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
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