MAA 2021 Benefits Guide

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Cigna Dental PPO Low Option + Cigna Dental PPO High Option 1%%SJJIVWX[SHIRXEPTPERSTXMSRWXLVSYKL'MKRE&SXLTPERWKMZI]SYXLIƽI\MFMPMX]XSVIGIMZI care in or outside of Cigna’s DPPO Network. However, when you receive care in-network, your costs are lower. Those who need less care can pay less by choosing the Low Option, while those who need more care, including Or thodontia, can choose the High Option. 2021 Bi-Weekly Associate Payroll Contributions by Dental Plan Option & Coverage Level Dental PPO Low Option Dental Plan High Option Employee Only $9.61 $13.51 Employee + Spouse $20.20 $28.38 Employee + Child(ren) $17.31 $29.72 Employee + Family $23.08 $40.54

Cigna Denta l PPO Low Opt ion Cigna Denta l PPO High Opt ion

Benef i t

In-Network

Out -of -Network

In-Network

Out -of -Network

Genera l Pl an Informat ion Re imbursement Leve l s Ca l endar Year Deduct ibl e Indi v idua l Fami l y Ca l endar Year Benef i ts Max imum Benef i t High l ights Class I : Diagnost i c & Prevent i ve Oral Exams, Cleanings, X-rays, Fluoride Appl ication & Sealants Class I I : Bas i c Restorat i ve Fi l l ings , Per iodont ics , Oral Surgery, Br idge Repai rs , Crowns & Dentures Class I I I : Major Restorat ive Inlays/Onlays , Prosthesis , Over Implant , Crown, Br idges , Dentures Class IV: Or thodont ia Coverage for Adul ts & Chi ldren, Li fet ime Benef i ts Maximum: $2,500

Max imum Re imbursabl e Charge (MRC)

Based on Cont racted Fees

$50 $150

$1 , 500 per person Appl i es to Cl ass I , I I , I I I expenses

$2 , 500 per person Appl i es to Cl ass I , I I , I I I , IX expenses

Pl an pays 100% of MRC

Pl an pays 100%

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% of MRC You pay remainder After Deductible Plan pays 60% of MRC You pay remainder No Deduct ible, Plan pays 50% up to Li fet ime Benef i ts Maximum Af ter Deduct ibl e Pl an pays 50% You pay rema i nder

Af ter Deduct ibl e Pl an pays 80% You pay 20% Af ter Deduct ibl e Pl an pays 50% You pay 50%

Af ter Deduct ibl e Pl an pays 80% You pay 20% Af ter Deduct ibl e Pl an pays 60% You pay 40% No Deduct ible, Plan pays 50% up to Li fet ime Benef i ts Maximum Af ter Deduct ibl e Pl an pays 50% You pay 50%

Not Covered

Class IX: Implants

Not Covered

Click here for the benefit summary for the Cigna PPO Low Option. Click here for the benefit summary for the Cigna PPO High Option.

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