Cigna DPPO
Services
In-Network
Out-of-Network
Annual Deductible
$50/$150
$50/$150
Calendar Year
Calendar Year
Deductible Accumulation
Annual Maximum Benefit
$2,500*
$2,500*
Preventive Dental Services (cleaning, exams, x-rays
Plan pays 100%
Plan pays 100%
Plan pays 80% You pay 20%
Plan pays 80% You pay 20%
Basic Dental Services (fillings, root canal)
Major Dental Services (extractions, crowns, inlays, onlays, bridges, dentures, repairs)
Plan pays 50% You pay 50%
Plan pays 50% You pay 50%
Plan pays 50% You pay 50%
Plan pays 50% You pay 50%
Orthodontia Services (Child/Adult)
Orthodontia Lifetime Max (Child/Adult)
$2,000
$2,000
Plan pays 50% You pay 50%
Plan pays 50% You pay 50%
Implants
Implant Max
$2,500
$2,500
Dependent Cut Off Age
26 years old
*Progressive Max Applies, max will increase by $100 increments each year up to 4th year.
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