California
Humana Dental
Summary of dental plans
Humana.com GN52018HD_CA 314
Prevention and early treatment of dental disease can help people take better care of their overall health as well as improve their oral health.
Make choosing the right dental plan painless We offer a range of plans that can be tailored to fit the needs of your employees. They have a large choice of dentists near where they live and work. Plus, our plans are affordable and provide discounts for you and your employees. • Offer a Humana dental plan at little or no additional cost to your benefits budget. •A dd other lines of coverage to a Humana medical or dental plan and save with our multiline discounts • Our PPO network is one of the largest with more than 190,000 dentist locations, and growing daily. • Your employees will benefit from national network discounts averaging 28 percent nationally. •R egular dental cleanings may prevent complications with serious health conditions, such as, heart disease, diabetes, and stroke. •O ur plans are easier to administer – our staff is here to quickly answer your questions.
Traditional Preferred and PPO Plans Traditional Preferred Deductible Options
PPO
See any dentist Individual Family
See an in-network dentist Individual Family
See an out-of-network dentist Individual Family
Deductible option 1
$0
$0
$0
$0
$25
$75
Deductible option 2
$25
$75
$25
$75
$50
$150
Deductible option 3
$50
$150
$50
$150
$50
$150
Deductible option 4 *Waive deductible option*
n/a
n/a
$50
$150
$100
$300
Annual Maximum Options
$1,000 $1,000 $1,250 $1,250 $1,500 $1,500 $2,000 $2,000 $2,500 $2,500 You have the option to receive 30 percent coinsurance on preventive, basic, and major services for the rest of the year after you reach your annual maximum. (Implants and orthodontia excluded)
*Extended annual maximum option*
Deductible applies to all services with the option to waive on preventive.
Deductible applies to all services with the option to waive on outof-network preventive. Deductible does not apply to in-network preventive.
Coinsurance Options
Option 1 Option 2 Option 3
Coinsurance Options
Option 1
Option 2
Option 3
in out of in out of in out of network network network network network network
See any dentist
Option 4 in network
out of network
Preventive Services
100%
100%
100%
100%
100%
100%
100%
100%
80%
100%
80%
Basic Services
90%
80%
50%
100%
80%
90%
80%
90%
80%
80%
50%
Major Services
60%
50%
50%
60%
50%
60%
50%
50%
50%
50%
50%
Oral examinations, X-rays, cleanings, topical fluoride treatment (through age 14, one per calendar year), sealants (through age 14) Space maintainers (through age 14), emergency care for pain relief, non-surgical extractions, fillings (amalgams, composite for anterior teeth), appliances for children (through age 14), prefabricated stainless steel crowns Crowns, inlays and onlays, bridgework, dentures, denture relines and rebases, denture repair and adjustments, oral surgery, periodontics (gum therapy), endodontics (root canals)
Plan Options Periodontics/Endodontics Composite fillings for molars Complex Oral Surgery Implants Orthodontia
If you do not choose orthodontia coverage, employees may be able to receive up to a 20 percent savings by visiting participating orthodontists and asking for the discount.
Periodontics and endodontics available as a basic service for an additional cost. Composite fillings for molars can be added to basic services for groups with 10 or more enrolled employees for an additional cost. Complex oral surgery available as a basic service for an additional cost. Implants can be added to major services for groups with 10 or more enrolled employees for an additional cost. $1,500 maximum implant benefit, subject to the annual maximum. Child orthodontia: Available for groups with 10 or more enrolled employees. Plan pays 50 percent (no deductible) of the covered child orthodontia services up to: $1,000 $1,500 $2,000 Adult/child orthodontia: Available for groups with 25 or more enrolled employees. Plan pays 50 percent (no deductible) of the covered adult/child orthodontia services up to: $1,000 $1,500 $2,000
Traditional Preferred and PPO Plans Additional Plan Options Out-of-network reimbursement options Based on maximum allowable fee (MAF): If a member sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee. Based on in-network fee schedule (INFS): If a member sees an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule in your area. If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee schedule. Funding options Employer sponsored: Your business only needs to contribute 25 percent of the single rate. Voluntary: Same group benefits to your employees at no cost to your business. Dual choice: Combine any two employer-sponsored or any two voluntary plans. (Available for groups with 10 or more enrolled employees.) Administrative services only (ASO): Your business funds the plan. Humana carefully manages your plan through our industry-leading claims system and nationwide PPO network. Enrollment options for employees joining late Open enrollment: Employees without a qualifying event can only join during the annual open enrollment period. Additional late applicant waiting periods do not apply (plan waiting periods may apply). Late applicants: Employees can join at any time during the plan year without a qualifying event. Late applicant waiting periods apply.
Genuine customer care Call 1-800-233-4013, Monday through Friday, 8 a.m. to 6 p.m. (TDD: 1-800-325-2025)
Preventive Plus Plans Preventive Plus Deductible
See any dentist Individual
Family
$50
$150
*Waive deductible option*
Deductible applies to all services with the option to waive on preventive.
Annual Maximum Deductible
$1,000
Additional Plan Options Out-of-network reimbursement options Based on maximum allowable fee (MAF): If a member sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee. Based on in-network fee schedule (INFS): If a member sees an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule in your area. If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee schedule.
