-Network Only. (subject to provider's discretion) You pay a pre‐set copay 

Orthodontia ‐ Adult and/or Child  50% 

Discount Available for In-Network Only. (subject to provider's discretion) You pay a pre‐set copay 

Orthodontia Lifetime Maximum for Each Member 

$2,000   N/A  $1,800 

ICUBA Dental Benefit Options from HumanaDental

Preventive Plus PPO Plan

The PPO plans have a deductible which must be met before the plan coverage begins. That deductible is waived for preventive care. For other services after your deductible is met, you pay a percentage of the allowed amount and the plan pays the rest.

Humana.com

Use MyHumana to manage your plan, understand your benefits, and take charge of your dental health.

As a Humana Dental member, you can:• Find network dentists• Check claims history and status• View coverage details• Review plan benefit details• Order a replacement identification card• View estimates for services• Exchange secure messages with Humana

Registration is simpleHave your Humana Dental identification card ready and go to Humanadental.com. Click on “Register,” then follow the instructions.

We’re here to helpCall 1-800-979-4760 for Customer Care.

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Manage your plan at MyHumana

Go to MyDentalIQ.com to find out how to improve your oral healthYou brush your teeth and floss daily and have regular dental checkups. What more can you do to improve your dental health?

Go to MyDentalIQ.com and take a free dental health assessment. You’ll answer a few questions to help evaluate your family history, general health, daily routine, and eating habits. You’ll receive a score that immediately rates your dental knowledge, along with a personalized action plan and tips. You can even print a copy of your plan to discuss with your dentist.

Humana.com

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Did you know that making regular preventive visits to your dentist can help detect problems throughout your body such as heart disease, diabetes, and stroke?*

Your HumanaDental® plan focuses on prevention, early detection, and education.

* Perio.org

What’s your dental IQ?

ICUBAFLORIDA

HumanaDental PPO 09 (High Option)

SGB0077A

1-800-233-4013 • Humana.com

If you use IN-NETWORK provider

If you use OUT-OF-NETWORK provider

Plan-year deductible(excludes orthodontia services)

Individual$50

Family$150

Individual$50

Family$150

Annual maximum (excludes orthodontia services)

$2,000After you reach the annual maximum amount, you willreceive 30 percent coinsurance on preventive, basic, andmajor services for the rest of the plan year. (Implants andorthodontia excluded.)

Preventive services• Oral examinations• X-rays• Cleanings (four per plan year)• Topical fluoride treatment

(through age 14, one per plan year)

• Periodontal cleanings (two per plan year)• Sealants (through age 14)

100% no deductible 80% no deductibleof maximum allowed fee

Basic services• Space maintainers (through age 14)• Emergency care for pain relief• Basic oral surgery services - basic

extractions of erupted tooth or root• Fillings (amalgam or composite)• Appliances for children (through age 14)• Prefabricated stainless steel crowns

80% after deductible 50% after deductibleof maximum allowed fee

• Composite fillings for molars• Periodontics• Endodontics (root canal)Major services• Crowns• Inlays and onlays• Bridgework• Dentures• Denture relines and rebases

50% after deductible 30% after deductibleof maximum allowed fee

• Denture repair and adjustments• Complex surgical extractions - surgical

removal of erupted tooth, impactedtooth, and tooth roots

.

Orthodontia Adult/child orthodontia - Plan pays 50 percent (nodeductible) of the covered orthodontia services, up to:$2,000 lifetime orthodontia maximum.

Non-participating dentists can bill you for charges above the amount covered by your HumanaDentalplan. To ensure you do not receive additional charges, visit a participating PPO Network dentist.

Extended Annual Maximum

Not every dental visit is routine.

Someday you could go into your dentist’s office for a routine cleaning and checkup, but you find out there’s a problem. When major dental work is needed, many of us don’t expect or plan for it, but putting it off might not be an option and may cause problems to worsen.

As an example, Kevin, a 40-year-old employee, goes to the dentist regularly. But rather unexpectedly, his dentist tells him there’s an issue. He’ll need a root canal and a crown, which are likely to cost more than his annual maximum benefit. With Extended Annual Maximum, Kevin has the benefits he needs when he needs them.

HumanaDental’s

Extended Annual

Maximum plans give

you a valuable

benefit and dental

coverage when it’s

needed.

