Page 18 - Phil Chai - Benefit Guide Phil Chai Corporate 3-1-2021 Final

Dental Option:

Mutual of Omaha

Rate Per Pay Period Dependent Information

Our company offers employees the opportunity to cover their de-
Employee Only $13.30
pendent children. Children can join or remain on a parent’s dental
plan until age 26.
Employee + One $30.44
When a child turns 26, they will lose dental coverage on the last
day of their birth month.
Employee + Two or More $45.30

(In-Network) Amount Paid
Type of Service Out of Network is Paid @ 90% of R&C

Preventive Services Covered at 100%; No Deductible

Basic Services Covered at 80% after Calendar Year Deductible

Major Services Covered at 50% after Calendar Year Deductible

Orthodontia Services Covered at 50% No Deductible to a Lifetime Maximum of $1,000 person

Calendar Year Deductible $50 Individual / $150 Family

Annual Maximum $1,000 Per Person

Waiting Periods for Major Services or Ortho NONE if you enroll during your enrollment period

Type of Service Benefit Description

Oral Exams, Cleanings, X-rays, Brush Biopsy/Cancer Screen, Space
Preventive Services
Maintainers, Sealants, Fluoride Treatment for Children under age 16

Fillings, Simple Extractions, Space Maintainers, Oral Surgery, General
Basic Services
Anesthesia, Endodontics and Periodontics

Major Services Crowns, Bridges, Full & Partial Dentures, Inlays & Onlays & Implants

Annual Maximum Applies January 1 to December 31
Orthodontia Only applies to children under age 19

NOTE: This is only a brief overview. Please see the Benefit Summary for more details.

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