Coinsurance Options
See any dentist
Preventive services
Oral examinations, X-rays, cleanings, topical fluoride treatment (through age 14, one per calendar year), sealants (through age 14)
Basic services
Emergency care for pain relief, nonsurgical extractions, fillings (amalgams, composite for anterior teeth)
Discount services Basic services Space maintainers (through age 14), appliances for children, prefabricated stainless steel crowns Major services Crowns, inlays and onlays, bridgework, dentures, denture relines and rebases, denture repair and adustments, oral surgery, periodontics (gum therapy), endodontics (root canals) Orthodontia services Adult and child orthodontia
100%
100%
Funding options Employer sponsored: Your business only needs to contribute 25 percent of the single rate. Voluntary: Same group benefits to your employees at no cost to your business.
80%
50%
You may be able to receive a discount on these services if you see participating dentists. These services are not covered under this plan. Out-of-pocket expenses do not apply to deductible and annual maximum.
Dual choice: Combine any two employer-sponsored or any two voluntary plans. (Available for groups with 10 or more enrolled employees.) Administrative services only (ASO): Your business funds the plan. Humana carefully manages your plan through our industry-leading claims system and nationwide PPO network. Enrollment options for employees joining late Open enrollment: Employees without a qualifying event can only join during the annual open enrollment period. Additional late applicant waiting periods do not apply (plan waiting periods may apply). Late applicants: Employees can join at any time during the plan year without a qualifying event. Late applicant waiting periods apply.
Humana Dental Plan Guidelines Eligibility– Traditional Preferred, PPO, Preventive Plus, and Prepaid 2+ eligible employees – Traditional Preferred, PPO, Preventive Plus, and Prepaid Participation Employer pays 100 percent of premium
100 percent
Employer contributes at least 25 percent of premium – For groups with two or more eligible employees, Humana Dental will lower the participation requirement to 50 percent if 25 percent or more of the eligible employees waive due to other credible coverage.
75 percent
Voluntary – Traditional Preferred, PPO, and Preventive Plus
Two enrolled employees or 25 percent, whichever is greater
Voluntary – Prepaid
Two or more enrolled employees
Waiting periods– Traditional Preferred, PPO, and Preventive Plus Humana Dental reimburses most services in your plan as of your effective date. There are no waiting periods for preventive services. There are no waiting periods for endodontics unless you are a late applicant. In some circumstances, benefits are available after 12 months. Please see the chart below. Enrollment type
Group size
Preventive
Basic
Major1
Initial enrollment, open enrollment, and timely add-on
2-9 enrolled employees
No
No
12 months Not available
Initial enrollment, open enrollment, and timely add-on
10 or more enrolled employees
No
No
No
Late applicant3
All group sizes
No
12 months
12 months 12 months4
1 2
3 4
Orthodontia 1 2
12 months2 (No waiting period for employersponsored)
Preventive Plus does not cover major and orthodontia services. The 12-month waiting period may be decreased or waived based on the number of months the member had dental coverage immediately before joining the Humana Dental plan. Members must have prior orthodontic coverage to reduce or waive the waiting period under orthodontia. Late applicants not allowed with open enrollment option. Orthodontia is not available for groups with 2-9 enrolled employees.
NOTE: If the oral surgery rider is selected for groups with 2-9 enrolled employees, there is a 12 month waiting period on the oral surgery rider.
This is not a complete disclosure of the plan qualifications and limitations. Specific limitations and exclusions as contained in the Regulatory and Technical Information Guide will be provided by the agent/broker. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the plan selection.
LIBERTY Dental plans The DHMO plan focuses on maintaining oral health with low or no-cost preventive procedures and includes restorative care at fees considerably lower than those charged by non-participating dentists. 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. • Members must select, and be assigned to, a LIBERTY Dental Plan contracted dental office to utilize covered benefits. Your assigned office will initiate a treatment plan or will initiate the specialty referral process with LIBERTY Dental Plan if the services are dentally necessary and outside the scope of general dentistry. • Member Co-payments are payable to the dental office at the time services are rendered. • This Schedule does not guarantee benefits. All services are subject to eligibility and dental necessity at the time of service. • Dental procedures not listed as covered benefits are available at the dental office’s usual and customary fee. • For a complete description of your Plan, please refer to the Evidence of Coverage in addition to this Schedule.