As a part of HumanaDental’s PPO High Plan, Extended Annual Maximum takes over after a plan’s annual maximum benefit is reached. It gives employees 30 percent coinsurance on preventive, basic and major services, and it makes those unexpected and costly dental procedures – such as root canals and crowns – easier to afford. There is no cap on dollars that may be paid, which means you can take advantage of the benefit whenever it’s needed within the plan year.

Kevin has the high option PPO with a $50 deductible and has met his $2,000 annual maximum. Now he needs a root canal and a crown. Kevin submits a claim for $875 for the root canal and Extended Annual Maximum picks up 30 percent of the cost, or $262.50. When Kevin later needs a crown, Extended Annual Maximum also pays 30 percent of that cost, $240.

Dental Service Cost Humana Pays

A root canalA crown

$875$800

$262.50 $240

Example is for illustration only. Actual savings may vary. Implants and orthodontia excluded.

ICUBAFLORIDA

HumanaDental Preventive Plus 09 (Low Option)

SGB0077A

1-800-233-4013 • Humana.com

Plan-year deductible(excludes orthodontia services)

Individual$50

Family$150

Annual maximum (excludes orthodontia services)

$1,000

Preventive services• Oral examinations• X-rays• Cleanings• Topical fluoride treatment

(through age 14, one per plan year)• Sealants (through age 14)

100% no deductible

Basic services• Emergency care for pain relief• Basic oral surgery services - basic

extractions of erupted tooth or root• Fillings (amalgams, composite for

anterior teeth)

80% after deductible

.

Discount Services

Basic services• Space maintainers (through age 14)• Appliances for children• Prefabricated stainless steel crownsMajor services• Crowns• Inlays and onlays• Bridgework• Dentures• Denture relines and rebases• Denture repair and adjustments• Complex surgical extractions - surgical

removal of erupted tooth, impactedtooth, and tooth roots

• Periodontics (gum therapy)• Endodontics (root canals)Orthodontia services• Adult and child orthodontia

These services are not covered under this plan. Members may receive a discount on non-covered services and may contact their participating provider to determine if any discounts are available on non-covered services.

Non-participating dentists can bill you for charges above the amount covered by your HumanaDentalplan. To ensure you do not receive additional charges, visit a participating PPO Network dentist. If amember sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee.

Feel good about choosing a HumanaDental plan

Make regular dental visits a priorityRegular cleanings can help manage problemsthroughout the body such as heart disease,diabetes, and stroke.* Your HumanaDental PPOplan focuses on prevention and early diagnosis,providing four exams and cleanings every planyear: two regular and two periodontal.* www.perio.org

Go to MyDentalIQ.comTake a health risk assessment that immediatelyrates your dental health knowledge. You’ll receivea personalized action plan with health tips. Youcan print a copy of your scorecard to discuss withyour dentist at your next visit.

Tips to ensure a healthy mouth• Use a soft-bristled toothbrush• Choose toothpaste with fluoride• Brush for at least two minutes twice a day• Floss daily• Watch for signs of periodontal disease such as

red, swollen, or tender gums• Visit a dentist regularly for exams and cleanings

Did you know that 74 percent of adult Americans believean unattractive smile could hurt a person’s chances forcareer success?* HumanaDental helps you feel good aboutyour dental health so you can smile confidently.* American Academy of Cosmetic Dentistry

Use your HumanaDental benefits

Find a dentistWith HumanaDental’ s PPO plan, you can see anydentist. You save an average of 28 percent whenyou visit a dentist in HumanaDental’ s PPONetwork. To find a dentist in HumanaDental’ s PPONetwork, log on to Humana.com or call1-800-233-4013.

Know what your plan coversThe other side of this page provides a summary ofHumanaDental benefits. Your plan certificatedescribes in detail your HumanaDental benefits.You can find it on MyHumana, your personal pageat Humana.com or call 1-800-233-4013.

See your dentistYour HumanaDental identification card contains allthe information your dentist needs to submit yourclaims. Be sure to share it with the office staffwhen you arrive for your appointment. If youdon’t have your card, you can print proof ofcoverage at Humana.com.

Learn what your plan paidAfter HumanaDental processes your dental claim,you will receive an explanation of benefits orclaims receipt. It provides detailed information oncovered dental services, amounts paid, plus anyamount you may owe your dentist. You can alsocheck the status of your claim on MyHumana at Humana.com or by calling 1-800-233-4013.

