Page 12 - Thompson Coburn 2022 Beneftits Summary
P. 12
Dental Plan
Dental Coverage Provided by Delta Dental
Delta Dental gives you the freedom to visit the Dental beneits are available on a voluntary basis
dentist of your choice and select any dentist on for beneit-eligible partners and employees and
a treatment by treatment basis. It is important their dependents. Dental beneit deductions
to remember your out-of-pocket costs may vary are taken on a pre-tax basis. Find a dentist at
depending on your choice. You have three options www.deltadentalmo.com or call Delta Dental
and the information provided on the chart to the Customer Service at 800.335.8266.
left describes what you can expect depending on
whether you receive services from a Delta Dental The beneit levels available both inside and outside
PPO dentist, a Delta Dental Premier dentist, or an the network are identiied in the dental beneits plan
out-of-network dentist. 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
$50 per person
Deductible $150 per family $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 $21.11 $42.22
Individual + spouse $40.98 $81.95
Individual + child(ren) $45.24 $90.47
Individual + family $65.15 $130.29
Deductible applies only to Type B and C services
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Dental Coverage Provided by Delta Dental
Delta Dental gives you the freedom to visit the Dental beneits are available on a voluntary basis
dentist of your choice and select any dentist on for beneit-eligible partners and employees and
a treatment by treatment basis. It is important their dependents. Dental beneit deductions
to remember your out-of-pocket costs may vary are taken on a pre-tax basis. Find a dentist at
depending on your choice. You have three options www.deltadentalmo.com or call Delta Dental
and the information provided on the chart to the Customer Service at 800.335.8266.
left describes what you can expect depending on
whether you receive services from a Delta Dental The beneit levels available both inside and outside
PPO dentist, a Delta Dental Premier dentist, or an the network are identiied in the dental beneits plan
out-of-network dentist. 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
$50 per person
Deductible $150 per family $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 $21.11 $42.22
Individual + spouse $40.98 $81.95
Individual + child(ren) $45.24 $90.47
Individual + family $65.15 $130.29
Deductible applies only to Type B and C services
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