Your Phillips & Jordan dental benefits are administered by Cigna Health and Life Insurance Company. The plan works like a PPO plan in that you can visit any dentist that you choose. However, if your provider is not in-network, he/ she may charge more than the usual and customary rate, and you may be responsible for the additional charges. To find an in-network provider, go to the online directory at www.cigna.com. Please be sure to carefully review the online directory or call Cigna to confirm that your provider participates in the network. Dental Benef i ts Ci gna 1-800-244-6224 www.myc i gna. com Group Number : 3332287
Dental Weekly Premiums Employee Only EMP + Spouse EMP + Child(ren)
Base Plan Buy-Up Plan
$2.43 $5.35 $4.87 $6.81
$3.71 $8.16 $7.43
EMP + Family
$10.39
DENTAL PLAN BENEFITS
Base Plan $50 / $150
Buy-Up Plan
Individual / Family Deductible Calendar Year Maximum (per enrolled person) Preventive Services (Deductible does not apply)
$25 / $75
$1,500
$2,500
100%
100%
80% after deductible 60% after deductible
80% after deductible 70% after deductible
Basic Services
Major Restorative Services
Orthodontic Services (Deductible does not apply) Orthodontic Lifetime Maximum (Covers children up to age 19, lifetime max per child)
50%
50%
$1,500
$2,500
Vision Benef i ts Ci gna 1-800-244-6224 www.myc i gna. com Group Number : 3332287
VisionWeekly Premiums
Employee Only EMP + Spouse EMP + Child(ren)
$1.59 $3.20 $3.18 $5.05
EMP + Family
Your Phillips & Jordan vision benefits are administered by Cigna Health and Life Insurance Company. When using in- network providers, this PPO plan covers most exams, eyeglasses, and medically necessary contacts in full. Discounts are available for upgrades on covered frames and lenses. Should you choose to see an out-of-network provider, Cigna will reimburse you up to a specified amount. The out-of-network reimbursement schedule is summarized in the Vision Plan Benefits table below.
To find an in-network provider or surgery center, review out- of-network benefits, and other plan details, go to the online directory at cigna.vsp.com and click on the “Find a Cigna Vision Network Eye Care Professional” button to begin your search. Please be sure to carefully review the online directory or call Cigna to confirm that your provider participates in the network.
VISION BENEFITS
In-Network $10 Copay
Out-of-Network $45 Allowance
Vision Exam
Lenses (once per year) Single / Bifocal / Trifocal / Lenticular Frames (once every 2 years) Contacts in lieu of eyeglasses (once per year) Medically Necessary Elective
$10 Copay / covered in full
Up to $80 Allowance depending on type
$140 Allowance
$77 Allowance
$10 Copay
Covered in full Up to $150
$210 Allowance $120 Allowance
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