Page 33 - SIH 2022 Re-Enrollment Guide
P. 33
2022
SIH Benefits Re-Enrollment
DENTAL OPTIONS
You have two dental options, a High plan and a You can also call your current dental provider to
Low plan, and they are administered by Cigna. Each ensure they are in Cigna’s network. If you enroll
option includes preventive, basic, major care, and family members in your dental option, you will be
orthodontic care. Our plans access the Cigna DPPO required to complete a coordination of beneits
network. Keep in mind the best discounts on your (COB). The plan administrator will mail you a packet
services are received when you use an in-network containing the required COB form. Please complete
provider to ensure you are not subject to balance and submit this form in a timely manner to avoid
billing. If you seek services from an out-of-network claim denials in the future.
provider, please note you may be subject to balance
billing, where a provider may bill you for the Please note: if your spouse is also an employee of
diference between what Cigna paid the provider SIH, you will need to choose employee coverage
and what the provider actually charged. under your own plan or spouse or family coverage
under your spouse’s plan. You cannot be enrolled in
To locate an in-network provider, visit both.
www.cigna.com (select Total Dental PPO) or call
800.244.6224.
SIH Dental Coverage High Option (A) Low Option (B)
Annual Deductible (per covered person for basic services) $50 $100
100% coverage/ 100% coverage/
Preventive Service (cleanings, luoride, routine exams, x-rays)
no deductible no deductible
80% coverage 60% coverage
Basic Services (illings, extractions, root canal, etc.)
after deductible after deductible
50% coverage 50% coverage
Major Services (bridges, dentures, inlays, crowns, etc.)
after deductible after deductible
Annual Maximum Beneit (excluding orthodontic treatment) $1,500 $1,250
Orthodontics (lifetime maximum beneit) $1,500 $1,250
The dental plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have
access to a computer, printed copies are available upon request from Human Resources.
33
SIH Benefits Re-Enrollment
DENTAL OPTIONS
You have two dental options, a High plan and a You can also call your current dental provider to
Low plan, and they are administered by Cigna. Each ensure they are in Cigna’s network. If you enroll
option includes preventive, basic, major care, and family members in your dental option, you will be
orthodontic care. Our plans access the Cigna DPPO required to complete a coordination of beneits
network. Keep in mind the best discounts on your (COB). The plan administrator will mail you a packet
services are received when you use an in-network containing the required COB form. Please complete
provider to ensure you are not subject to balance and submit this form in a timely manner to avoid
billing. If you seek services from an out-of-network claim denials in the future.
provider, please note you may be subject to balance
billing, where a provider may bill you for the Please note: if your spouse is also an employee of
diference between what Cigna paid the provider SIH, you will need to choose employee coverage
and what the provider actually charged. under your own plan or spouse or family coverage
under your spouse’s plan. You cannot be enrolled in
To locate an in-network provider, visit both.
www.cigna.com (select Total Dental PPO) or call
800.244.6224.
SIH Dental Coverage High Option (A) Low Option (B)
Annual Deductible (per covered person for basic services) $50 $100
100% coverage/ 100% coverage/
Preventive Service (cleanings, luoride, routine exams, x-rays)
no deductible no deductible
80% coverage 60% coverage
Basic Services (illings, extractions, root canal, etc.)
after deductible after deductible
50% coverage 50% coverage
Major Services (bridges, dentures, inlays, crowns, etc.)
after deductible after deductible
Annual Maximum Beneit (excluding orthodontic treatment) $1,500 $1,250
Orthodontics (lifetime maximum beneit) $1,500 $1,250
The dental plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have
access to a computer, printed copies are available upon request from Human Resources.
33
