Dental Value – HI215 Ohio Individual Dental About your plan Good health starts with a healthy mouth. Regular dental exams and cleanings can lower the risk of gum disease, which is linked to heart disease, diabetes, stroke, and other serious conditions. 1 Good oral health means more than an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist are integral to overall health. The Humana Dental Value – HI215 is a dental HMO plan that covers preventive, basic and major dental services provided by the primary care dentist of your choice from our dental network. This plan has no waiting periods, no claims to file, no annual maximum, and no deductibles. Copayments for listed services are applicable only at a participating primary care dentist. Visit Humana.com to find a participating dentist. Who can enroll in this plan – Anyone can enroll in this plan What to expect • You will be required to choose a general dentist as your primary care dentist from our network when you enroll in this plan. If you wish to change your primary care dentist in the future, contact Customer Service to update your plan. • The service copayments are paid directly to your primary care dentist when you receive dental care. Note, your primary care dentist may or may not provide services for all of the listed ADA codes. • Services provided by specialists are not covered by these copays and in some instances are only available through a specialist, like oral surgery procedures. You may however receive services from an in-network specialist and may receive a 25% discount. To find an in-network dental provider, including specialists, visit Humana.com. How your plan works Following is a summary of the Humana Dental Value – HI215 benefits. Services marked with an asterisk (*) require separate payment of laboratory charges. The laboratory charges must be paid to the plan dentist in addition to any applicable copayment for the service. Out-of-network dentists can bill you for charges above the amount covered by your dental plan. To ensure you do not receive additional charges, you can visit a dentist in the Humana dental network. Waiting periods and other limitations may apply; please see your policy for coverage details. OH52590HD 0221 Page 1 of 17 ADA Member Code Description of Benefit Frequency/Limitations Co-Pay Appointments Consultation - may not be the same dentist D9310 who provides treatment $ 45 D9430 Office Visit – during normal hours No limit $ 15 D9440 Office Visit – after regularly scheduled hours $ 55 D9986 Missed appointment $ 10 Diagnostic D0120 Periodic oral evaluation Two per calendar year No charge D0140 Limited oral evaluation – problem focused No charge D0145 Oral evaluation for a patient under three years No limit No charge of age and counseling with primary caregiver D0150 Two per calendar year Comprehensive oral evaluation – new or No charge established patient D0160 Detailed and extensive oral evaluation – problem No charge focused, by report No Limit D0170 Re-evaluation – problem focused (not post- No charge operative) D0180 Comprehensive periodontal evaluation – new or Two per calendar year established patient $ 35 D0210 X-rays, complete series (including bitewings) One per three calendar years No Charge D0220 X-rays, intraoral periapical – first film No Charge D0230 X-rays, intraoral periapical – each additional film No Charge D0240 X-rays, intraoral – occlusal film No Charge D0250 Extra-oral, 2D projection radiographic image No Limit created using a stationary radiation source and No Charge detector D0251 Extra–oral posterior dental radiographic image No Charge D0270 X-rays (bitewing) – single film No Charge D0272 X-rays (bitewings) – two films No Charge D0273 X-rays (bitewings) – three films Two per calendar year No Charge D0274 X-rays (bitewings) – four films No Charge D0277 X-rays (bitewings, vertical) – seven to eight films No Charge D0330 X-rays (panoramic film) One per three calendar years No Charge D0350 Oral/facial photographic images No limit No Charge OH52590HD 0221 Page 2 of 17 ADA Member Code Description of Benefit Frequency/Limitations Co-Pay Diagnostic - continued Collection of microorganisms for culture and D0415 No charge sensitivity D0425 Caries susceptibility tests No limit No charge D0431 Oral cancer screening using a special light $ 70 source D0460 Pulp vitality tests Not covered if a root canal is performed No charge D0470 Diagnostic casts No charge D0472 Pathology report – gross examination of lesion No charge D0473 Pathology report – microscopic examination of No limit No charge lesion D0474 Pathology report – microscopic examination of lesion and area No charge Preventive D1110 Cleaning – adult Two per calendar year, age 17 and older No charge D1120 Cleaning – child No charge