Cigna Dental PPO Plan
Visit providers who are part of the DPPO network to keep your costs low.
|CIGNA ADVANTAGE NETWORK||CIGNA DPPO NETWORK/ OUT-OF-AREA**||OUT-OF-NETWORK***|
|Calendar Year Deductible|
|Annual Benefit Maximum Per Member (excluding orthodontia)|
|You Pay||You Pay||You Pay|
|Exams, Cleanings, X-rays, Flouride Treatments||$0|
|Fillings, Space Maintainers, Sealants, Extractions, Oral Surgery, Endodontics, Periodontics, Emergency Exams||10%*||20%*||10%*|
|Crowns, Inlays/Onlays, Dentures and Bridgework, Repairs||50%*||50%*||50%*|
|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