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Benefit
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Milwaukee County Conventional Plan
(Humana Dental)
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FirstCommonwealth
(DMO)
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Care-Plus (DMO)
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Network of providers
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Services may be performed by the dentist of your choice
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Services must be performed at a First Cornmonweath provider
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Services must be performed at a Dental Associates, Ltd. Dental Center
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Annual Maximum Benefit
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$1,000 per person
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No maximum
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No Maximum
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Annual Deductible
Diagnostic and Preventive:
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$25 per person
(Maximum of 3 deductibles per family per year)
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None
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None
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- Dental exams and cleanings
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100% of approved charges (1)
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100% of approved charges
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100% of approved charges
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- Bitewing x-rays
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100% of approved charges (1)
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100% of approved charges
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100% of approved charges
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- Full mouth x-rays
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100% of approved charges (2)
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100% of approved charges
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100% of approved charges
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Minor Restorations
(regular fillings: acrylics, amalgams, & composites)
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80% of approved charges
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100% of approved charges
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100% of approved charges
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Major Restorations (crowns, inlays, onlays)
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50% of approved charges
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100% of approved charges3
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100% of approved charges3
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Prosthetics
(dentures, bridges)
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50% of approved charges
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100% of approved charges3
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100% of approved charges3
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Simple Extractions
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80% of approved charges
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100% of approved charges
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100% of approved charges
|
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Endodontics
(root canal treatment)
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80% of approved charges
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100% of approved charges
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100% of approved charges
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Periodontics
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80% of approved charges
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100% of approved charges
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100% of approved charges
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Orthodontics
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50% of approved charges with a $1500 life time maximum benefit
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100% of approved charges
(includes coverage for adults if approved by the plan) after $450 maximum patient payment.
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100% of approved charges (includes coverage for adults if
approved by the plan) after $450 maximum patient payment.
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Emergency Treatment
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80% of approved charges
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100% of approved charges at
network provider. All other
providers limited to a $50.00 benefit maximum
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100% of approved charges at
network provider. All other
providers limited to a $50.00 benefit maximum
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Ancillary Services
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80% of approved charges
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100% of approved charges
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100% of approved charges
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Oral Surgery
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80% of approved charges
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100% of approved charges
(surgeon fee only)
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100% of approved charges
(surgeon fee only)
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