Two per calendar year, age 16 and under D1206 Topical application of fluoride varnish No charge D1208 Topical application of fluoride – excluding Two per calendar year No charge varnish D1310 Nutrition counseling for the control or avoidance of No charge dental disease Tobacco counseling services for the control or No limit D1320 No charge prevention of oral disease D1330 Oral hygiene instructions No charge D1351 Sealant – per tooth Permanent teeth only to age 16 $ 20 Space maintainer – fixed unilateral, per D1510* quadrant, excludes a distal shoe space $ 95 maintainer D1516 Space maintainer – fixed bilateral, maxillary $ 135 D1517 Space maintainer – fixed bilateral, mandibular $ 135 Through age 14 D1520* Space maintainer – removable unilateral, per quadrant $ 105 D1526 Space maintainer – removable bilateral, maxillary $ 115 D1527 Space maintainer – removable bilateral, mandibular $ 115 Re-cement or re-bond bilateral space maintainer, D1551* $ 20 maxillary D1552* Re-cement or re-bond bilateral space maintainer, No limit $ 20 mandibular D1553* Re-cement or re-bond unilateral space maintainer - $ 20 per quadrant Distal shoe space maintainer – fixed, unilateral - per D1575 Through age 14 $ 205 quadrant OH52590HD 0221 Page 3 of 17 ADA Member Code Description of Benefit Frequency/Limitations Co-Pay Restorative D2140 Amalgam – one surface, primary or permanent $ 30 D2150 Amalgam – two surfaces, primary or permanent $ 35 No limit D2160 Amalgam – three surfaces, primary or permanent $ 40 D2161 Amalgam – four or more surfaces, primary or $ 45 permanent D2940 Sedative filling $ 25 Resin Restorative D2330 Resin-based composite – one surface, anterior $ 45 D2331 Resin-based composite – two surfaces, $ 60 anterior D2332 Resin-based composite – three surfaces, $ 75 anterior D2335 Resin-based composite – four or more $ 95 surfaces or involving incisal angle (anterior) D2390 Resin-based composite crown, anterior No limit $ 90 D2391 Resin-based composite – one surface, posterior $ 70 D2392 Resin-based composite – two surfaces, posterior $ 90 Resin-based composite – three surfaces, D2393 posterior $ 110 Resin-based composite – four or more surfaces, D2394 $ 130 posterior D2510* Inlay – metallic, one surface $ 345 D2520* Inlay – metallic, two surfaces $ 355 D2530* Inlay – metallic, three or more surfaces $ 365 D2542* Onlay – metallic, two surfaces $ 370 D2543* Onlay – metallic, three surfaces $ 380 D2544* Onlay – metallic, four or more surfaces Limited to one per tooth every $ 390 five calendar years D2610* Inlay – porcelain/ceramic, one surface $ 370 D2620* Inlay – porcelain/ceramic, two surfaces $ 380 Inlay – porcelain/ceramic, three or more D2630* $ 390 surfaces D2642* Onlay – porcelain/ceramic, two surfaces $ 395 D2643* Onlay – porcelain/ceramic, three surfaces $ 405 D2644* Onlay – porcelain/ceramic, four or more surfaces $ 415 OH52590HD 0221 Page 4 of 17 ADA Member Code Description of Benefit Frequency/Limitations Co-Pay Resin Restorative (continued) D2650* Inlay - resin based composite, one surface $ 345 D2651* Inlay - resin based composite, two surfaces $ 355 D2652* Inlay - resin based composite, three or more $ 365 surfaces Limited to one per tooth every five D2662* Onlay – resin based composite, two surfaces $ 370 calendar years D2663* Onlay – resin based composite, three surfaces $ 380 D2664* Onlay – resin based composite, four or more $ 410 surfaces Crowns and Bridges D2710* Crown - resin based composite, indirect $ 410 D2712* Crown – ¾ resin based composite, indirect $ 410 D2720* Crown - resin with high noble metal $ 410 D2721 Crown – resin with predominantly base metal $ 410 D2722* Crown - resin with noble metal $ 410 D2740* Crown – porcelain/ceramic $ 410 D2750* Crown – porcelain fused to high noble metal $ 410 D2751 Crown – porcelain fused to predominantly base metal $ 410 D2752* Crown – porcelain fused to noble metal $ 410 D2753* Crown – porcelain fused to titanium and titanium One per tooth every five calendar years $ 410 alloy D2780* Crown – ¾ cast high noble metal $ 410 D2781 Crown – ¾ cast predominantly base metal $ 410 D2782* Crown – ¾ cast noble metal $ 410 D2783* Crown – ¾ porcelain/ceramic $ 410 D2790* Crown – full cast high noble metal $ 410 D2791 Crown – full cast predominately base metal $ 410 D2792 Crown – full cast noble metal $ 410 D2794* Crown – titanium and titanium alloy $ 410 Provisional crown – titanium and titanium D2799 No charge alloy D2910 Recement inlay, onlay or veneer $ 25 D2915 Recement cast or prefabricated post and core No limit No charge D2920 Recement crown $ 25 Prefabricated porcelain/ceramic crown – D2928 Limited to one per tooth every $ 35 permanent tooth five calendar years OH52590HD 0221 Page 5 of 17 ADA Member Code Description of Benefit Frequency/Limitations