Summary of services Diagnostic services
LS100
LS200
LS300
D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0330 D0415 D0425 D0460 D0470 D0472 D0474
no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge
no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge
no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge no charge
Preventive services
LS100
LS200
LS300
D1110
no charge $45.00 no charge $35.00 no charge $10.00 no charge no charge
no charge $45.00 $35.00 $10.00 no charge no charge no charge no charge
$8.00 $45.00 $35.00 $10.00 $9.00 $9.00 no charge no charge
D1120 D1203 D1204 D1206
Periodic oral evaluation Limited oral evaluation Oral Evaluation under age 3 Comprehensive oral evaluation Oral evaluation, problem focused Re-evaluation, limited, problem focused Comprehensive periodontal evaluation Intraoral, complete series (includes bitewings) Intraoral, periapical, first film Intraoral, periapical, each additional film Intraoral, occlusal film Extraoral, first film Extraoral, each additional film Bitewing, single film Bitewings, 2 films Bitewings, 3 films Bitewings, 4 films Vertical bitewings, 7 to 8 films Panoramic Film Collection of microorganisms for culture Caries susceptibility tests Pulp vitality tests Diagnostic casts Accession of tissue, gross exam, prep & report Accession of tissue, gross/micro. exam, report Prophylaxis, adult Prophylaxis, adult (3rd or more per 12 months) Prophylaxis, child Prophylaxis, child (3rd or more per 12 months) Topical application of fluoride, child Topical application fluoride, child (3rd + in 12 mo.) Topical application of fluoride, adult Topical fluoride varnish
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
Preventive services—continued
LS100
LS200
LS300
D1310 D1320 D1330 D1351 D1352 D1510 D1515 D1520 D1525 D1550 D1555
no charge no charge no charge $5.00 $5.00 $15.00 $15.00 $15.00 $15.00 $5.00 $5.00
no charge $10.00 $10.00 $10.00 $10.00 $25.00 $25.00 $25.00 $25.00 $10.00 $10.00
no charge $15.00 $15.00 $15.00 $15.00 $40.00 $40.00 $40.00 $40.00 $15.00 $15.00
Restorative
LS100
LS200
LS300
D2140 Amalgam, 1 surface, primary or permanent D2150 Amalgam, 2 surfaces, primary or permanent D2160 Amalgam, 3 surfaces, primary or permanent D2161 Amalgam, 4 or more surfaces, primary/permanent D2330 Resin-based composite, 1 surface, anterior D2331 Resin-based composite, 2 surfaces, anterior D2332 Resin-based composite, 3 surfaces, anterior D2335 Resin-based composite, 4+ surfaces/incisal angle D2390 Resin-based composite crown, anterior D2391 Resin-based composite, 1 surface, posterior D2392 Resin-based composite, 2 surfaces, posterior D2393 Resin-based composite, 3 surfaces, posterior D2394 Resin-based composite, 4+ surfaces, posterior *GUIDELINES for Inlays, Onlays, and Single Crowns:
no charge no charge no charge no charge no charge no charge no charge no charge $20.00 $45.00 $50.00 $60.00 $75.00
$5.00 $10.00 $17.00 $20.00 $10.00 $17.00 $26.00 $37.00 $50.00 $55.00 $60.00 $70.00 $80.00
$12.00 $16.00 $20.00 $30.00 $16.00 $28.00 $40.00 $52.00 $60.00 $65.00 $70.00 $80.00 $90.00
Nutritional counseling for control of dental disease Tobacco counseling, control/prevention oral disease Oral hygiene instruction Sealant, per tooth Preventive resin restoration – permanent tooth Space maintainer, fixed, unilateral Space maintainer, fixed, bilateral Space maintainer, removable, unilateral Space maintainer, removable, bilateral Recementation of space maintainer Removal of fixed space maintainer
The total maximum amount chargeable to the member for elective upgraded procedures (explained below) is $250.00 per tooth. Providers are required to explain covered benefits as well as any elective differences in materials and fees prior to providing an elective upgraded procedure. 1.
Brand name restorations (e.g. Sunrise, Captek, Vitadur-N, Hi-Ceram, Optec, HSP, In-Ceram, Empress, Cerec, AllCeram, Procera, Lava, etc.) may be considered elective upgraded procedures if their related CDT procedure codes are not listed as covered benefits.
2.
Benefits for anterior and bicuspid teeth: Resin, porcelain and any resin to base metal or porcelain to base metal crowns are covered benefits for anterior and bicuspid teeth. Adding a porcelain margin may be considered an elective upgraded procedure.
3.
Benefits for molar teeth: Cast base metal restorations are covered benefits for molar teeth. Resin-based composite and porcelain/ceramic crowns are not covered benefits on molar teeth. Any resin to metal or porcelain to metal crowns may be considered elective upgraded procedures. Adding a porcelain margin may be considered an elective upgraded procedure.
4.
Base metal is the benefit. If elected, the member may be charged additional lab costs for a) noble metal, b) high noble metal, or c) titanium.
D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662
Inlay, metallic, 1 surface Inlay, metallic, 2 surfaces Inlay, metallic, 3 or more surfaces Onlay, metallic, 2 surfaces Onlay, metallic, 3 surfaces Onlay, metallic, 4 or more surfaces Inlay, porcelain/ceramic, 1 surface Inlay, porcelain/ceramic, 2 surfaces Inlay, porcelain/ceramic, 3 or more surfaces Onlay, porcelain/ceramic, 2 surfaces Onlay, porcelain/ceramic, 3 surfaces Onlay, porcelain/ceramic, 4 or more surfaces Inlay, resin-based composite, 1 surface Inlay, resin-based composite, 2 surfaces Inlay, resin-based composite, 3 or more surfaces Onlay, resin-based composite, 2 surfaces