Questions? Simply call 1-800-233-4013 to speak with a friendly,

knowledgeable Customer Care specialist, or visit Humana.com.

Plan summary created on: 6/20/12 08:38

Insured or administered by HumanaDental Insurance Company

This is not a complete disclosure of plan qualifications and limitations. Your broker will provide youwith specific limitations and exclusions as contained in the Regulatory and Technical Information Guide.Please review this information before applying for coverage. The amount of benefits provided dependsupon the plan selected. Premiums will vary according to the selection made.

Policy Number: FL-70090-HD 3/08 et.al.

HumanaDental Preventive Plus 09

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HumanaDental DHMO 250 CS Plan

Use your HumanaDental benefitsThe HumanaDental CS Series dental plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect with HumanaDental.

• No waiting periods• No claims to file• No annual maximums

Know what your plan coversAttached is a summary of HumanaDental CS Series plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1-800-979-4760. Here’s what you can expect:

• You have the freedom to select any participatingdentist. To select a dental provider from ournetwork, simply visit HumanaDental.com. Oncethere, you can also check your benefits, email usand get a new or temporary ID card. If you prefer,contact us at 1-800-979-4760.

• Life without claim forms! With HumanaDental DHMOplan you pay your dentist directly, when applicable.

• Your primary dentist will provide all of your routinedental care and any copayment or discounted chargeswill be paid at the time of service. Copayments areapplicable at either a participating general dentist or aparticipating specialist.

Choose HumanaDental benefitsBe healthyGood oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.

Questions?Check out HumanaDental.comCall 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.

Check your dental IQ anytimeLog on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.

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The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. CS plans copayments are applicable at either a participating general dentist or a participating specialist.

Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to see a network specialist.

Specialists services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For CS plans, copayment amounts are applicable when treatment is performed by participating specialists.

Summary of servicesAppointments Member paysD9310 Consultation (diagnostic service provided by

dentist other than practitionerproviding treatment) . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00

D9430 Office visit (normal hours) . . . . . . . . . . . . . . . . . . . . $ 5 .00D9440 Office visit (after regularly scheduled hours) . . . $ 35 .00D9999 Emergency visit during regularly scheduled

hours, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D9999 Broken appointments (without 24 hr . notice,

per 15 min) —maximum $40 per brokenappointment . No charge will be made dueto emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00

Diagnostic Member paysD0120 Periodic oral examination . . . . . . . . . . . . . . . . . . . . . no chargeD0140 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0150 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0160 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0180 Comprehensive periodontal evaluation . . . . . . . . $ 15 .00D0210 X-ray intraoral—complete series

including bitewings . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0220 X-ray intraoral—periapical, first radiographic

image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0230 X-ray intraoral—periapical, each additional

radiographic image . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0270 X-ray bitewing—single radiographic image . . . no chargeD0272 X-ray bitewings—two radiographic images . . . no chargeD0274 Bitewings—four radiographic images . . . . . . . . . no chargeD0330 Panoramic radiographic image . . . . . . . . . . . . . . . no chargeD0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargePreventive Member paysD1110 Prophylaxis—adult, routine

(once every 6 months) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1120 Prophylaxis—child, routine

(once every 6 months) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1110 Prophylaxis—adult/child, (additional) . . . . . . . . . $ 25 .00D1120 Prophylaxis—adult/child, (additional) . . . . . . . . . $ 25 .00D1206 Topical application of fluoride varnish (for child

<16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D1208 Topical application of fluoride (not includingprophylaxis)—child (up to 16 years of age) . . . . no charge

