|
Benefit |
Milwaukee County
Conventional Plan
(Humana Dental) |
First Commonwealth
(DMO) |
Care-Plus (DMO) |
|
Network of providers |
Services may be performed by the dentist of your choice |
Services must be performed at a First Cornmonweath provider |
Services must be performed at a Dental Associates, Ltd. Dental Center |
|
Annual Maximum Benefit |
$1,000 per person |
No maximum |
No Maximum |
|
Annual Deductible
Diagnostic and Preventive: |
$25 per person
(Maximum of 3 deductibles per family per year) |
None |
None |
|
- Dental exams and cleanings |
100% of approved charges (1) |
100% of approved charges |
100% of approved charges |
|
- Bitewing x-rays |
100% of approved charges (1) |
100% of approved charges |
100% of approved charges |
|
- Full mouth x-rays |
100% of approved charges (2) |
100% of approved charges |
100% of approved charges |
|
Minor Restorations
(regular fillings: acrylics, amalgams, & composites) |
80% of approved charges |
100% of approved charges |
100% of approved charges |
|
Major Restorations (crowns, inlays, onlays) |
50% of approved charges |
100% of approved charges3 |
100% of approved charges3 |
|
Prosthetics
(dentures, bridges) |
50% of approved charges |
100% of approved charges3 |
100% of approved charges3 |
|
Simple Extractions |
80% of approved charges |
100% of approved charges |
100% of approved charges |
|
Endodontics
(root canal treatment) |
80% of approved charges |
100% of approved charges |
100% of approved charges |
|
Periodontics |
80% of approved charges |
100% of approved charges |
100% of approved charges |
|
Orthodontics |
80% of approved charges |
100% of approved charges
(includes coverage for adults if
approved by the plan) |
100% of approved charges
(includes coverage for adults if
approved by the plan) |
|
Emergency Treatment |
80% of approved charges |
100% of approved charges at
network provider. All other
providers limited to a $50.00 benefit maximum |
100% of approved charges at
network provider. All other
providers limited to a $50.00 benefit maximum |
|
Ancillary Services |
80% of approved charges |
100% of approved charges |
100% of approved charges |
|
Oral Surgery |
80% of approved charges |
100% of approved charges
(surgeon fee only) |
100% of approved charges
(surgeon fee only) |
Notes: This at-a-glance guide is intended as a summary only. For specific terms, provisions, conditions, limitations, or
exclusions, please refer to your Summary Plan Description.
(1) limited to one service per 6 months
(2) limited to 1 service per 36 months
(3) Precious metal (Noble/High Noble) costs are extra and are the responsibility of the patient/insured
*Note: Dental plans are only for active employees and their dependents.
Milwaukee County is an equal opportunity/affirmative action employer that is actively seeking qualified applicants for various positions throughout County government. Milwaukee County does not discriminate based on age, ancestry/national origin, arrest/conviction record, color, creed, disability, marital status, military membership, race, sex or sexual orientation.
If special accommodations are needed, please contact 414-278-4143. |