$80.00* $85.00* $90.00* $90.00* $95.00* $100.00* $80.00* $85.00* $90.00* $95.00* $100.00* $110.00* $80.00* $85.00* $90.00* $90.00*
$120.00* $140.00* $145.00* $145.00* $155.00* $160.00* $130.00* $140.00* $145.00* $155.00* $160.00* $170.00* $130.00* $135.00* $150.00* $145.00*
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
$140.00* $155.00* $160.00* $160.00* $170.00* $175.00* $140.00* $150.00* $160.00* $170.00* $175.00* $185.00* $145.00* $160.00* $180.00* $175.00*
Restorative—continued
LS100
LS200
LS300
D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2930 D2931 D2932 D2933 D2934 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2970 D2971 D2980
$95.00* $100.00* $60.00* $60.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00 $70.00* $70.00* $70.00* $70.00 $70.00* $70.00* $40.00 no charge no charge no charge no charge $15.00 $10.00 $5.00 $5.00 no charge $10.00 $10.00 $20.00* $20.00* $20.00 $10.00 $10.00 $200.00 $300.00 $350.00 $5.00 $20.00 $15.00
$160.00* $165.00* $85.00* $85.00* $90.00* $90.00* $90.00* $100.00* $115.00* $115.00* $115.00* $115.00* $100.00 $100.00* $100.00* $100.00* $100.00 $100.00* $100.00* $65.00 $5.00 $5.00 $5.00 $25.00 $25.00 $30.00 $20.00 $10.00 no charge $20.00 $10.00 $30.00* $25.00* $30.00 $15.00 $15.00 $200.00 $325.00 $425.00 $20.00 $30.00 $25.00
$180.00* $185.00* $150.00* $150.00* $175.00* $175.00* $175.00* $175.00* $185.00* $185.00* $185.00* $185.00* $190.00 $190.00* $195.00* $175.00* $175.00 $175.00* $175.00* $70.00 $10.00 $10.00 $10.00 $40.00 $40.00 $45.00 $45.00 $45.00 no charge $50.00 $15.00 $50.00* $30.00* $50.00 $20.00 $25.00 $250.00 $325.00 $500.00 $30.00 $50.00 $30.00
Endodontics
LS100
LS200
LS300
D3110 D3120 D3220 D3221 D3230 D3240 D3310
Pulp cap – direct (excluding final restoration) Pulp cap – indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary & permanent teeth Pulpal therapy (resorbable filling), anterior, primary Pulpal therapy (resorbable filling), posterior, primary Anterior (excluding final restoration)
no charge no charge no charge $10.00 $5.00 $10.00 $40.00
no charge no charge $10.00 $15.00 $25.00 $25.00 $50.00
$5.00 $5.00 $20.00 $25.00 $35.00 $35.00 $100.00
D3320 D3330
Bicuspid (excluding final restoration) Molar (excluding final restoration)
$80.00 $100.00
$90.00 $115.00
$150.00 $220.00
Onlay, resin-based composite, 3 surfaces Onlay, resin-based composite, 4 or more surfaces Crown, resin-based composite (indirect) Crown, 3/4 resin-based composite (indirect) Crown, resin with high noble metal Crown, resin with predominantly base metal Crown, resin with noble metal Crown, porcelain/ceramic substrate Crown, porcelain fused to high noble metal Crown, porcelain fused to predominantly base metal Crown, porcelain fused to noble metal Crown, 3/4 cast high noble metal Crown, 3/4 cast predominantly base metal Crown, 3/4 cast noble metal Crown, 3/4 porcelain/ceramic Crown, full cast high noble metal Crown, full cast predominantly base metal Crown, full cast noble metal Crown, titanium Provisional crown Recement inlay, onlay, partial coverage restoration Recement cast or prefabricated post & core Recement crown Prefabricated stainless steel crown, primary tooth Prefabricated stainless steel crown, permanent tooth Prefabricated resin crown Prefabricated stainless steel crown, resin window Prefabricated esthetic coated SS crown, primary Protective restoration (temporary) Core build-up, including any pins Pin retention, per tooth, in addition to restoration Post & core in addition to crown, indirect fabric. Each additional indirect fabric. post, same tooth Prefabricated post & core in addition to crown Post removal (not in conj. with endodontic therapy) Each additional prefabricated post, same tooth Labial veneer (resin laminate), chairside Labial veneer (resin laminate), laboratory Labial veneer (porcelain laminate), laboratory Temporary crown (fractured tooth) Add’l procedure/new crown, existing partial denture Crown repair, by report
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
Endodontics
LS100
LS200
LS300
D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3910 D3920 D3950
$50.00 $45.00 $55.00 $50.00 $90.00 $150.00 $65.00 $55.00 $50.00 $50.00 $50.00 $50.00 $20.00 $15.00 $50.00 $20.00 $90.00 no charge
$80.00 $70.00 $90.00 $75.00 $100.00 $175.00 $85.00 $65.00 $65.00 $70.00 $70.00 $70.00 $30.00 $30.00 $60.00 $35.00 $105.00 $10.00
$95.00 $80.00 $95.00 $100.00 $150.00 $220.00 $95.00 $75.00 $75.00 $95.00 $95.00 $95.00 $45.00 $55.00 $70.00 $50.00 $120.00 $15.00
Periodontics
LS100
LS200
LS300
D4210 Gingivectomy/gingivoplasty, 4+ teeth per quadrant D4211 Gingivectomy/gingivoplasty, 1-3 teeth per quadrant D4240 Ging. flap procedure, 4+ teeth per quadrant D4241 Ging. flap procedure, 1-3 teeth per quadrant D4245 Apically positioned flap D4249 Clinical crown lengthening, hard tissue D4260 Osseous surgery, 4+ teeth per quadrant D4261 Osseous surgery, 1-3 teeth per quadrant D4263 Bone replacement graft, 1st site in quadrant D4264 Bone replacement graft, ea. additional site, quad. D4265 Biologic materials to aid soft osseous tissue D4266 Guided tissue regeneration-resorbable, per site D4267 Guided tissue regeneration- non resorbable, per site D4270 Pedicle soft tissue graft procedure D4271 Free soft tissue graft procedure (incl. donor site) D4273 Subepithelial connective tissue graft, per tooth D4274 Distal/proximal wedge procedure D4275 Soft tissue allograft D4320 Provisional splinting - intracoronal D4321 Provisional splinting - extracoronal GUIDELINE:
$40.00 $16.00 $85.00 $85.00 $96.00 $130.00 $200.00 $100.00 $75.00 $40.00 $95.00 $230.00 $275.00 $135.00 $135.00 $350.00 $90.00 $380.00 $45.00 $45.00
$70.00 $30.00 $115.00 $115.00 $125.00 $175.00 $250.00 $125.00 $120.00 $64.00 $115.00 $290.00 $375.00 $216.00 $216.00 $400.00 $105.00 $425.00 $72.00 $72.00
$95.00 $48.00 $150.00 $150.00 $155.00 $220.00 $325.00 $250.00 $147.00 $78.00 $135.00 $360.00 $425.00 $236.00 $236.00 $425.00 $120.00 $460.00 $80.00 $80.00
$20.00 $10.00 $20.00 $15.00 $35.00 no charge
$30.00 $15.00 $30.00 $18.00 $40.00 $5.00
$45.00 $23.00 $35.00 $25.00 $45.00 $10.00
Prosthodontics – removable
LS100
LS200
LS300
D5110 D5120 D5130
$120.00 $120.00 $120.00
$175.00 $175.00 $175.00
$250.00 $250.00 $250.00
Treatment of root canal obstruction; non-surgical Incomplete endodontic therapy, inoperable Internal root repair of perforation defects Retreatment of previous root canal – anterior Retreatment of previous root canal – bicuspid Retreatment of previous root canal – molar Apexification/recalcification/pulp reg. – initial visit Apexification/recalcification/pulp reg. – interim med. Apexification/recalcification – final visit Apicoectomy/periradicular surgery – anterior Apicoectomy/periradicular surgery – bicuspid Apicoectomy/periradicular surgery – molar Apicoectomy/periradicular surgery – ea. add. root Retrograde filling – per root Root Amputation – per root Surgical procedure for isolation with rubber dam Hemisection (incl. root removal), not incl. root canal Canal prep. & fitting of preformed dowel/post
No more than two (2) quadrants of periodontal scaling and root planing per appointment/per day are allowable. D4341 D4342 D4355 D4381 D4910 D4920
Periodontal scaling & root planing, 4+ teeth/quad. Periodontal scaling & root planing, 1-3 teeth/quad. Full mouth debridement Localized delivery of antimicrobial agent/per tooth Periodontal maintenance Unscheduled dressing change/non-treating dentist Complete denture, maxillary Complete denture, mandibular Immediate denture, maxillary
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
Prosthodontics – removable—continued
LS100
LS200
LS300
D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811
Immediate denture, mandibular Maxillary partial denture, resin base Mandibular partial denture, resin base Maxillary partial denture, cast metal/resin base Mandibular partial denture, cast metal/resin base Maxillary partial denture, flexible base Mandibular partial denture, flexible base Removable unilateral partial denture, 1 pc. cast Adjust complete denture, maxillary Adjust complete denture, mandibular Adjust partial denture, maxillary Adjust partial denture, mandibular Repair broken complete denture base Replace missing/broken teeth, complete denture Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth, per tooth Add tooth to existing partial denture Add clasp to existing partial denture Replace all teeth & acrylic/cast metal frame, max. Replace all teeth & acrylic/cast metal frame, mand. Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture, chairside Reline complete mandibular denture, chairside Reline maxillary partial denture, chairside Reline mandibular partial denture, chairside Reline complete maxillary denture, laboratory Reline complete mandibular denture, laboratory Reline maxillary partial denture, laboratory Reline mandibular partial denture, laboratory Interim complete denture, maxillary Interim complete denture, mandibular
$120.00 $110.00 $110.00 $150.00 $150.00 $150.00 $150.00 $105.00 no charge no charge no charge no charge no charge $5.00 no charge no charge $5.00 $5.00 $5.00 $5.00 $88.00 $88.00 $35.00 $35.00 $35.00 $35.00 no charge no charge no charge no charge $30.00 $30.00 $30.00 $30.00 $88.00 $88.00
$175.00 $120.00 $120.00 $180.00 $180.00 $180.00 $180.00 $145.00 no charge no charge no charge no charge $15.00 $10.00 $15.00 $15.00 $10.00 $10.00 $10.00 $10.00 $105.00 $105.00 $75.00 $75.00 $75.00 $75.00 $16.00 $16.00 $16.00 $16.00 $50.00 $50.00 $50.00 $50.00 $100.00 $100.00
$250.00 $205.00 $205.00 $235.00 $235.00 $235.00 $235.00 $225.00 $14.00 $14.00 $14.00 $14.00 $30.00 $27.00 $30.00 $40.00 $25.00 $25.00 $25.00 $25.00 $130.00 $130.00 $144.00 $144.00 $144.00 $144.00 $25.00 $25.00 $25.00 $25.00 $75.00 $75.00 $75.00 $75.00 $130.00 $130.00
D5820 D5821 D5850 D5851
Interim partial denture, maxillary Interim partial denture, mandibular Tissue conditioning, maxillary Tissue conditioning, mandibular
$20.00 $20.00 no charge no charge
$40.00 $40.00 no charge no charge
$90.00 $90.00 $22.00 $22.00
LS100
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Implants
GUIDELINE:
Implants and all services associated with implants are listed at the actual member co-payment amount. No additional fee is allowable for porcelain, noble metal, high noble metal, or titanium for implants and procedures associated with implants. D6010 D6056 D6058 D6059 D6060 D6061 D6062 D6063