D1330 Oral hygiene instruction . . . . . . . . . . . . . . . . . . . . . . no chargeD1351 Sealant-per tooth . . . . . . . . . . . . . . . . . . . . . . . . . .$ 15 .00D1510 Space maintainer—fixed, unilateral . . . . . . . . .$ 55 .00+labD1515 Space maintainer—fixed, bilateral . . . . . . . . . .$ 55 .00+labD1520 Space maintainer—removable, unilateral . . .$ 95 .00+labD1525 Space maintainer—removable, bilateral . . . .$ 95 .00+lab D1550 Recementation of space maintainer . . . . . . . .$ 15 .00Restorative Member paysD2140 Amalgam—one surface, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 20 .00D2150 Amalgam—two surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 25 .00D2160 Amalgam—three surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 30 .00D2161 Amalgam—four or more surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 40 .00D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 20 .00D2999 Sedative base (under fillings), by report . . . . . .no chargeResin restorative Member paysD2330 Resin based composite—one surface, anterior . .$ 40 .00D2331 Resin based composite—two

surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 45 .00D2332 Resin based composite—three

surfaces, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 55 .00D2391 Resin based composite—one

surface, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 70 .00D2392 Resin based composite—two

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 90 .00D2393 Resin based composite—three

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 110 .00D2394 Resin based composite—four or more

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . .$ 130 .00D2510 Inlay—metallic, one surface . . . . . . . . . . . . . . . .$ 115 .00D2520 Inlay—metallic, two surfaces . . . . . . . . . . . . . . .$ 125 .00D2530 Inlay—metallic, three or more surfaces . . . . .$ 150 .00Crown and bridge Member paysD2740 Crown—porcelain/ceramic substrate . . . . . . .$ 310 .00+labD2750* Crown—porcelain fused to high noble metal . .$ 310 .00D2751 Crown—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 310 .00

HumanaDental DHMO 250 CS Plan

GCA0AWGHH 4/13

D2752* Crown—porcelain fused to noble metal . . . . . . $ 310 .00D2790* Crown—full cast high noble metal . . . . . . . . . . . $ 310 .00D2791 Crown—full cast predominantly base metal . $ 310 .00D2792* Crown—full cast noble metal . . . . . . . . . . . . . . . . $ 310 .00D2910 Recement inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D2929 Crown—prefabricated porcelain/ceramic crown

- primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00D2930 Prefabricated stainless steel crown—

primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00D2950 Core buildup, including any pins . . . . . . . . . . . . . $ 50 .00D2951 Pin retention—per tooth, in addition

to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00D2952 Cast post and core in addition to crown . . . . . . $ 100 .00+labD2953 Each additional cast post—same tooth . . . . . . $ 100 .00+labD2954 Prefabricated post and core in addition to crown . $ 100 .00D2962 Labial veneer (porcelain laminate)—laboratory . . . . . . . . . . . . . . . . . . . . . . $ 310 .00+labProsthodontics (fixed) Member paysD6210* Pontic—cast high noble metal . . . . . . . . . . . . . . . $310 .00D6211 Pontic—cast predominantly base metal . . . . . $ 310 .00D6212* Pontic—cast noble metal . . . . . . . . . . . . . . . . . . . $ 310 .00D6240* Pontic—porcelain fused to high noble metal . $ 310 .00D6241 Pontic—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 310 .00D6242* Pontic—porcelain fused to noble metal . . . . . . $ 310 .00 D6750* Crown—porcelain fused to high noble metal . $ 310 .00D6751 Crown—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 310 .00D6752* Crown—porcelain fused to noble metal . . . . . . $ 310 .00D6790* Crown—full cast high noble metal . . . . . . . . . . . $ 310 .00D6791 Crown—full cast predominantly base metal . $ 310 .00D6792* Crown—full cast noble metal . . . . . . . . . . . . . . . . $ 310 .00D6930 Recement fixed partial denture (per unit) . . . . . $ 15 .00Endodontics Member paysD3220 Therapeutic pulpotomy . . . . . . . . . . . . . . . . . . . . . $ 40 .00D3221 Pulpal debridement, primary and

permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 110 .00D3310 Root canal therapy—anterior

(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 150 .00D3320 Root canal therapy—bicuspid

(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 250 .00D3330 Root canal therapy—molar

(excluding final restoration) . . . . . . . . . . . . . . . . . . $ 300 .00D3410 Apicoectomy/periradicular surgery—anterior . . $ 150 .00Periodontics (gum treatment) Member paysD4210 Gingivectomy/gingivoplasty per quadrant . . . $ 150 .00D4211 Gingivectomy/gingivoplasty per tooth . . . . . . . . $ 45 .00D4260 Osseous surgery, per quadrant . . . . . . . . . . . . . . . $ 375 .00D4261 Osseous surgery—1 to 3 teeth, per quadrant . $ 375 .00D4277 Free soft tissue graft procedure (including donor

site surgery) - first tooth . . . . . . . . . . . . . . . . . . . . . $250 .00D4278 Free soft tissue graft procedure (including donor

site surgery), ea add’l . . . . . . . . . . . . . . . . . . . . . . . . $ 188 .00D4341 Periodontal scaling and root planing,

per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00D4342 Periodontal scaling and root planing

