Dental Plan C550

Humana

Overview

With the HumanaOne Dental Plan C550 (formerly CompBenefits Plan 550), you won’t be surprised by any hidden costs. There just aren’t any. Your dental needs are covered right from the start. Any pre-existing condition you may have is covered immediately and the plan can be purchased on a standalone basis without a Humana health insurance plan.

The HumanaOne Pre-Paid Dental Plan C550 gives you access to services with low co-payments through a wide network of dentists. This is a great plan for individuals who want:

  • No co-payments on many diagnostic and preventive procedures
  • Confidence that you will save money on dental care.
  • No benefit maximums

 

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Plan Features

  • 100% coverage on many diagnostic and preventive procedures. You pay nothing for this dental work.
  • Low $10 office visit co-payment
  • Discounts on Specialty Care and certain Cosmetic Procedures
  • No benefit maximum or claim forms
  • A provider network with more than 5,000 network dentists
  • Specialty care and some cosmetic procedures covered at a discount

How It Works

  • First, sign up for coverage. When you are filling in your application you will need to select your Primary Care Dentist from the dental directory list. Participating dentists are located near your home or office. Each dentist is licensed and is a skilled and experienced professional. CompBenefits carefully reviews the credentials of each dentist in the network before they are selected. Family members under the same plan may select different dentists. You can find a dentist by visiting Humana’s Dentist Finder.
  • When you see your participating dentist, you’ll receive no charge services on
    • X-rays
    • Routine Cleanings
    • Topical Flouride
    • Oral Exams
    • Local Anesthesia
  • You pay only the fees listed on the schedule of benefits.

Procedure Prices

Dental ServicesYou Pay
Office Visit$10 copayment
Periodic Oral Evaluation$0
X-rays$0
Filling (silver)$30
Filling (tooth-colored)$50
Extraction$35
View a list of procedure prices

Complete Procedure Price List

CodeServicesMember Pays

Appointments

D9310Consultation (diagnostic service provided by dentist other than practitioner providing treatment).$30.00
D9430Office visit (normal hours)$10.00
D9440Office visit (after regularly scheduled hours)$35.00
D9999Emergency visit during regularly scheduled hours, by report.$20.00
D9999Broken appointments (without 24 hr. notice, per 15 min) -maximum $40 per broken appointment. No charge will be made due to emergencies$10.00
Code

Diagnostic

Member Pays
D0120Periodic oral examinationno charge
D0140Limited/comprehensive/detailed and extensive oral evalno charge
D0150Limited/comprehensive/detailed and extensive oral evalno charge
D0160Limited/comprehensive/detailed and extensive oral evalno charge
D0180Comprehensive periodontal evaluation$25.00
D0210X-ray intraoral-complete series including bitewingsno charge
D0220X-ray intraoral-periapical, first filmno charge
D0230X-ray intraoral-periapical, each additional filmno charge
D0270X-ray bitewing-single filmno charge
D0272X-ray bitewings-two filmsno charge
D0274Bitewings-four filmsno charge
D0330Panoramic filmno charge
D0460Pulp vitality testsno charge
D0470Diagnostic castsno charge
Code

Preventive

Member Pays
D1110Prophylaxis-adult, routine (once every 6 months)no charge
D1120Prophylaxis-child, routine (once every 6 months)no charge
D1110Prophylaxis-adult/child, (additional)$35.00
D1120Prophylaxis-adult/child, (additional)$35.00
D1203Topical application of fluoride (not including prophylaxis)— child (up to 16 years of age)no charge
D1206Topical fluoride varnish (for child <16)no charge
D1330Oral hygiene instructionno charge
D1351Sealant-per tooth$20.00
D1510Space maintainer-fixed, unilateral$65.00 + lab
D1515Space maintainer-fixed, bilateral$65.00 + lab
D1520Space maintainer-removable, unilateral$105.00 + lab
D1525Space maintainer-removable, bilateral$105.00 + lab
D1550Recementation of space maintainer$20.00
Code

Restorative

Member Pays
D2140Amalgam-one surface, primary or permanent$30.00
D2150Amalgam-two surfaces, primary or permanent$35.00
D2160Amalgam-three surfaces, primary or permanent$40.00
D2161Amalgam-four or more surfaces, primary or permanent.$50.00
D2940Sedative filling$30.00
D2999Sedative base (under fillings), by reportno charge
Code

Resin Restorative

Member Pays
D2330Resin based composite-one surface, anterior$50.00
D2331Resin based composite-two surfaces, anterior$55.00
D2332Resin based composite-three surfaces, anterior$65.00
D2391Resin based composite-one surface, posterior$90.00
D2392Resin based composite-two surfaces, posterior$110.00
D2393Resin based composite-three surfaces, posterior$130.00
D2394Resin based composite-four or more surfaces, posterior$150.00
D2510Inlay-metallic, one surface$155.00
D2520Inlay-metallic, two surfaces$165.00
D2530Inlay-metallic, three or more surfaces$190.00
Code

