Preventive Plus 3

HumanaOne

    Monthly Premium

    $19.24

    Select

    PLAN TYPE

    PPO

    DEDUCTIBLE

    $50-single, up to $150-family

    COVERAGE MAX

    $1,000

    PROCEDURE COSTS

    Plan Pays

    • Cleaning: 100%
    • Filling: 50%
    • Crown: discount

    Diagnostic

    Clinical Oral Evaluation
    comprehensive oral evaluation
    plan pays 100%
    periodic oral evaluation - established patient
    plan pays 100%
    limited oral evaluation-problem focused
    plan pays 100%
    comprehensive oral evaluation - new or established patient
    plan pays 100%
    Radiographs/Diagnostic Imaging (Including Interpretation)
    intraoral - periapical first film
    plan pays 100%
    intraoral - periapical each additional film
    plan pays 100%
    intraoral - occlusal film
    plan pays 100%
    extraoral - first film
    plan pays 100%
    extraoral - each additional film
    plan pays 100%
    bitewing - single film
    plan pays 100%
    bitewings - two films
    plan pays 100%
    bitewings - three films
    plan pays 100%
    bitewings - four films
    plan pays 100%
    vertical bitewings - 7 to 8 films
    plan pays 100%

    Preventive

    Dental Prophylaxis
    prophylaxis - adult
    plan pays 100%
    prophylaxis - child
    plan pays 100%
    Topical Fluoride Treatment (Office Procedure)
    topical application of fluoride (including prophylaxis) - child
    plan pays 100%
    Other Preventive Services
    sealant - per tooth
    plan pays 100%
    Space Maintenance (Passive Appliances)
    space maintainer - fixed - unilateral
    plan pays 50%
    space maintainer - fixed - bilateral
    plan pays 50%
    space maintainer - removable - unilateral
    plan pays 50%
    space maintainer - removable - bilateral
    plan pays 50%

    Restorative

    Amalgam Restorations (Including Polishing)
    amalgam - one surface, primary or permanent
    plan pays 50%
    amalgam - two surfaces, primary or permanent
    plan pays 50%
    Resin - Based Composite Restorations - Direct
    resin-based composite - one surface, anterior
    plan pays 50%
    resin-based composite - two surfaces, anterior
    plan pays 50%
    Crowns - Single Restorations Only
    crown - porcelain fused to high noble metal
    plan pays discount
    Other Restorative Services
    prefabricated stainless steel crown - primary tooth
    plan pays 50%
    prefabricated stainless steel crown - permanent tooth
    plan pays 50%

    Endodontics

    Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care)
    endodontic therapy, molar (excluding final restoration)
    plan pays discount

    Periodontics

    Non-Surgical Periodontal Service
    periodontal scaling and root planing - four or more teeth per quadrant
    plan pays discount
    Other Periodontal Services
    periodontal maintenance
    plan pays discount

    Prosthodontics (removable)

    Complete Dentures (Including Routine Post-Delivery Care)
    complete denture - maxillary
    plan pays discount
    complete denture - mandibular
    plan pays discount
    Adjustments to Dentures
    adjust complete dentures - maxillary
    plan pays discount
    adjust complete dentures - mandibular
    plan pays discount

    Implant Services

    Implant Services
    surgical placement of implant body: endosteal implant
    plan pays discount
    surgical placement of interim implant body for transitional prosthesis: endosteal implant
    plan pays discount

    Oral and Maxillofacial Surgery

    Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care)
    extraction, erupted tooth or exposed root (elevation and/or forceps removal)
    plan pays 50%

    Orthodontics

    Comprehensive Orthodontic Treatment
    comprehensive orthodontic treatment of the adolescent dentition
    plan pays discount
    comprehensive orthodontic treatment of the adult dentition
    plan pays discount

    Physicians that accept this plan.

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    (800) 498-4601

    (800) 498-4601