1 to 3 teeth per quadrant . . . . . . . . . . . . . . . . . . . . $ 55 .00D4355 Full mouth debridement to enable

comprehensive evaluation and diagnosis . . . . $ 50 .00

D4381 Localized delivery of chemotherapeuticagents (per tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00

D4910 Periodontal maintenance . . . . . . . . . . . . . . . . . . . . $ 55 .00Prosthodontics Member paysD5110 Complete denture—maxillary . . . . . . . . . . . . . . . $ 325 .00+labD5120 Complete denture—mandibular . . . . . . . . . . . . . $ 325 .00+labD5130 Immediate denture—maxillary . . . . . . . . . . . . . $ 325 .00+labD5140 Immediate denture—mandibular . . . . . . . . . . . $ 325 .00+labD5211 Maxillary partial denture—resin base . . . . . . . . $ 325 .00+labD5212 Mandibular partial denture—resin base . . . . . . $ 325 .00+labD5213 Maxillary partial denture—cast metal

framework, resin denture bases . . . . . . . . . . . . . . $ 325 .00+labD5214 Mandibular partial denture—cast metal

framework, resin denture bases . . . . . . . . . . . . . . $ 325 .00+labD5410 Adjust complete denture—maxillary . . . . . . . . $ 20 .00D5411 Adjust complete denture—mandibular . . . . . . $ 20 .00D5421 Adjust partial denture—maxillary . . . . . . . . . . . $ 20 .00D5422 Adjust partial denture—mandibular . . . . . . . . . $ 20 .00Repairs to prosthetics Member paysD5510 Repair broken complete denture base . . . . . . . . $ 20 .00+labD5520 Replace missing or broken teeth—complete

denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . . $ 20 .00+labD5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . $ 20 .00+labD5630 Repair or replace broken clasp . . . . . . . . . . . . . . . $ 20 .00+labD5640 Replace broken teeth—per tooth . . . . . . . . . . . . $ 20 .00+labD5650 Add tooth to existing partial denture . . . . . . . . . $ 35 .00+labD5730 Reline complete maxillary denture (chairside) . . $ 55 .00D5731 Reline complete mandibular

denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00D5740 Reline maxillary partial denture (chairside) . . . $ 55 .00D5741 Reline mandibular partial denture (chairside) . . $ 55 .00D5750 Reline complete maxillary denture (laboratory) . . $ 40 .00+labD5751 Reline complete mandibular

denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . $ 40 .00+labD5760 Reline maxillary partial denture (laboratory) . . $ 40 .00+labD5761 Reline mandibular partial denture (laboratory) . . $ 40 .00+labD5850 Tissue conditioning—maxillary . . . . . . . . . . . . . . $ 35 .00D5851 Tissue conditioning—mandibular . . . . . . . . . . . . $ 35 .00Extractions/oral and maxillofacial surgery Member paysD7111 Coronal remnants, deciduous tooth . . . . . . . . . . $ 25 .00D7140 Extraction, erupted tooth or exposed tooth . . $ 25 .00D7210 Surgical removal of erupted tooth . . . . . . . . . . . . $ 45 .00D7220 Removal of impacted tooth—soft tissue . . . . . $ 60 .00D7230 Removal of impacted tooth—partially bony . . $ 80 .00D7240 Removal of impacted tooth—completely bony . . $ 100 .00 D7250 Surgical removal of residual tooth roots . . . . . . $ 45 .00 D7310 Alveoloplasty in conjunction with

extractions—per quadrant . . . . . . . . . . . . . . . . . . . $ 45 .00D7311 Alveoplasty in conjunction with extractions—

one to three teeth or tooth spaces,per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 45 .00

D7320 Alveoloplasty not in conjunction with extractions—per quadrant . . . . . . . . . . . . . . . . . . . $ 80 .00

D7321 Alveoplasty not in conjunction withextractions—one to three teeth or toothspaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . $ 80 .00

D7510 Incision and drainage of abscess—intraoral . . $ 30 .00Anesthesia Member paysD9215 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD9230 Analgesia (nitrous oxide), per 15 minutes . . . . $ 20 .00

GCA0AWGHH 4/13

Insured or administered by Humana Insurance Company, The Dental Concern, Inc., CompBenefits Dental, Inc., CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., or CompBenefits Insurance Company.

