Cigna Dental Preferred Provider Insurance
The Schedule
For You and Your Dependents
The Dental Benefits Plan offered by your Employer includes Participating Provider and non-Participating Providers. If you select a Participating Provider, your cost will be less than if you select a non-Participating Provider. Emergency Services The Benefit Percentage payable for Emergency Services charges made by a non-Participating Provider is the same Benefit Percentage as for Participating Provider Charges. Dental Emergency Services are required immediately to either alleviate pain or to treat the sudden onset of an acute dental condition. These are usually minor procedures performed in response to serious symptoms, which temporarily relieve significant pain, but do not effect a definitive cure, and which, if not rendered, will likely result in a more serious dental or medical complication. Deductibles Deductibles are expenses to be paid by you or your Dependent. Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached you and your family need not satisfy any further dental
deductible for the rest of that year. Participating Provider Payment
Participating Provider services are paid based on the Contracted Fee that is agreed to by the provider and Cigna. Based on the provider’s Contracted Fee, a higher level of plan payment may be made to a Participating Provider resulting in a lower payment responsibility for you. To determine how your Participating Provider compares refer to your provider directory. Provider information may change annually; refer to your provider directory prior to receiving a service. You have access to a list of all providers who participate in the network by visiting www.mycigna.com. Non-Participating Provider Payment Non-Participating Provider services are paid based on the Maximum Reimbursable Charge. For this plan, the Maximum Reimbursable Charge is calculated at the 90th percentile of all provider charges in the geographic area.
Simultaneous Accumulation of Amounts
Benefits paid for Participating Provider and non-Participating Provider services will be applied toward both the Participating Provider and non-Participating Provider maximum shown in the Schedule. Expenses incurred for either Participating Provider or non-Participating Provider charges will be used to satisfy both the Participating Provider and non-Participating Provider Deductibles shown in the Schedule. .
NON-PARTICIPATING PROVIDER
BENEFIT HIGHLIGHTS
PARTICIPATING PROVIDER
Classes I, II, III Combined Calendar Year Maximum
$1,500
Calendar Year Deductible
Individual
$50 per person
Not Applicable to Class I
Family Maximum
$150 per family
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myCigna.com
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