The Company offers dental 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 to pay the difference between Mutual Of Omaha’s allowed amount and what the dentist may charge, also known as “balance billing”. Mutual Of Omaha uses several Dental Networks to provide you plenty of options. You can find a dentist by visiting www. mutualofomaha.com/dental or calling 877-999-2330 for more information. The chart below provides a brief overview of the plan. DENTAL INSURANCE
Dental PPO Plan
In-Network
Out-of Network*
Calendar Year Deductible Individual
$50
$50
$150
$150
Family
Annual Maximum
$1,000 Per Person
Diagnostic & Preventive Exams
Cleanings Fluoride X-Rays Sealants Regular Restorative Services Amalgam Fillings Extractions - Single Tooth Endodontics (Root Canal) Periodontics (Gum Disease) Major Services Crowns Bridges Dentures Orthodontia Dependents under 19 years old
Covered in full
Covered in full
Covered at 90% after deductible
Covered at 80% after deductible
Covered at 60% after deductible
Covered at 50% after deductible
50% ($1,000 lifetime maximum)
• Out of network claims are subject to reasonable and customary charges. • If you or your dependents do not enroll when first eligible, there is a 12 month waiting period for Basic, Major and Orthodontia coverage.
Employee Cost Per Pay Period
Employee Only
$ 5.15 $12.12 $12.85 $20.26
Employee + Spouse Employee + Child(ren)
Family
6
Made with FlippingBook - Online catalogs