Page 5 - Wiese 2021 Benefits Guide
P. 5
Wiese Benefits Enrollment
Dental
Dental Plan—Delta Dental
We partner with Delta Dental of Missouri for our
dental carrier. Please see below for a high level plan
design and an outline of payroll premiums.
Service PPO/Premier and Out-of-Network*
Calendar Year Maximum $1,500
Deductible $50 individual/$150 family
Preventive Services* 100%
Basic Services* 80%
Major Services* 50%
Orthodontics 50%
Lifetime Maximum $1,500
* Out-of-network reimbursements are based upon Delta Dental’s
reasonable and customary charges. You will receive a greater beneit
by visiting an in-network provider.
Team Member Cost Per Week
TM Only $2.25
TM + Spouse $4.25
TM + Child(ren) $3.50
TM + Family $5.50
To Find a Provider
Go to deltadentalmo.com
Click the “Find a Provider” link
Under Find a Dentist, follow the link that says “Click
Here to Find A Dental Care Provider”
Select the Specialty you’re searching for
Choose the Delta Dental PPO Plus Premier Network
Click on “Find Dentists”
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Dental
Dental Plan—Delta Dental
We partner with Delta Dental of Missouri for our
dental carrier. Please see below for a high level plan
design and an outline of payroll premiums.
Service PPO/Premier and Out-of-Network*
Calendar Year Maximum $1,500
Deductible $50 individual/$150 family
Preventive Services* 100%
Basic Services* 80%
Major Services* 50%
Orthodontics 50%
Lifetime Maximum $1,500
* Out-of-network reimbursements are based upon Delta Dental’s
reasonable and customary charges. You will receive a greater beneit
by visiting an in-network provider.
Team Member Cost Per Week
TM Only $2.25
TM + Spouse $4.25
TM + Child(ren) $3.50
TM + Family $5.50
To Find a Provider
Go to deltadentalmo.com
Click the “Find a Provider” link
Under Find a Dentist, follow the link that says “Click
Here to Find A Dental Care Provider”
Select the Specialty you’re searching for
Choose the Delta Dental PPO Plus Premier Network
Click on “Find Dentists”
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