Surgical placement of implant body, endosteal Prefabricated abutment, includes placement Abutment supported porcelain/ceramic crown Abutment supported porcelain/high noble crown Abutment supported porcelain/base metal crown Abutment supported porcelain/noble metal crown Abutment supported cast metal crown, high noble Abutment supported cast metal crown, base metal
$2000.00 $210.00 $1110.00 $1096.00 $1035.00 $1056.00 $1003.00 $861.00
$2000.00 $210.00 $1110.00 $1096.00 $1035.00 $1056.00 $1003.00 $861.00
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
$2000.00 $210.00 $1110.00 $1096.00 $1035.00 $1056.00 $1003.00 $861.00
Implants—continued
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D6064 D6094 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6194 D6075 D6076 D6077 D6092 D6093
$912.00 $670.00 $1040.00 $1013.00 $984.00 $1110.00 $1096.00 $1035.00 $1056.00 $1028.00 $930.00 $1005.00 $670.00 $1092.00 $1064.00 $984.00 $45.00 $65.00
$912.00 $670.00 $1040.00 $1013.00 $984.00 $1110.00 $1096.00 $1035.00 $1056.00 $1028.00 $930.00 $1005.00 $670.00 $1092.00 $1064.00 $984.00 $45.00 $65.00
$912.00 $670.00 $1040.00 $1013.00 $984.00 $1110.00 $1096.00 $1035.00 $1056.00 $1028.00 $930.00 $1005.00 $670.00 $1092.00 $1064.00 $984.00 $45.00 $65.00
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Abutment supported cast metal crown, noble metal Abutment supported crown, titanium Implant supported porcelain/ceramic crown Implant supported porcelain/metal crown Implant supported metal crown Abutment supported retainer, porcelain/ceramic FPD Abutment supported retainer, metal FPD, high noble Abut. support. retainer, porc./metal FPD, base metal Abut. support. retainer, porc./metal FPD, noble Abut. support. retainer, cast metal FPD, high noble Abut. support. retainer, cast metal FPD, base metal Abut. support. retainer, cast metal FPD, noble Abut. supported retainer crown, FPD, titanium Implant supported retainer for ceramic FPD Implant supported retainer for porc./metal FPD Implant supported retainer for cast metal FPD Recement implant/abutment supported crown Recement implant/abutment supported FPD
Prosthodontics - fixed
* GUIDELINES for Pontics and Abutment Inlays, Onlays and Crowns
The total maximum amount chargeable to the member for elective upgraded procedures (explained below) is $250.00 per tooth. Providers are required to explain covered benefits as well as any elective differences in materials and fees prior to providing an elective upgraded procedure. 1.
Brand name restorations (e.g. Sunrise, Captek, Vitadur-N, Hi-Ceram, Optec, HSP, In-Ceram, Empress, Cerec, AllCeram, Procera, Lava, etc.) may be considered elective upgraded procedures if their related CDT procedure codes are not listed as covered benefits.
2.
Benefits for anterior and bicuspid teeth: Resin, porcelain and any resin to base metal or porcelain to base metal crowns are covered benefits for anterior and bicuspid teeth. Adding a porcelain margin may be considered an elective upgraded procedure.
3.
Benefits for molar teeth: Cast base metal restorations are covered benefits for molar teeth. Resin-based composite and porcelain/ceramic crowns are not covered benefits on molar teeth. Any resin to metal or porcelain to metal crowns may be considered elective upgraded procedures. Adding a porcelain margin may be considered an elective upgraded procedure.
4.
Base metal is the benefit. If elected, the member may be charged additional lab costs for a) noble metal, b) high noble metal, or c) titanium.
D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6600 D6601 D6602 D6603 D6604 D6605 D6606
Pontic, indirect resin based composite Pontic, cast high noble metal Pontic, cast predominantly base metal Pontic, cast noble metal Pontic, titanium Pontic, porcelain fused to high noble metal Pontic, porcelain fused to predominantly base metal Pontic, porcelain fused to noble metal Pontic, porcelain/ceramic Pontic, resin with high noble metal Pontic, resin with predominantly base metal Pontic, resin with noble metal Provisional pontic Retainer, cast metal for resin bonded fixed prosth. Retainer, proc./ceramic, resin bonded fixed prosth. Inlay, porcelain/ceramic, 2 surfaces Inlay, porcelain/ceramic, 3 or more surfaces Inlay, cast high noble metal, 2 surfaces Inlay, cast high noble metal, 3 or more surfaces Inlay, cast base metal, 2 surfaces Inlay, cast base metal, 3 or more surfaces Inlay, cast noble metal, 2 surfaces
$60.00* $70.00* $70.00 $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00 $70.00* $50.00 $90.00* $100.00* $85.00* $90.00* $85.00 $85.00 $60.00*
$85.00* $100.00* $100.00 $100.00* $100.00* $115.00* $115.00* $115.00* $100.00* $90.00* $90.00* $90.00* $90.00 $90.00* $80.00 $140.00* $150.00* $140.00* $145.00* $140.00 $145.00 $135.00*
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
$150.00* $185.00* $175.00 $175.00* $175.00* $185.00* $185.00* $185.00* $175.00* $175.00* $175.00* $175.00* $120.00 $110.00* $90.00 $160.00* $165.00* $150.00* $160.00* $150.00 $160.00 $150.00*
Prosthodontics - fixed—continued
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D6607 D6624 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6793 D6794 D6930 D6940 D6970 D6972 D6973 D6976 D6977 D6980
$85.00* $95.00 $100.00* $105.00* $100.00* $100.00* $90.00 $95.00 $90.00* $95.00* $95.00* $60.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00* $70.00 $70.00* $70.00* $70.00* $70.00 $70.00* $40.00 $70.00* no charge $10.00 $20.00* $20.00 $20.00 $20.00* $20.00 $15.00
