Image

Dental Plan

Cigna Dental PPO Plan

Visit providers who are part of the DPPO network to keep your costs low.

Cigna DPPO
CIGNA ADVANTAGE NETWORK
CIGNA DPPO NETWORK/ OUT-OF-AREA**
OUT-OF-NETWORK***
Calendar Year Deductible
Individual
$50
$100
$100
Family
$100
$200
$200
Annual Benefit Maximum Per Member (excluding orthodontia)
Per Individual
$2,000
$1,000
You Pay
You Pay
You Pay
Preventive Care
Exams, Cleanings, X-rays, Flouride Treatments
$0
Basic Services
Fillings, Space Maintainers, Sealants, Extractions, Oral Surgery, Endodontics, Periodontics, Emergency Exams
10%*
20%*
10%*
Major Procedures
Crowns, Inlays/Onlays, Dentures and Bridgework, Repairs
50%*
50%*
50%*
Orthodontia
24-Month Treatment Fee - Additional fees will apply for pre-ortho visits and treatment, records and retention and banding.
Adults
50%* up to lifetime maximum of $2,000
Children (up to 19th birthday)
50%* up to lifetime maximum of $2,000

*Copay applies after plan deductible is met.
**For employees who do not have a participating primary dentist within 25 miles of their home.
***Out-of-network provider fees over the Plan’s reasonable and customary limits are your responsibility

Image

Dental Plan

Cigna Dental PPO Plan

Visit providers who are part of the DPPO network to keep your costs low.

Cigna DPPO
CIGNA ADVANTAGE NETWORK
CIGNA DPPO NETWORK/ OUT-OF-AREA**
OUT-OF-NETWORK***
Calendar Year Deductible
Individual
$50
$100
$100
Family
$100
$200
$200
Annual Benefit Maximum Per Member (excluding orthodontia)
Per Individual
$2,000
$1,000
You Pay
You Pay
You Pay
Preventive Care
Exams, Cleanings, X-rays, Flouride Treatments
$0
Basic Services
Fillings, Space Maintainers, Sealants, Extractions, Oral Surgery, Endodontics, Periodontics, Emergency Exams
10%*
20%*
10%*
Major Procedures
Crowns, Inlays/Onlays, Dentures and Bridgework, Repairs
50%*
50%*
50%*
Orthodontia
24-Month Treatment Fee - Additional fees will apply for pre-ortho visits and treatment, records and retention and banding.
Adults
50%* up to lifetime maximum of $2,000
Children (up to 19th birthday)
50%* up to lifetime maximum of $2,000

*Copay applies after plan deductible is met.
**For employees who do not have a participating primary dentist within 25 miles of their home.
***Out-of-network provider fees over the Plan’s reasonable and customary limits are your responsibility

Part-time and Temporary employees are eligible for a limited subset of benefits.  Union employees: refer to your collective bargaining agreement for your benefits eligibility.