
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 |
**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