$145.00* $145.00 $160.00* $ 165.00* $155.00* $155.00* $145.00 $155.00 $145.00* $150.00* $155.00* $85.00* $90.00* $90.00* $90.00* $100.00* $115.00* $115.00* $115.00* $115.00* $100.00 $100.00* $100.00* $100.00* $100.00 $100.00* $65.00 $100.00* no charge $15.00 $30.00* $30.00 $30.00 $50.00* $50.00 $24.00
$165.00* $165.00 $175.00* $180.00* $175.00* $175.00* $160.00 $170.00 $160.00* $165.00* $170.00* $150.00* $175.00* $175.00* $175.00* $175.00* $185.00* $185.00* $185.00* $185.00* $190.00 $190.00* $195.00* $175.00* $175.00 $175.00* $75.00 $175.00* $17.00 $21.00 $50.00* $50.00 $50.00 $55.00* $55.00 $30.00
Oral and maxillofacial surgery
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D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7261 D7270 D7280 D7282 D7283 D7285
no charge no charge $15.00 $45.00 $55.00 $80.00 $130.00 $40.00 $95.00 $55.00 $95.00 $30.00 $30.00 no charge
no charge $8.00 $20.00 $68.00 $100.00 $130.00 $140.00 $45.00 $152.00 $75.00 $105.00 $48.00 $45.00 $15.00
$5.00 $15.00 $35.00 $115.00 $145.00 $175.00 $195.00 $50.00 $170.00 $95.00 $140.00 $55.00 $55.00 $25.00
Inlay, cast noble metal, 3 or more surfaces Inlay, Titanium Onlay, porcelain/ceramic, 2 surfaces Onlay, porcelain/ceramic, 3 or more surfaces Onlay, cast high noble metal, 2 surfaces Onlay, cast high noble metal, 3 or more surfaces Onlay, cast base metal, 2 surfaces Onlay, cast base metal, 3 or more surfaces Onlay, cast noble metal, 2 surfaces Onlay, cast noble metal 3 or more surfaces Onlay, titanium Crown, indirect resin based composite Crown, resin with high noble metal Crown, resin with predominantly base metal Crown, resin with noble metal Crown, porcelain/ceramic Crown, porcelain fused to high noble metal Crown, porcelain fused to predominantly base metal Crown, porcelain fused to noble metal Crown, 3/4 cast high noble metal Crown, 3/4 cast predominantly base metal Crown, 3/4 cast noble metal Crown, 3/4 porcelain/ceramic Crown, full cast high noble metal Crown, full cast predominantly base metal Crown, full cast noble metal Provisional retainer crown Crown, titanium Recement fixed partial denture Stress breaker Post & core in addition to FPD retainer, indirect Prefabricated post & core in add. to FPD retainer Core buildup for retainer, including any pins Each additional indirectly fabricated post/same tooth Each additional prefabricated post, same tooth Fixed partial denture repair, by report Extraction, coronal remnants, deciduous tooth Extraction, erupted tooth or exposed root Surgical removal of erupted tooth Removal of impacted tooth, soft tissue Removal of impacted tooth, partially bony Removal of impacted tooth, completely bony Removal impacted tooth, complete bony,complication Surgical removal residual tooth roots, cutting proc. Primary closure of a sinus perforation Tooth reimplantation/stabilization, accident Surgical access of an unerupted tooth Mobilization of erupted/malpositioned tooth Placement, device to facilitate eruption, impaction Biopsy of oral tissue, hard (bone, tooth)
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
Oral and maxillofacial surgery—continued
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D7286 D7287 D7288 D7310 D7311 D7320 D7321 D7340 D7350 D7450 D7451 D7460 D7461 D7471 D7472 D7473 D7485 D7510 D7511 D7520 D7521 D7530 D7560 D7960 D7963 D7970 D7971
no charge $10.00 $10.00 $30.00 $30.00 $35.00 $50.00 $40.00 $55.00 $45.00 $90.00 $50.00 $70.00 $55.00 $40.00 $40.00 $30.00 $5.00 $10.00 $5.00 $8.00 $10.00 $25.00 no charge no charge $40.00 $30.00
$15.00 $20.00 $20.00 $45.00 $40.00 $50.00 $60.00 $64.00 $88.00 $70.00 $144.00 $80.00 $112.00 $85.00 $65.00 $65.00 $40.00 $10.00 $15.00 $10.00 $12.00 $12.00 $40.00 no charge no charge $45.00 $40.00
$25.00 $30.00 $30.00 $70.00 $60.00 $70.00 $70.00 $70.00 $100.00 $80.00 $160.00 $90.00 $125.00 $100.00 $75.00 $75.00 $60.00 $15.00 $25.00 $15.00 $20.00 $18.00 $45.00 $25.00 $25.00 $55.00 $45.00
Adjunctive general services
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D9110 Palliative (emergency) treatment, minor procedure D9120 Fixed partial denture sectioning D9210 Local anesthesia not with operative/surgical proced. D9211 Regional block anesthesia D9212 Trigeminal division block anesthesia D9215 Local anesthesia with operative/surgical procedure ** GUIDELINE:
$5.00 no charge no charge no charge no charge no charge
$10.00 no charge no charge no charge no charge no charge
$20.00 $5.00 no charge no charge no charge no charge
Biopsy of oral tissue, soft Exfoliative cytological sample collection Brush biopsy, tranepithelial sample collection Alveoloplasty with extractions, 4+ teeth, quadrant Alveoloplasty with extractions, 1-3 teeth, quadrant Alveoloplasty, w/o extractions, 4+ teeth, quadrant Alveoloplasty, w/o extractions, 1-3 teeth, quadrant Vestibuloplasty, ridge extension (2nd epithelialization) Vestibuloplasty, ridge extension Removal, benign odotogenic cyst/tumor, up to 1.25 Removal, benign odotogenic cyst/tumor, over 1.25 Removal, benign nonodontogenic cyst/tumor, to 1.25 Removal, benign nonodontogenic cyst/tumor, 1.25+ Removal of lateral exostosis, maxilla or mandible Removal of torus palatinus Removal of torus mandibularis Surgical reduction of osseous tuberosity Incision & drainage of abscess, intraoral soft tissue Incision/drainage, abscess, intraoral soft, complicated Incision & drainage, abscess, extraoral soft tissue Incision/drainage, abscess, extraoral soft, complicate Remove foreign body, mucosa, skin, tissue Maxillary sinusotomy, remove th. frag./foreign body Frenulectomy (frenectomy or frenotomy), sep. proc. Frenuloplasty Excision of hyperplastic tissue, per arch Excision of pericoronal gingival
