Page 11 - 2018 Thompson Coburn Enrollment
P. 11
Thompson Coburn
Dental Plan
Dental Coverage provided by Delta Dental Delta Dental gives you the
Dental Benefits Plan Design freedom to visit the dentist of
your choice and select any dentist
Delta Dental Coverage on a treatment by treatment basis.
Coverage Type PPO Network Premier Network Out-of-Network It is important to remember
Type A: cleanings, 100% 100% 100%
oral examinations your out-of-pocket costs may
Type B: illings 90% 80% 80% vary depending on your choice.
Type C: bridges and 60% 50% 50% You have three options and the
dentures information provided on the chart
Type D: orthodontia 50% 50% 50%
(dependents under to the left describes what you can
age 19) expect depending on whether
In-Network Out-of-Network you receive services from a Delta
Deductible $50 per person $50 per person $50 per person
$150 per family $150 per family $150 per family Dental PPO dentist, a Delta
Annual maximum $1,500 per person $1,500 per person $1,500 per person Dental Premier dentist, or an out-
beneit of-network dentist.
Orthodontia lifetime $1,000 per person $1,000 per person $1,000 per person
maximum
Dental beneits are available on
Note: Your out-of-pocket expenses may be more when you use an out-of-network dentist. a voluntary basis for beneit-
Dental Premiums eligible partners and employees
Eligibility Options Monthly Rate Bi-weekly Rate and their dependents. Dental
Individual $39.98 $18.45 beneit deductions are taken on
Individual + spouse $77.60 $35.82 a pre-tax basis. Find a dentist at
Individual + child(ren) $85.67 $39.54 www.deltadentalmo.com or call
Individual + family $123.38 $56.94 Delta Dental Customer Service at
Deductible applies only to Type B and C services 800.335.8266.
The beneit levels available both
inside and outside the network are
identiied in the dental beneits
plan design chart.
11
Dental Plan
Dental Coverage provided by Delta Dental Delta Dental gives you the
Dental Benefits Plan Design freedom to visit the dentist of
your choice and select any dentist
Delta Dental Coverage on a treatment by treatment basis.
Coverage Type PPO Network Premier Network Out-of-Network It is important to remember
Type A: cleanings, 100% 100% 100%
oral examinations your out-of-pocket costs may
Type B: illings 90% 80% 80% vary depending on your choice.
Type C: bridges and 60% 50% 50% You have three options and the
dentures information provided on the chart
Type D: orthodontia 50% 50% 50%
(dependents under to the left describes what you can
age 19) expect depending on whether
In-Network Out-of-Network you receive services from a Delta
Deductible $50 per person $50 per person $50 per person
$150 per family $150 per family $150 per family Dental PPO dentist, a Delta
Annual maximum $1,500 per person $1,500 per person $1,500 per person Dental Premier dentist, or an out-
beneit of-network dentist.
Orthodontia lifetime $1,000 per person $1,000 per person $1,000 per person
maximum
Dental beneits are available on
Note: Your out-of-pocket expenses may be more when you use an out-of-network dentist. a voluntary basis for beneit-
Dental Premiums eligible partners and employees
Eligibility Options Monthly Rate Bi-weekly Rate and their dependents. Dental
Individual $39.98 $18.45 beneit deductions are taken on
Individual + spouse $77.60 $35.82 a pre-tax basis. Find a dentist at
Individual + child(ren) $85.67 $39.54 www.deltadentalmo.com or call
Individual + family $123.38 $56.94 Delta Dental Customer Service at
Deductible applies only to Type B and C services 800.335.8266.
The beneit levels available both
inside and outside the network are
identiied in the dental beneits
plan design chart.
11