* The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal.The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal.

Note:• Notallparticipatingdentistsperformalllistedprocedures,includingamalgams.Pleaseconsultyourdentistpriorto

treatment for availabilty of services.• Unlistedproceduresareavailableatcertainparticipatingdentistsusualfeeless25%.VisitHumanaDental.comtofind

a participating dentist who offers the discount on non-covered services.• Whencrownand/orbridgeworkexceedssixunitsinthesametreatmentplan,thepatientmaybechargedanadditional

$50 per unit.• Ifyoubreakyourappointmentwithyourdentistwithout24-houradvancenotice,youwillbesubjecttoyourdentist’s

broken appointment fee.• Additionalexclusionsandlimitationsarelistedalongwithfullplaninformationinyourcertificateofbenefits.

Adjunctive general services Member paysD9450 Case presentation, detailed and extensive

treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD9951 Occlusal adjustment—limited . . . . . . . . . . . . . . . $ 30 .00D9952 Occlusal adjustment—complete . . . . . . . . . . . . $ 175 .00Orthodontics Member paysD8070 Comprehensive orthodontic treatment of the

transitional/adolescent dentition; Children upto 19 years of age; Up to 24 months of routineorthodontic treatment for Class I andClass II cases

Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00

Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,800 .00

D8080 Comprehensive orthodontic treatment of thetransitional/adolescent dentition; Children upto 19 years of age; Up to 24 months of routineorthodontic treatment for Class I andClass II cases

Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00

Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,800 .00

D8090 Comprehensive orthodontic treatment of theadult dentition; Adult 19 years of age and overUp to 24 months of routine orthodontictreatment for Class I and Class II cases

Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00

Records/treatment planning . . . . . . . . . . . . . . . . . . $ 250 .00Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 2,000 .00

D8680 Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 450 .00

Humana.com

If You Have Previously Enrolled in the DHMO, you MUST Contact Humana Directly to Select or to Change Your Primary Care Dentist

Contact customer support center at 

1‐800‐979‐4760Hours of Operation: Monday thru Friday 8 a.m.‐ 6 p.m. EST

Humana Dental DHMO MembersHow to Select Your Primary Care Dentist (PCD)2017

Effective Date of Your Change –Any changes done prior to the 15th of the month will be effective on the first day of the next month.  (i.e. a change on July 12 will be effective August 1)

Any changes made after the 15th of the month will become effective for the first day of the second following month. (i.e. a change on July 16 will be effective September 1)

How to Select Your PCD at the Time of Enrollment (First‐Time Only) Log on to the ICUBA Benefits Portal website

at http://icubabenefits.org For the dental enrollment, select the  DHMO HumanaDental

Prepaid radio button On the Dental – Primary Care Provider screen, enter the six digit Dentist ID number In the drop down box, select if you are a new or established patient

How to Search for a PCD Visit www.humanadental.com Click on Find a Dentist Select the DHMO radio button and enter your zip code Select HD DHMO/Prepaid CS250 Network Set your search criteria Search for a dentist Select a dentist and locate the Dentist ID number Select Show Info radio button to verify that the provider

is accepting new patients

Relationships are built on trust. Respect for an individual’s privacy goes a long way toward building trust.Humana values our relationship with you, and we take your personal privacy seriously. Humana’s Noticeof Privacy Practices outlines how Humana may use or disclose your personal and health information. Italso tells how we protect this information. The notice provides an explanation of your rights concerningyour information, including how you can access this information and how to limit access to yourinformation. In addition, it provides instructions on how to file a privacy complaint with Humana or toexercise any of your rights regarding your information.

If you’d like a copy of Humana’s Notice of Privacy Practices, you can request a copy by:

• Visiting Humana.com and clicking the Privacy Practices link at the bottom of the home page• E-mailing us at privacyoffice@humana.com• Sending a written request to:

Humana Privacy OfficeP.O. Box 1438Louisville, KY 40202