Dental Insurance
______ offers dental coverage through Cigna. The PPO Dental Plan allows you to use in-network or out-of-network dentists. To find participating in-network dentists, go to www.cigna.com and click on “Find a Doctor.” If out-of-network dentists are used, you will be responsible for paying the difference between Cigna’s allowed amount and what the dentist may charge, also known as “balance billing.” The chart below provides a brief overview of the plan.
DENTAL PPO PLAN In-Network
Out-of Network 1
Calendar Year Deductible Individual
$--.-- $--.-- $--.--
$--.-- $--.-- $--.--
Family
Annual Maximum
Diagnostic & Preventive Exams Cleanings Fluoride X-Rays Sealants Regular Restorative Services Fillings Extractions - Single Tooth Endodontics (Root Canal) Periodontics (Gum Disease) Major Services Crowns
Covered in full
Covered in full
Covered 80% after deductible
Covered 80% after deductible
Bridges Dentures Orthodontia
Covered 50% after deductible
Covered 50% after deductible
50% $1,000 lifetime maximum per person
50% $1,000 lifetime maximum per person
(Children under the age of 19)
1 Subject to balance billing. Please refer to your plan document for specific details.
EMPLOYEE PAYS PER PAY PERIOD
Employee Only
$ --.-- $--.-- $--.-- $--.--
Employee + Spouse Employee + Child(ren)
Family
HEALTHESYSTEMS BENEFITS AT A GLANCE BENEFIT AT A GLANCE
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