INSURANCE

Jan 13 2020

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Humanaone dental

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Humanaone dental

Family prices are based on 3 members in the family.

Comments that are highlighted in Blue are observations by Savon

HumanaOne Dental Loyalty Plus Plan Exclusions And Limitations

This is an outline of the limitations and exclusions for the HumanaOne Dental Loyalty Plus plan:

    Any expenses incurred while you qualify for any worker�s compensation or occupational disease act or law, whether or not you applied for coverage.
    Since Savon is not Insurance, if you have workers’ compensation or are self-employed, you are still entitled to your Savon benefits.

  • Services:
    • A. That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law;
    • B. Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or
    • C. Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected with sickness or bodily injury.
  • Any loss caused or contributed by:
    • A. War or any act of war, whether declared or not;
    • B. Any act of international armed conflict; or
    • C. Any conflict involving armed forces of any international authority.
  • Any expense arising from the completion of forms.
  • Your failure to keep an appointment with the dentist.
  • Any service we consider cosmetic dentistry unless it is necessary as a result of an accidental injury sustained while you are covered under the policy. We consider the following cosmetic dentistry procedures:
    • A. Facings on crowns or pontics (the portion of a fixed bridge between the abutments) posterior to the second bicuspid.
    • B. Any service to correct congenital malformation;
    • C. Any service performed primarily to improve appearance; or
    • D. Characterizations and personalization of prosthetic devices.
  • Charges for:
    • A. Any type of implant and all related services, including crowns or the prosthetic device attached to it.
    • B. Precision or semi-precision attachments.
    • C. Overdentures and any endodontic treatment associated with overdentures.
    • D. Other customized attachments.
  • Any service related to:
    • A. Altering vertical dimension of teeth;
    • B. Restoration or maintenance of occlusion;
    • C. Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth; a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, Delta Dental will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law.
    • E. Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction; or
    • E. Bite registration or bite analysis.
  • Infection control, including but not limited to sterilization techniques.
  • Fees for treatment performed by someone other than a dentist except for scaling and teeth cleaning, and the topical application of fluoride that can be performed by a licensed dental hygienist. The treatment must be rendered under the supervision and guidance of the dentist in accordance with generally accepted dental standards.
  • Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
  • Prescription drugs or pre-medications, whether dispensed or prescribed.
  • Any service not specifically listed in your plan benefits.
  • Any service shown as �Not Covered� in the Schedule.
  • Any service that we determine:
    • A. Is not a dental necessity;
    • B. Does not offer a favorable prognosis;
    • C. Does not have uniform professional endorsement; or
    • D. Is deemed to be experimental or investigational in nature.
  • Orthodontic services.
    This is especially important for anyone in need of braces.

  • Any expense incurred before your effective date or after the date your coverage under the policy terminates.
  • Services provided by someone who ordinarily lives in your home or who is a family member.
  • Charges exceeding the reimbursement limit for the service.
  • Treatment resulting from any intentionally self-inflicted injury or bodily illness.
  • Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, temporary dental services, study models, treatment plans, occlusal adjustments, or tissue preparation associated with the impression or placement of a restoration when charged as a separate service. These services are considered an integral part of the entire dental service.
  • Repair and replacement of orthodontic appliances.
  • Any surgical or nonsurgical treatment for any jaw joint problems, including any temporomandibular joint disorder, craniomaxillary, craniomandibular disorder or other conditions of the joint linking the jaw bone and skull; or treatment of the facial muscles used in expression and chewing functions, for symptoms including, but not limited to, headaches.
  • Elective removal of non-pathologic impacted teeth.
  • HumanaOne Dental Preventive Plus and Veterans Major Dental Service Limits

    There is no coverage for major dental services including:

    1. Crowns
    2. Bridgework
    3. Dentures including repair and adjustments
    4. Periodontics such as periodontic cleanings and gum therapies
    5. Endodontics (root canals)
    6. Orthodontia services for Adult and children

    You may receive a discount on these services if you see participating dentists and ask for the discount. These services are not covered under this plan. Out-ofpocket expenses do not apply to deductible and annual maximum. Members are responsible for 100% of the discounted service.

    *Network providers are not required to offer non-covered services at a discounted rate. HumanaOne Dental encourages all providers to extend discounts, but can not legally require.

    **Composite (white) fillings are only covered on anterior (front) teeth. An alternate benefit is allowed for composite fillings on posterior (back) teeth where the plan will cover the cost of an amalgam (silver) filling and the member is responsible for any cost over the covered amount.

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    SOURCE: http://www.savondentalplan.com/exclusions/HumanaExclusions.php

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