Crown and Bridge

Member Pays
D2740Crown-porcelain/ceramic substrate$370.00 + lab
D2750*Crown-porcelain fused to high noble metal$370.00
D2751Crown-porcelain fused to predominantly base metal$370.00
D2752*Crown-porcelain fused to noble metal$370.00
D2790*Crown-full cast high noble metal$370.00
D2791Crown-full cast predominantly base metal$370.00
D2792*Crown-full cast noble metal$370.00
D2910Recement inlay$30.00
D2920Recement crown$30.00
D2930Prefabricated stainless steel crown-primary tooth$120.00
D2950Core buildup, including any pins$60.00
D2951Pin retention-per tooth, in addition to restoration$30.00
D2952Cast post and core in addition to crown$120.00 + lab
D2953Each additional cast post-same tooth$120.00 + lab
D2954Prefabricated post and core in addition to crown$120.00
D2962Labial veneer (porcelain laminate)—laboratory$370.00 + lab
Code

Endodontics

Member Pays
D3220Therapeutic pulpotomy$50.00
D3221Pulpal debridement, primary and permanent teeth$130.00
D3310Root canal therapy-anterior (excluding final restoration)$250.00
D3320Root canal therapy-bicuspid (excluding final restoration)$350.00
D3330Root canal therapy-molar (excluding final restoration)$450.00
D3410Apicoectomy/periradicular surgery-anterior$200.00
Code

Peridontics (gum treatment)

Member Pays
D4210Gingivectomy/gingivoplasty per quadrant$200.00
D4211Gingivectomy/gingivoplasty per tooth$55.00
D4341Periodontal scaling and root planing, per quadrant$65.00
D4342Periodontal scaling and root planing 1 to 3 teeth per quadrant$65.00
D4355Full mouth debridement to enable comprehensive evaluation and diagnosis$60.00
D4381Localized delivery of chemotherapeutic agents (per tooth)$60.00
D4910Periodontal maintenance$65.00
Code

Prosthodontics

Member Pays
D5110Complete denture-maxillary$375.00+lab
D5120Complete denture-mandibular$375.00+lab
D5130Immediate denture-maxillary$375.00+lab
D5140Immediate denture-mandibular$375.00+lab
D5211Maxillary partial denture-resin base$375.00+lab
D5212Mandibular partial denture-resin base$375.00+lab
D5213Maxillary partial denture-cast metal framework, resin denture bases$375.00+lab
D5214Mandibular partial denture-cast metal framework, resin denture bases$375.00+lab
D5410Adjust complete denture-maxillary$30.00
D5411Adjust complete denture-mandibular$30.00
D5421Adjust partial denture-maxillary$30.00
D5422Adjust partial denture-mandibular$30.00
Code

Repairs to prosthetics

Member Pays
D5510Repair broken complete denture base$30.00+lab
D5520Replace missing or broken teeth-complete denture (each tooth)$30.00+lab
D5610Repair resin denture base$30.00+lab
D5630Repair or replace broken clasp$30.00+lab
D5640Replace broken teeth-per tooth$30.00+lab
D5650Add tooth to existing partial denture$45.00+lab
D5730Reline complete maxillary denture (chairside)$65.00
D5731Reline complete mandibular denture (chairside)$65.00
D5740Reline maxillary partial denture (chairside)$65.00
D5741Reline mandibular partial denture (chairside)$65.00
D5750Reline complete maxillary denture (laboratory)$50.00+lab
D5751Reline complete mandibular denture (laboratory)$50.00+lab
D5760Reline maxillary partial denture (laboratory)$50.00+lab
D5761Reline mandibular partial denture (laboratory)$50.00+lab
D5850Tissue conditioning-maxillary$45.00
D5851Tissue conditioning-mandibular$45.00
Code

Prosthodontics (fixed)

Member Pays
D6210*Pontic-cast high noble metal$370.00
D6211Pontic-cast predominantly base metal$370.00
D6212*Pontic-cast noble metal$370.00
D6240*Pontic-porcelain fused to high noble metal$370.00
D6241Pontic-porcelain fused to predominantly base metal$370.00
D6242*Pontic-porcelain fused to noble metal$370.00
D6750*Crown-porcelain fused to high noble metal$370.00
D6751Crown-porcelain fused to predominantly base metal$370.00
D6752*Crown-porcelain fused to noble metal$370.00
D6790*Crown-full cast high noble metal$370.00
D6791Crown-full cast predominantly base metal$370.00
D6792*Crown-full cast noble metal$370.00
D6930Recement fixed partial denture (per unit)$25.00
Code

