Page 11 - 2017 Benefits Enrollment
P. 11
2017 BENEFITS ENROLLMENT
Dental Plan
New for 2017 Delta Dental gives you the
Dental Coverage provided by Delta Dental freedom to visit the dentist
Dental Benefits Plan Design of your choice and select
Delta Dental Coverage any dentist on a treatment by
Coverage Type PPO Network Premier Network Out-of-Network treatment basis. It is important
Type A: to remember your out-of-pocket
cleanings, oral 100% 100% 100% costs may vary depending on
examinations your choice. You have three
Type B: illings 90% 80% 80% options and the information
Type C: bridges 60% 50% 50%
and dentures provided on the chart to the left
Type D: 50% 50% 50% describes what you can expect
orthodontia depending on whether you
In-Network Out-of-Network receive services from a Delta
$50 per person
$50 per person
Deductible $150 per family $150 per family $50 per person Dental PPO dentist, a Delta
$150 per family
Annual maximum $1,500 per $1,500 per $1,500 per Dental Premier dentist, or an
beneit person person person out-of-network dentist.
Orthodontia $1,000 per $1,000 per $1,000 per
lifetime maximum person person person Dental beneits are available on
Note: Your out-of-pocket expenses may be more when you use a out-of-network a voluntary basis for beneit-
dentist . eligible partners and employees
Dental Premiums and their dependents. Dental
Eligibility Options Monthly Rate Bi-weekly Rate beneit deductions are taken on
Individual $39.98 $18.45 a pre-tax basis. Find a dentist at
Individual + spouse $77.60 $35.82
Individual + child(ren) $85.67 $39.54 www.deltadentalmo.com or call
Individual + family $123.38 $56.94 Delta Dental Customer Service
at 800.335.8266.
Deductible applies only to Type B and C services
The beneit levels available both
inside and outside the network
are identiied in the dental
beneits plan design chart.
Thompson Coburn LLP 11
Dental Plan
New for 2017 Delta Dental gives you the
Dental Coverage provided by Delta Dental freedom to visit the dentist
Dental Benefits Plan Design of your choice and select
Delta Dental Coverage any dentist on a treatment by
Coverage Type PPO Network Premier Network Out-of-Network treatment basis. It is important
Type A: to remember your out-of-pocket
cleanings, oral 100% 100% 100% costs may vary depending on
examinations your choice. You have three
Type B: illings 90% 80% 80% options and the information
Type C: bridges 60% 50% 50%
and dentures provided on the chart to the left
Type D: 50% 50% 50% describes what you can expect
orthodontia depending on whether you
In-Network Out-of-Network receive services from a Delta
$50 per person
$50 per person
Deductible $150 per family $150 per family $50 per person Dental PPO dentist, a Delta
$150 per family
Annual maximum $1,500 per $1,500 per $1,500 per Dental Premier dentist, or an
beneit person person person out-of-network dentist.
Orthodontia $1,000 per $1,000 per $1,000 per
lifetime maximum person person person Dental beneits are available on
Note: Your out-of-pocket expenses may be more when you use a out-of-network a voluntary basis for beneit-
dentist . eligible partners and employees
Dental Premiums and their dependents. Dental
Eligibility Options Monthly Rate Bi-weekly Rate beneit deductions are taken on
Individual $39.98 $18.45 a pre-tax basis. Find a dentist at
Individual + spouse $77.60 $35.82
Individual + child(ren) $85.67 $39.54 www.deltadentalmo.com or call
Individual + family $123.38 $56.94 Delta Dental Customer Service
at 800.335.8266.
Deductible applies only to Type B and C services
The beneit levels available both
inside and outside the network
are identiied in the dental
beneits plan design chart.
Thompson Coburn LLP 11
