BENEFIT MAXIMUMS AND DEDUCTIBLES
PARTICIPATING PROVIDER
NON-PARTICIPATING PROVIDER
Calendar Year Deductible Individual
$50 per person Not Applicable to Class I $150 per family Not Applicable to Class I
Family Maximum
. Expenses incurred for either Participating or Non-Participating Provider charges will be used to satisfy both the Participating and Non-Participating Provider Deductibles shown in the Schedule. Benefits Paid for Participating and Non-Participating Provider Services will be applied toward both the Participating and Non-Participating maximum shown in the Schedule.
BENEFIT HIGHLIGHTS
PARTICIPATING PROVIDER
NON-PARTICIPATING PROVIDER
Class I
The Percentage of Covered Expenses the Plan Pays
The Percentage of Covered Expenses the Plan Pays
Preventive Care
100%
100%
Class II
The Percentage of Covered Expenses the Plan Pays 80% after plan deductible The Percentage of Covered Expenses the Plan Pays 60% after plan deductible The Percentage of Covered Expenses the Plan Pays
The Percentage of Covered Expenses the Plan Pays 80% after plan deductible The Percentage of Covered Expenses the Plan Pays 60% after plan deductible The Percentage of Covered Expenses the Plan Pays
Basic Restorative
Class III
Major Restorative
Class IV
Orthodontia
50%
50%
. Class IX
The Percentage of Covered Expenses the Plan Pays 50% after plan deductible
The Percentage of Covered Expenses the Plan Pays 50% after plan deductible
Implants
myCigna.com
12
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