Pavement Restoration 2019

DENTAL INSURANCE

Pavement Restoration offers two dental plans through Mutual of Omaha. The Dental PPO Plan allows you to use in-network or out-of- network benefits. If out-of-network dentists are used, you will be responsible for pay the difference between Mutual of Omaha’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

Low Dental PPO Plan (Option 1)

High Dental PPO Plan (Option 2)

Out-of Network 1

In-Network

In-Network

Out-of Network 1

Calendar Year Deductible Individual

$50

$100 $300

$50

$50

Family

$150

$150

$150

Annual Maximum

$1,000

$1,500 $1,000

Diagnostic & Preventive Exams Cleanings Fluoride X-Rays Sealants Regular Restorative Services Fillings Extractions - Single Tooth Periodontics (Gum Disease) Endodontics (Root Canal) Major Services Crowns

Covered in full

Covered in full

Covered in full

Covered in full

Covered 80% after deductible

Covered 50% after deductible

Covered 80% after deductible

Covered 50% after deductible

Covered 50% after deductible

Covered 25% after deductible

Covered 50% after deductible

Covered 25% after deductible

Bridges Dentures Orthodontia Child Only

Not Available

Not Available

Not Available

Not Available

1 Subject to balance billing. Please refer to your plan document for specific details.

Low PPO Dental Plan (Option 1)

High PPO Dental Plan (Option 2)

Employee Contributions (Weekly)

Employee Only

$ 3.92 $ 9.00 $ 9.92 $14.54

$ 6.23 $14.31 $15.69 $23.08

Employee + Spouse Employee + Child(ren)

Family

5

Made with FlippingBook - Online Brochure Maker