Dental Benefits
Effective October 1, 2020
Here is a snapshot of the coverage offered through the 2020-2021 dental plans.
BENEFITS - Cigna
DMO
PPO
Type I – Preventive Services Oral examinations (2 Per Year)
X-rays
100%
$5 Copay/ 100%
Cleanings (2 Per Year) Type II – Basic Services Fillings
Extractions
$50 Deductible/ 80%
$5 Copay/ 100%
Root Canal Type III – Major Services Crowns
Removable / fixed bridge-work Partial or complete dentures Type IV - Orthodontia Adult & Child / Child Only
$50 Deductible/ 50%
$5 Copay/ 60%
Adult & Child
Child up to Age 19 Only
$2,400
50%
Annual Deductible Individual
$50
$0 $0
Family
$150
Annual Maximums Dental Annual Maximum
$1,500 $1,500
None None
Orthodontia Lifetime Maximum Network Website www.cigna.com
Cigna PPO Network
Cigna DMO Network
NOTE: This is a brief summary and not intended to be a contract.
DMO $0.00 $4.44 $6.64 $12.23
Dental Costs – Per Pay Period
PPO $0.00
Employee Only
Employee & Spouse Employee & Children Employee & Family
$11.75 $18.44 $29.56
*Employees may not change plans mid-year without a Qualifying Life Event.
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