Microsoft Word - ABC Company Enrollment Guide.docx

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Dental
Good dental health is important to your overall well-being. At the same time, we all need different
levels of dental treatment. We are offering two dental plans, High PPO Dental and Low PPO Dental
through Cigna’s Dental Network. Both dental plans provides affordable coverage based on the type of
services obtained – Preventive, Basic or Major Restorative – whether or not you obtain services
from a network or non-network provider. Under the dental PPO plans, you may obtain covered
services from any dentist. However, if an out-of-network provider is used, reimbursement is based on
Cigna’s reasonable and customary charge.
Dental Benefits Description
Cigna High PPO Dental Cigna Low PPO Dental
In-Network
CIGNA DPPO - Core
Out-of-Network
CIGNA Savings - Core
In-Network
CIGNA DPPO
Out-of-Network
CIGNA Savings
Deductible (waived for preventive care)
Individual
Family
$50
$100
$100
$200
$100
$200
$100
$200
Class I - Preventive & Diagnostic Care
Oral Exams, Routine Cleanings, X-Rays, Fluoride
Applications, Sealants, Space Maintenance
Plan pays 100% Plan pays 80% Plan pays 90% Plan pays 70%
Class II - Basic Restorative Care
Fillings, Endodontics-Root Canal, Periodontics, Oral
Surgery, General Anesthesia
Plan pays 80%
(subject to annual
deductible)
Plan pays 60%
(subject to annual
deductible)
Plan pays 70%
(subject to annual
deductible)
Plan pays 50%
(subject to annual
deductible)
Class III - Major Restorative Care
Inlays & Onlays, Crowns, Dentures, Bridges
Plan pays 50%
(subject to annual
deductible)
Plan pays 40%
(subject to annual
deductible)
Plan pays 50%
(subject to annual
deductible)
Plan pays 40%
(subject to annual
deductible)
Class IV - Orthodontia
Lifetime Maximum
Plan pays 50%
Plan pays
$1,500/dependent children
to age 26
Plan pays 40%
Plan pays
$1,500/dependent children
to age 26
Not Covered
Class IX - Implants
Deductible
Annual Maximum
Plan pays 50%
(Subject to annual
deductible)
Subject to plan maximum
Plan pays 40%
(Subject to annual
deductible)
Subject to plan maximum
Plan pays 50%
(Subject to annual
deductible)
Subject to plan maximum
Plan pays 40%
(Subject to annual
deductible)
Subject to plan maximum
Calendar Year Maximum (Class I, II and III
expenses) $1,500 $750