Deep sedation/general anesthesia is a covered benefit only when in conjunction with covered oral surgery and pedodontic procedures when dispensed in a dental office by a practitioner acting within the scope of his/her licensure; and when warranted by documented conditions that local anesthetic is contraindicated. General anesthesia, as used for dental pain control, means the elimination of all sensations accompanied by a state of unconsciousness. Patient apprehension and/or nervousness are not of themselves sufficient justification for deep sedation/general anesthesia or intravenous conscious sedation/analgesia. D9220 D9221 D9230 D9241 D9242 D9248 D9310 D9430 D9440 D9450 D9630 D9910
Deep sedation/general anesthesia, 1st 30 minutes Deep sedation/general anesthesia, each add. 15 min. Inhalation of nitrous oxide/analgesia, anxiolysis Intravenous conscious sedation/analgesia, 1st 30 min. IV conscious sedation/analgesia, each add. 15 min. Non-intravenous conscious sedation Consultation, other than requesting dentist Office visit, observation, regular hrs., no other serv. Office visit, after regularly scheduled hours Case presentation, detailed & extensive treatment Other drugs and/or medicaments, by report Application of desensitizing medicament
$ $100.00** $15.00 $ $70.00** $100.00 no charge no charge $25.00 no charge $15.00 no charge
165.00** $110.00** $30.00 165.00** $90.00** $100.00 no charge no charge $30.00 no charge $20.00 no charge
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
$195.00** $ 125.00** $40.00 $185.00** $ 100.00** $100.00 $50.00 no charge $35.00 no charge $25.00 $5.00
Adjunctive general services—continued
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D9911 D9930 D9940 D9942 D9950 D9951 D9952 D9971 D9972
no charge no charge $100.00 $40.00 no charge $10.00 $10.00 $5.00 $175.00 $10.00 no charge
no charge $5.00 $115.00 $50.00 no charge $15.00 $20.00 $5.00 $185.00 $20.00 no charge
$5.00 $10.00 $130.00 $55.00 no charge $15.00 $30.00 $10.00 $210.00 $20.00 no charge
Orthodontic services
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D0340 D0470 D9310 D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680
$100.00 $75.00 $0.00 $1,300.00 $1,300.00 $1,300.00 $1,300.00 $500.00 $500.00 $1,550.00 $1,550.00 $1,695.00 $350.00 $350.00 $0.00 $0.00 $250.00
$100.00 $75.00 $0.00 $1,300.00 $1,300.00 $1,300.00 $1,300.00 $500.00 $500.00 $1,550.00 $1,550.00 $1,695.00 $350.00 $350.00 $0.00 $0.00 $250.00
$100.00 $75.00 $0.00 $1,300.00 $1,300.00 $1,300.00 $1,300.00 $500.00 $500.00 $1,550.00 $1,550.00 $1,695.00 $350.00 $350.00 $0.00 $0.00 $250.00
$20.00
$20.00
$20.00
Application of desensitizing resin, per tooth Treatment of complications, post surgical, unusual Occlusal guard, by report Repair and/or reline of occlusal guard Occlusion analysis, mounted case Occlusal adjustment, limited Occlusal adjustment, complete Odontoplasty 1-2 teeth External bleaching – per arch Broken appointment, less than 24 hour notice Office visit, per visit Cephalometric x-ray and tracings for orthodontic puposes Diagnostic casts for orthodontic purposes Initial consultation for orthodontic purposes Limited orthodontic treatment of the primary dentition Limited orthodontic treatment of the transitional dentition Limited orthodontic treatment of the adolescent dentition Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment of the primary dentition Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the adolescent dentition Comprehensive orthodontic treatment of the adult dentition Removable appliance therapy Fixed appliance therapy Pre-orthodontic treatment visits Periodic orthodontic visits (as part of contract) Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Broken appointment (less than 24 hour notice)
LIBERTY Dental Plan will arrange for you to receive services from a contracted Dental Specialist if the necessary treatment is outside the scope of General Dentistry. Your General Dentist will initiate the referral process with LIBERTY Dental Plan. When you receive services from a Dental Specialist utilizing the proper referral process, the Member Co-Payments listed in this Copayment Schedule will apply. Underwritten by LIBERTY Dental Plan of California, Inc. For more information on participation, eligibility, and waiting periods, see the Plan Guidelines section.
CDT-2013/2014: Current Dental Terminology, © 2012 American Dental Association. All rights reserved.
thank you
for considering Humana Dental.
Dental PPO, Traditional Preferred, and Preventive Plus products are insured or administered by Humana Insurance Company or HumanaDental Insurance Company. LIBERTY Dental Plans are underwriten by LIBERTY Dental Plan of California, Inc. Be sure to capitalize Insurance Company, currently in lower case on document.
GN52018HD_CA 314
