a tip from
To see if a provider is in the network, log on to myCigna.com or the myCigna App.
2018 Bi-Weekly associate payroll contributions by dental plan option & coverage level
Dental PPO Low Option Dental PPO High Option
$8.77 $18.42 $15.79 $21.05
$10.57 $22.19 $23.24 $31.70
Employee Only
Employee + Spouse Employee + Child(ren) Employee + Family
Cigna dental ppo HIGH option
Cigna dental ppo low option
benefit
in-network
out-of-network
in-network
out-of-network
Maximum Reimbursable Charge (MRC)
Based on Contracted Fees Maximum Reimbursable Charge (MRC)
Based on Contracted Fees $50 $150 $1,500 per person Applies to Class I, II, III expenses
Reimbursement Levels
$50 $150
$50 $150
$50 $150
Calendar Year Deductible Individual Family
$2,500 per person Applies to Class I, II, III, & IX expenses
$1,500 per person Applies to Class I, II, III expenses
$2,500 per person Applies to Class I, II, III, & IX expenses
Calendar Year Benefits Maximum
Class I: Diagnostic & Preventive Oral Exams, Cleanings, X-rays, Fluoride Application, Sealants Class II: Basic Restorative Fillings, Periodontics, Oral Surgery, Repairs to Bridges, Crowns and Dentures Class III: Major Restorative Inlays and Onlays, Prosthesis Over Implant, Crowns, Bridges, and Dentures Class IV: Orthodontia Coverage for Adults & Children Lifetime Benefits Maximum: $2,500
Plan pays 100% of MRC
Plan pays 100% of MRC
Plan pays 100%
Plan pays 100%
After Deductible, Plan pays 80% You pay 20% After Deductible, Plan pays 50% You pay 50%
After Deductible, Plan pays 80% of MRC You pay remainder After Deductible, Plan pays 60% of MRC You pay remainder No Deductible Plan pays 50% up to Lifetime Benefits Maximum After Deductible, Plan pays 50% of MRC You pay remainder
After Deductible, Plan pays 80% of MRC You pay remainder After Deductible, Plan pays 50% of MRC You pay remainder
After Deductible, Plan pays 80% You pay 20% After Deductible, Plan pays 60% You pay 40% No Deductible Plan pays 50% up to Lifetime Benefits Maximum After Deductible, Plan pays 50% You pay 50%
Not Covered
Not Covered
Class IX: Implants
plan links
Click here for the benefit summary for the Cigna PPO Low Option. Click here for the benefit summary for the Cigna PPO High Option.
18
Made with FlippingBook flipbook maker