Page 13 - Harvard Maintenance HPS Field Ops 2022 Benefits Guide
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Calendar Year 2022
Benefits Enrollment
Dental Coverage—Cigna
Plan Highlights In-Network Out-of-Network
Annual Calendar Year Deductible (Excludes Orthodontia Services)
Individual $100 $100
Family $300 $300
Annual Maximum Beneit
$1,000 per person
Preventive Services
Oral Examinations (a) 100% (deductible waived) 100%
Bitewing Images (a)
Cleanings (once every six months) (a)
Fluoride (a)
Sealants: (permanent molars only) (a)
Basic Services
Amalgam and Composite Fillings (anterior teeth only) 50% 50%
Stainless Steel Crowns
Major Services
Root Canal 30% 30%
Dentures
Inlays and Onlays
Crowns
General Anesthesia*
Surgical Removal of Erupted Tooth*
Repair and Maintenance of Dentures
Simple Extractions
Dependent Age Limit
26
* Certain services may be covered under the Medical Plan . Contact Member Services for more details .
(a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certiicate.
Out-of-network reimbursement based on schedule of maximum allowable charge. Network dentists agreed to accept the allowances as payment in
full for covered services. Out-of-network dentists may bill member for any diference between the allowed amount and their fee.
The above information is a summary only. Please refer to your evidence of coverage for complete details of plan beneits, limitations, and exclusions.
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Benefits Enrollment
Dental Coverage—Cigna
Plan Highlights In-Network Out-of-Network
Annual Calendar Year Deductible (Excludes Orthodontia Services)
Individual $100 $100
Family $300 $300
Annual Maximum Beneit
$1,000 per person
Preventive Services
Oral Examinations (a) 100% (deductible waived) 100%
Bitewing Images (a)
Cleanings (once every six months) (a)
Fluoride (a)
Sealants: (permanent molars only) (a)
Basic Services
Amalgam and Composite Fillings (anterior teeth only) 50% 50%
Stainless Steel Crowns
Major Services
Root Canal 30% 30%
Dentures
Inlays and Onlays
Crowns
General Anesthesia*
Surgical Removal of Erupted Tooth*
Repair and Maintenance of Dentures
Simple Extractions
Dependent Age Limit
26
* Certain services may be covered under the Medical Plan . Contact Member Services for more details .
(a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certiicate.
Out-of-network reimbursement based on schedule of maximum allowable charge. Network dentists agreed to accept the allowances as payment in
full for covered services. Out-of-network dentists may bill member for any diference between the allowed amount and their fee.
The above information is a summary only. Please refer to your evidence of coverage for complete details of plan beneits, limitations, and exclusions.
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