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P. 11
2020
Thompson Coburn Enrollment Guide
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% your out-of-pocket costs may
oral examinations
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% to the left describes what you can
(dependents under expect depending on whether
age 19)
In-Network Out-of-Network you receive services from a Delta
Deductible $50 per person $50 per person $50 per person Dental PPO dentist, a Delta
$150 per family $150 per family $150 per family Dental Premier dentist, or an out-
Annual maximum $1,500 per person $1,500 per person $1,500 per person of-network dentist.
beneit
Orthodontia lifetime $1,000 per person $1,000 per person $1,000 per person Dental beneits are available on
maximum a voluntary basis for beneit-
eligible partners and employees
Note: Your out-of-pocket expenses may be more when you use an out-of-network dentist. and their dependents. Dental
beneit deductions are taken on
Dental Premiums a pre-tax basis. Find a dentist at
Eligibility Options Per Pay Period Monthly Rate www.deltadentalmo.com or call
Individual $21.99 $43.98 Delta Dental Customer Service
Individual + spouse $42.68 $85.36 at 800.335.8266.
Individual + child(ren) $47.12 $94.24
Individual + family $67.86 $135.72 The beneit levels available both
inside and outside the network are
Deductible applies only to Type B and C services identiied in the dental beneits
plan design chart.
11
Thompson Coburn Enrollment Guide
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% your out-of-pocket costs may
oral examinations
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% to the left describes what you can
(dependents under expect depending on whether
age 19)
In-Network Out-of-Network you receive services from a Delta
Deductible $50 per person $50 per person $50 per person Dental PPO dentist, a Delta
$150 per family $150 per family $150 per family Dental Premier dentist, or an out-
Annual maximum $1,500 per person $1,500 per person $1,500 per person of-network dentist.
beneit
Orthodontia lifetime $1,000 per person $1,000 per person $1,000 per person Dental beneits are available on
maximum a voluntary basis for beneit-
eligible partners and employees
Note: Your out-of-pocket expenses may be more when you use an out-of-network dentist. and their dependents. Dental
beneit deductions are taken on
Dental Premiums a pre-tax basis. Find a dentist at
Eligibility Options Per Pay Period Monthly Rate www.deltadentalmo.com or call
Individual $21.99 $43.98 Delta Dental Customer Service
Individual + spouse $42.68 $85.36 at 800.335.8266.
Individual + child(ren) $47.12 $94.24
Individual + family $67.86 $135.72 The beneit levels available both
inside and outside the network are
Deductible applies only to Type B and C services identiied in the dental beneits
plan design chart.
11
