11 / 19
Page 8
Cigna Dental
Benefit
PPO Network
(You Pay)
Out-of-Network
(You Pay)
Individual Deductible
Family Deductible
$50
$150
$50
$150
Type I - Preventive Care
(Exams, Cleanings)
0%
0%
Type II - Basic Procedures
(Fillings, Extractions)
Deductible, then you
pay 0%
Deductible, then you
pay 20%
Type III—Major Procedures
(Caps, Crowns)
Deductible, then you
pay 40%
Deductible, then you
pay 50%
Endodontics
Deductible, then you
pay 0%
Deductible, then you
pay 20%
Periodontics
Deductible, then you
pay 0%
Deductible, then you
pay 20%
Type IV - Orthodontia
Dependent Children Only
You pay 50% to a
$1,000 Lifetime Max
(No Deductible)
You pay 50% to a
$1,000 Lifetime Max
(No Deductible)
Annual Maximum Year 1
$1,000
$1,000
EMPLOYEE COST
Type of Coverage
Monthly
Cost
Employee Only
$29.64
Employee & Spouse
$60.95
Employee & Child(ren)
$64.32
Employee & Family
$96.85
VOLUNTARY DENTAL INSURANCE
How to find a Dentist in your area:
1: Go to
www.cigna.com,click on Find a
Doctor. Then, select the orange box that
reads “If your insurance plan is offered
through work.”
2: Choose Dentist, then indicate the
Geographical location you want to search.
3: Select your Plan—Cigna Dental PPO.
4: Choose the Search button for your
results.
Increasing Calendar Year Maximum (Wellness
Plus
)
Receiving regular dental care often catches minor problems before they become serious and expensive to treat.
Therefore, Wellness
Plus
rewards you and your family for receiving preventive dental care. When you receive any
preventive care in one plan year, your annual dollar maximum will increase in the following plan year, allowing you to
build your annual dollar maximum for other services you may need in the future. Each family member qualifies for the
increased annual maximum based on whether or not they choose to receive preventive care during a given plan year. It
is possible family members will have a different plan maximum in future years.
Here’s how the benefits work (example):
YEAR ONE
: Jane starts with a $1,000 Plan Annual Maximum. She obtains a preventive cleaning and her provider
submits the dental claim. Since she obtained a preventive service, she receives a $200 increase to her annual maximum
in Year 2.
YEAR TWO
: Jane now has an increased Plan Annual Maximum of $1,200. This year, she has a preventive cleaning and
receives an additional $200 that is added to her Plan Annual Maximum in Year 3.
YEAR THREE
: Jane now has an increased Plan Annual Maximum of $1,400. Unfortunately, she has to cancel her
preventive cleaning and forgets to reschedule it. She does not get any additional money added to her Plan Annual
Maximum in Year 4, but she doesn’t lose her $1,400 maximum she has already accumulated either.