Rag & Bone - 2023 Benefit Guide

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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