Page 11 - Thompson Coburn 2021 Annual Benefits Enrollment
P. 11
2021
Enrollment Guide
DENTAL PLAN
Dental Coverage Provided by Delta Dental
Delta Dental gives you the freedom to visit the dentist Dental beneits are available on a voluntary basis
of your choice and select any dentist on a treatment for beneit-eligible partners and employees and
by treatment basis. It is important to remember your their dependents. Dental beneit deductions
out-of-pocket costs may vary depending on your are taken on a pre-tax basis. Find a dentist at
choice. You have three options and the information www.deltadentalmo.com or call Delta Dental
provided on the chart to the left describes what you Customer Service at 800.335.8266.
can expect depending on whether you receive services
from a Delta Dental PPO dentist, a Delta Dental The beneit levels available both inside and outside
Premier dentist, or an out-of-network dentist. the network are identiied in the dental beneits plan
design chart.
Dental Benefits Plan Design
Delta Dental Coverage
Coverage Type PPO Network Premier Network Out-of-Network
Type A: cleanings, oral 100% 100% 100%
examinations
Type B: illings 90% 80% 80%
Type C: bridges and dentures 60% 50% 50%
Type D: orthodontia 50% 50% 50%
(dependents under age 19)
In-Network Out-of-Network
$50 per person
$50 per person
Deductible $150 per family $50 per person $150 per family
$150 per family
Annual maximum beneit $1,500 per person $1,500 per person $1,500 per person
Orthodontia lifetime maximum $1,000 per person $1,000 per person $1,000 per person
Note: Your out-of-pocket expenses may be more when you use an out-of-network dentist.
Dental Premiums
Eligibility Options Per Pay Period Monthly Rate
Individual $21.99 $43.98
Individual + spouse $42.68 $85.36
Individual + child(ren) $47.12 $94.24
Individual + family $67.86 $135.72
Deductible applies only to Type B and C services
11
Enrollment Guide
DENTAL PLAN
Dental Coverage Provided by Delta Dental
Delta Dental gives you the freedom to visit the dentist Dental beneits are available on a voluntary basis
of your choice and select any dentist on a treatment for beneit-eligible partners and employees and
by treatment basis. It is important to remember your their dependents. Dental beneit deductions
out-of-pocket costs may vary depending on your are taken on a pre-tax basis. Find a dentist at
choice. You have three options and the information www.deltadentalmo.com or call Delta Dental
provided on the chart to the left describes what you Customer Service at 800.335.8266.
can expect depending on whether you receive services
from a Delta Dental PPO dentist, a Delta Dental The beneit levels available both inside and outside
Premier dentist, or an out-of-network dentist. the network are identiied in the dental beneits plan
design chart.
Dental Benefits Plan Design
Delta Dental Coverage
Coverage Type PPO Network Premier Network Out-of-Network
Type A: cleanings, oral 100% 100% 100%
examinations
Type B: illings 90% 80% 80%
Type C: bridges and dentures 60% 50% 50%
Type D: orthodontia 50% 50% 50%
(dependents under age 19)
In-Network Out-of-Network
$50 per person
$50 per person
Deductible $150 per family $50 per person $150 per family
$150 per family
Annual maximum beneit $1,500 per person $1,500 per person $1,500 per person
Orthodontia lifetime maximum $1,000 per person $1,000 per person $1,000 per person
Note: Your out-of-pocket expenses may be more when you use an out-of-network dentist.
Dental Premiums
Eligibility Options Per Pay Period Monthly Rate
Individual $21.99 $43.98
Individual + spouse $42.68 $85.36
Individual + child(ren) $47.12 $94.24
Individual + family $67.86 $135.72
Deductible applies only to Type B and C services
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