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5
Dental Coverage
Regular dental exams can help you
and your dentist detect problems in
the early stages when treatment is
simpler and costs are lower.
Keeping your teeth and gums
clean and healthy will help prevent
most tooth decay and periodontal
disease, and is an important part of
maintaining your medical health.
The dental provider network is
Cigna DPPO. You will pay more if
you see a non-network dentist.
2017 Plan Enhancements
• No waiting period for timely
enrollment.
• All extractions covered as a
Basic service.
Plan Provisions
Cigna
Total Cigna DPPO
Out-of-Network
Annual Deductible
(Individual/Family)
$50/$150
$50/$150
Annual Maximum
(per person)
$1,000
$1,000
Diagnostic & Preventive Care
includes cleanings, fluoride treatments,
routine x-rays
100%, no deductible
100%, no deductible
Basic Services: includes
fillings, sealants,
extractions
80%
80%
Major Restorative includes
:
Periodontics, root canals, crowns, bridges,
dentures
50%
50%
Implants
50%
50%
Orthodontia
(Children only – up to age 19)
50% after deductible
$750 lifetime maximum
Benefit
In-Network
Out-of-Network
Well Vision Exam
$10 copay
Up to $50
Frequency
• Exam
• Lenses
• Frames
Once in every 12 months
Once in every 12 months
Once in every 24 months
Once in every 12 months
Once in every 12 months
Once in every 24 months
Frames
$120 allowance; 20% discount on
remaining balance
Up to $70
Lenses
• Single Vision Lenses
• Bifocal Lenses
• Trifocal Lenses
$30 copay
$30 copay
$30 copay
Up to $50
Up to $75
Up to $100
Contacts
(instead of glasses)
Up to $60 copay/$120 allowance
Up to $105 allowance
Plan Provisions
Cigna
Total Cigna DPPO
Out-of-Network
Annual Deductible
(Individual/Fa ily)
$50/$150
$50/$150
Annual axi u
(per person)
$1,000
$1, 0
iagnostic r
ti r
includes cl
i s, fl ri tr t
t ,
routi e x-r s
100%, no deductible
100%, no deductible
asic r i
: i l
,
extr cti
80
80%
j r
ri
i ,
t r
50
50%
I
l t
50
50%
rt
ti
(Childre l t
19)
50% after deductible
$750 lifetime maximum
fit
In- et ork
Out-of-Network
ell Vision Exa
$10 copay
Up to $50
Frequency
• Exam
• Lenses
• Frames
Once in every 12 months
Once in every 12 months
Once in every 24 months
Once in every 12 months
Once in every 12 months
Once in every 24 months
Frames
$120 allowance; 20% discount on
remaining balance
Up to $70
Lenses
• Single Vision Lenses
• Bifocal Lenses
• Trifocal Lenses
$30 copay
$30 copay
$30 copay
Up to $50
Up to $75
Up to $100
Contacts
(instead of glasses)
Up to $60 copay/$120 allowance
Up to $105 allowance
Vision Coverage
SLFHC will continue to partner with
VSP to bring you eye care benefits.
The vision plan covers routine eye
exams and also pays for all or a
portion of the cost of glasses or
contact lenses if you need them.
The vision network is VSP Signature.
You will pay more if you see a
non-network provider.
Medical Coverage continued
A new plan utilizing Cigna’s LocalPlus Network is available to you for 2017. There is no change to the plan design; the change is to the
provider network only. LocalPlus is a limited network of local doctors and hospitals designed to offer employees access to quality, cost-
effective care. In
Maricopa and Pinal Counties
the LocalPlus Network includes:
• Cigna Medical Group – over 150 physicians and allied health professionals across Maricopa County
• Banner Health Network – with over 3,000 physicians and 11 hospital campuses
• Honor Health Network – with over 200 physicians and 5 hospital campuses is a joint affiliation between Scottsdale Healthcare
and John C. Lincoln Health Network
• Scottsdale Health Partners – with over 400 physicians at 50 locations
In
Pima County
the LocalPlus Network includes:
• Physician Practices – Arizona Community Physicians, Arizona Connected Care, Northwest Allied Physicians
• Hospitals – TucsonMedical Center, Northwest Medical Center and Oro Valley Medical Center
If you elect this plan and you are in an area of the country with Local Plus Network, you must use a Local Plus provider. If you travel
to a NON-Local Plus area, you can use the full Away From Home Care Network of providers. If you choose to go outside the LocalPlus
Network when it is available (or outside the Away From Home Care Network when LocalPlus isn’t available), your care will be covered
on an out-of-network basis except in emergencies.
Please check that the doctors and hospitals that you and your family use are in the LocalPlus Network
BEFORE
you elect this plan
.