DENTAL PLANS - Coverage Chart Administered by CIGNA
Dental DHMO
Dental Low
Dental High
Cigan Dental Care Access
Network Name
Total Cigna DPPO (Cigna DPPO Advantage and Cigna DPPO)
Plan Feature
In-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Deductibles – What You Pay First for Some Services Individual None $50
$50
$50
$50
Family
None
$150
$150
$150
$150
Covered Services – What You Pay Each Calendar Year Annual Maximum Benefit Unlimited
$1,000
$1,500
Preventative Care (includes cleanings, exams, routine X-rays) Basic Services (includes fillings, root canals, oral surgery) Major Services (includes crowns,
No charge
No charge
No charge
No charge
No charge
Refer to schedule of benefits
20% coinsurance, after deductible
20% coinsurance, after deductible
20% coinsurance, after deductible
20% coinsurance, after deductible
Refer to schedule of benefits
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
50% coinsurance, after deductible
dentures, implants)
Orthodontics (adult & child) Orthodontia Lifetime Maximum (adult & child)
50% coinsurance, after deductible
50% coinsurance after deductible*
$1,944 copay
Not covered
No maximum
Not covered
$1,000
*Out-of-Network benefits are paid based on the Reasonable and Customary (R&C) charge for a service. You are responsible for paying any amounts above the R&C charge.
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