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