Extractions/oral and maxillofacial surgery

Member Pays
D7111Coronal remnants, deciduous tooth$35.00
D7140Extraction, erupted tooth or exposed tooth$35.00
D7210Surgical removal of erupted tooth$55.00
D7220Removal of impacted tooth-soft tissue$100.00
D7230Removal of impacted tooth-partially bony$125.00
D7240Removal of impacted tooth-completely bony$150.00
D7250Surgical removal of residual tooth roots$65.00
D7310Alveoloplasty in conjunction with extractions-per quadrant$65.00
D7311Alveoplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant$65.00
D7320Alveoloplasty not in conjunction with extractions-per quadrant$100.00
D7321Alveoplasty not in conjunction with extractions-one to three teeth or tooth spaces, per quadrant$100.00
D7510Incision and drainage of abscess-intraoral$40.00
Code

Anesthesia

Member Pays
D9215Local anesthesiano charge
D9230Analgesia (nitrous oxide), per 15 minutes$30.00
Code

Adjunctive general services

Member Pays
D9450Case presentation, detailed and extensive treatment planningno charge
D9951Occlusal adjustment-limited$40.00
D9952Occlusal adjustment-complete$225.00

Orthodontics

NOTE: Members can receive a 25 percent savings by visiting an in-network orthodontist.

* 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:

  1. NOT ALL PARTICIPATING DENTISTS PERFORM ALL LISTED PROCEDURES, INCLUDING AMALGAMS. PLEASE CONSULT YOUR DENTIST PRIOR TO TREATMENT FOR AVAILABILITY OF SERVICES.
  2. UNLISTED PROCEDURES ARE AT THE DENTIST’S USUAL FEE LESS 25 percent INCLUDING, BUT NOT LIMITED TO, MAXILLOFACIAL PROSTHETICS, ENAMEL MICROABRASION, AND BLEACHING.
  3. WHEN CROWN AND/OR BRIDGEWORK EXCEEDS SIX UNITS IN THE SAME TREATMENT PLAN, THE PATIENT MAYBE CHARGED AN ADDITIONAL $50.00 PER UNIT.
Waiting Periods on Types of Services
PreventiveNone
DiagnosticNone
BasicNone
MajorNone

Preventive care

  • Routine oral exams
  • Prophylaxis (cleaning and scaling of teeth) – two per year
  • Topical fluoride application (up to age 16 and not including prophylaxis) – two per calendar year

Diagnostic care

  • Intra-oral occlusal film
  • Bitewing X-rays (up to a set of four)
  • Full-mouth X-rays (panoramic film)

Endodontics care

  • Root canal therapy
  • Pulpal debridement, primary and permanent teeth
  • Apexification/recalcification
  • Apicoectomy/periradicular surgery

Periodontics care

  • Gingivectomy/gingivoplasty
  • Osseous surgery
  • Pedicle/free soft tissue grafts
  • Periodontal scaling and root planing

Orthodontia

  • NOTE: Members can receive a 25 percent savings by visiting an in-network orthodontist.

Plan C550 Rates

FeePrice
One-Time Enrollment Fee$35.00 (total)
The fee for both 1 person or 4 persons is $35.
Monthly Premium (1 person)$14.18
Monthly Premium (2 persons)$23.50
Monthly Premium (3 persons)$31.52
Monthly Premium (4 persons)$39.37
Monthly Admin Fee
(Included in rates above, waived if you pay yearly)
$1.00

Effective Dates

DHMO (Dental C550) effective dates are calculated as follows:

  • If application is received between the 1st and 15th of the month, the policy effective date will be the 1st of the following month 1. Example: Application received on May 10th will have an effective date of June 1st.
  • If application is received between the 16th and end of the month, the policy effective date will be the 1st of the 2nd following month (the month after the following month) 1. Example: Application received May 18th for processing will have a policy effective date of July 1st.

The reason for the difference in effective dates is due to the member having to select a primary care dentist and being included in the monthly membership rosters sent to providers.

Can I Terminate My Coverage at Anytime?

No, there is a one year contract with these plans. However, Dental C550 members can terminate their coverage within the first 30 days of their effective date, but they will only be refunded their premium (not enrollment fee) and will be responsible for any claims incurred during this time. After the 30 day window, cancellations are not accepted unless for approved exceptions.

Payment Options

Payment options include monthly and annual bank draft, monthly and annual credit card payments (Visa and MasterCard), and monthly and annual bills.

After Enrollment

After enrollment, members will receive a welcome packet and ID cards 7-10 days after the application is received and enrollment is processed, and should bring their ID cards with them when visiting the dentist. Members should inform their provider of their plan when scheduling their appointment to avoid any issues at the time of service.

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