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Dental
The dental coverage offered by Summary of Benefits—Dental
The Carlstar Group is designed Total Cigna DPPO
to assist you and your covered Cigna Beneits In-Network Out-of-Network
dependents by paying a portion Calendar year maximum $2,000 Class I $2,000 Class I
applies
(Class I, II, III Expenses)
applies
of eligible expenses incurred for Calendar year deductible $50 per person $50 per person
a wide range of dental services. $150 per family $150 per family
100%, no
You may enroll for employee, Class I Expenses deductible 100%, no
deductible
Preventive and diagnostic care
employee and spouse, employee Oral exams, cleanings, routine x-rays, Reimbursement MAC: based
based upon
on maximum
and child(ren), or family coverage. luoride application, sealants, emergency contracted fees allowable charges
care to relieve pain, brush biopsy
The dental plan is through Cigna Class II Expenses—Basic Restorative 80%, after 80%, after
deductible
deductible
Dental. Care Reimbursement MAC: based
Space maintainers (limited to non-
orthodontic treatment), non-routine x-rays, based upon on maximum
Your Cost illings, oral surgery—simple extractions; contracted fees allowable charges
surgical extraction of impacted teeth;
Your cost for Dental coverage relines, rebases, and adjustments; repairs—
bridges, crowns, and inlays; repairs—
is deducted from your pay on dentures; endodontic procedures—pulp
a pretax basis. Refer to page 46 caps/pulpotomy; periodontal services—non-
surgical services—scaling and root planning
titled “Employee Contributions” Class III Expenses—Major Restorative 50%, after 50%, after
deductible
deductible
for the cost applicable to dental Care Reimbursement MAC: based
Anesthetics; all periodontal services except
coverage offered by The Carlstar scaling and root planning; endodontic based upon on maximum
Group. procedures (with the contracted fees allowable charges
Exception of pulp caps/pulpotomy); root
canal therapy/endodontics; crowns/inlays/
onlays; dentures; bridges; stainless steel/
resin crowns; surgical implants
Class IV Expenses—Orthodontia 50%, no ortho 50%, no ortho
Coverage for eligible children only (age deductible deductible
18 and under); lifetime maximum; plan $2,000 lifetime $2000 lifetime
deductible does not apply maximum maximum
Reimbursement MAC: based
based upon on maximum
contracted fees allowable charges
Missing tooth provision Full coverage for replacement of teeth
missing prior to the effective date
Late entrant limit No limit
Pretreatment review Available on a voluntary basis when
extensive work in excess of $200 is
proposed
Out-of-network reimbursement Based on contracted fee schedule (for
location of service rendered); dentist
may balance bill up to usual fees
Student/dependent age 26 26
31
The dental coverage offered by Summary of Benefits—Dental
The Carlstar Group is designed Total Cigna DPPO
to assist you and your covered Cigna Beneits In-Network Out-of-Network
dependents by paying a portion Calendar year maximum $2,000 Class I $2,000 Class I
applies
(Class I, II, III Expenses)
applies
of eligible expenses incurred for Calendar year deductible $50 per person $50 per person
a wide range of dental services. $150 per family $150 per family
100%, no
You may enroll for employee, Class I Expenses deductible 100%, no
deductible
Preventive and diagnostic care
employee and spouse, employee Oral exams, cleanings, routine x-rays, Reimbursement MAC: based
based upon
on maximum
and child(ren), or family coverage. luoride application, sealants, emergency contracted fees allowable charges
care to relieve pain, brush biopsy
The dental plan is through Cigna Class II Expenses—Basic Restorative 80%, after 80%, after
deductible
deductible
Dental. Care Reimbursement MAC: based
Space maintainers (limited to non-
orthodontic treatment), non-routine x-rays, based upon on maximum
Your Cost illings, oral surgery—simple extractions; contracted fees allowable charges
surgical extraction of impacted teeth;
Your cost for Dental coverage relines, rebases, and adjustments; repairs—
bridges, crowns, and inlays; repairs—
is deducted from your pay on dentures; endodontic procedures—pulp
a pretax basis. Refer to page 46 caps/pulpotomy; periodontal services—non-
surgical services—scaling and root planning
titled “Employee Contributions” Class III Expenses—Major Restorative 50%, after 50%, after
deductible
deductible
for the cost applicable to dental Care Reimbursement MAC: based
Anesthetics; all periodontal services except
coverage offered by The Carlstar scaling and root planning; endodontic based upon on maximum
Group. procedures (with the contracted fees allowable charges
Exception of pulp caps/pulpotomy); root
canal therapy/endodontics; crowns/inlays/
onlays; dentures; bridges; stainless steel/
resin crowns; surgical implants
Class IV Expenses—Orthodontia 50%, no ortho 50%, no ortho
Coverage for eligible children only (age deductible deductible
18 and under); lifetime maximum; plan $2,000 lifetime $2000 lifetime
deductible does not apply maximum maximum
Reimbursement MAC: based
based upon on maximum
contracted fees allowable charges
Missing tooth provision Full coverage for replacement of teeth
missing prior to the effective date
Late entrant limit No limit
Pretreatment review Available on a voluntary basis when
extensive work in excess of $200 is
proposed
Out-of-network reimbursement Based on contracted fee schedule (for
location of service rendered); dentist
may balance bill up to usual fees
Student/dependent age 26 26
31
