Page 12 - Revelations Group 2 - 2021 Arl. Res. Benefit Guide (R3)

Dental Option:

Mutual of Omaha

26 Pay Period Dependent Information

Employee Only $15.74 The Revelations HealthCare Group Company offers
employees the opportunity to cover their dependent
Employee + Spouse $31.33
children. Children can join or remain on a parent’s
dental plan until age 26.
Employee + Child(ren) $36.00
When a child turns 26, they will lose dental coverage
Employee + Family $54.42 on the last day of their birth month.

Type of Service (In-Network) Amount Paid

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
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

The Rollover Benefit can increase your annual maximum each year
Max Rewards $250 or $350 for (In-Network) providers to a maximum of $1,000 in
your MaxMultiplier Account. See policy summary for details!

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,
Basic Services
General 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

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