Cigna Dental Preferred Provider Insurance The Schedule
Benefits For You and Your Dependents The Dental Benefits Plan offered by Your Employer includes Participating and Non-Participating Providers. If You select a Participating Provider, Your cost will be less than if You select a Non-Participating Provider. Emergency Services The Benefit Percentage for Emergency Services incurred for charges made by a Non-Participating Provider is the same Benefit Percentage as for Participating Provider charges. Deductibles Deductibles are expenses to be paid by You or Your Dependent. Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached You and Your family need not satisfy any further dental Services are paid based on the Contracted Fee that is agreed to by the provider and Us. Based on the provider’s Contracted Fee, a higher level of plan payment (shown below as “The Percentage of Covered Expenses the Plan Pays”) may be made to a Participating Provider resulting in a lower payment responsibility for You. To determine how Your Participating Provider compares refer to Your provider directory. Provider information may change annually; refer to Your provider directory prior to receiving a service. You have access to a list of all providers who participate in the network by visiting www.mycigna.com. . Non-Participating Provider Payment Benefit Payment Services are paid based on the Maximum Reimbursable Charge. For this plan, the Maximum Reimbursable Charge is calculated at the 90th percentile. See definition section for further explanation of Maximum Reimbursable Charge. . BENEFIT MAXIMUMS AND DEDUCTIBLES PARTICIPATING PROVIDER NON-PARTICIPATING PROVIDER Classes I, II, III, IX Combined Calendar Year Maximum $2,500 deductible for the rest of that year. Participating Provider Payment
Class IV Lifetime Maximum
$2,500
$2,500
myCigna.com
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