Page 13 - 2022 Apollo Healthcare - Benefit Guide Oasis at Galleria Eff. 8-1-22
P. 13
Dental Options:
Mutual of Omaha
26 Pay Periods HIGH Plan LOW Plan Dependent Information
Employee Only $15.97 $ 8.36
We offer our employees and eligible dependents dental coverage.
Employee + Spouse $31.94 $14.84
Children can join or remain on a parent’s dental plan until age 26.
Employee + Child(ren) $38.30 $18.42 When a child turns 26, they will lose dental coverage on the last
Employee + Family $57.18 $28.08 day of their birth month. This is an automated process.
BRIEF OVERVIEW Amount You Pay—High Plan Amount You Pay—Low Plan
Non-Network Dentists Non-Network Dentists
Type of Service Reimbursed at 90% of U&C Reimbursed at Network Fee Maximum
Annual Deductible (CYD) $50 Individual / $150 Family $50 Individual / $150 Family
Preventive Services Covered at 100%; CYD Waived Covered at 100%; CYD Waived
Basic Services Covered at 80% after CYD Covered at 80% after CYD
Major Services Covered at 50% after CYD Covered at 50% after CYD
Annual Maximum $1,500 $1,000
The Rollover Benefit can increase your
The Rollover Benefit can increase your
Rollover Benefit (Additional annual maximum each year up to $375 to a annual maximum each year up to $250 to
Annual Maximum Benefits) maximum of $1,500 in the Rollover Benefit a maximum of $1,000 in your Rollover
Account. See policy summary for details! Benefit Account. See policy summary for
details!
Covered at 50% - CYD Waived
Orthodontia (Child Only) Not Covered
Lifetime Maximum of 1,500
Type of Service Benefit Description
See Summary of Benefits and Policy for the age and frequency limitations of benefits.
Oral Exams, Cleanings, X-rays, Brush Bi- Oral Exams, Cleanings, X-rays, Brush Biopsy/
opsy/Cancer Screen, Space Maintainers, Cancer Screen, Space Maintainers, Sealants,
Preventive Services
Sealants, Fluoride Treatment for Fluoride Treatment for Children
Children under age 16 under age 16
Fillings, Simple Extractions, Palliative Fillings, Palliative Treatments, Stainless Steel
Treatments, Oral Surgery, Stainless Steel Crowns, General Anesthesia,
Basic Services Crowns, General Anesthesia, Non-
Surgical or Surgical Periodontics and
Endodontics (Root Canals)
Crowns, Bridges, Full & Partial Dentures, Crowns, inlays, onlays, endodontics (root
Major Services Inlays & Onlays, Labial Veneers canals), periodontics, simple extractions, oral
surgery, bridges full or partial dentures
Annual Maximum Applies January 1 to December 31 Applies January 1 to December 31
Orthodontia Children under age 19 Not Covered
NOTE: This is only a brief overview. Please see Benefit
13 Summary and policy for more details.
