DENTAL BENEFITS

Dental insurance makes it easier and less expensive to get the care you need to maintain good oral health. You will have the option to choose between three voluntary dental plans offered by Mutual of Omaha.

In-Network Benefits
Dental High Plan
Dental Medium Plan
Dental Low Plan
Annual Deductible (Individual/Family)

$25 per person/$75 per family

$50 per person/$150 per family

$50 per person/$150 per family
Annual Plan Maximum
$2,250 per person
$1,500 per person
$750 per person
Preventive Services (no deductible)
No Charge (deductible waived)
No Charge (deductible waived)
No Charge (deductible waived)

Basic Services

20% after deductible
20% after deductible
50% after deductible
Major Services
50% after deductible
50% after deductible
50% after deductible
Orthodontia
50% after deductible $1,500 Lifetime Benefit Max
Not Covered
Not Covered

PER PAY PERIOD RATES

YOU PAY
Dental High Plan
Dental Medium Plan
Dental Low Plan
Employee Only
$15.44
$12.74
$9.74
Employee + Spouse
$33.81
$25.46
$18.89
Employee + Child(ren)
$33.35
$26.64
$21.71
Family
$49.00
$36.92
$28.75

VISION BENEFITS

You and your dependents have access to vision coverage through Vision Service Plan (VSP). Your vision coverage is bundled with your medical plan. Please note, you will not receive an ID card for this plan election. Your vision provider will only need the employee’s SSN and the vision plan/group ID number to verify benefits.

Key Features
IN-NETWORK
Provider Choice

VSP Network Provider

Exam (every 12 months)
$10 Copay
Materials
$10 Copay

Lenses (every 12 months)

Single/Bifocal/Trifocal: Included in materials copay
Frames (every 12 months)
Included in materials copay
(up to $240 for featured brands, all others up to $220 allowance + 20% discount on cost over allowance)
Contact Lenses (every 12 months)
(in lieu of glasses)
No charge ($130 allowance for contacts)
Up to $60 for contact lens exam (fitting & evaluation)

PER PAY PERIOD RATES

Employee Only
$3.04
Employee + Spouse
$4.86
Employee + Child(ren)
$4.96
Family
$7.99
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