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Dental Finding In-Network
Providers
We partner with Cigna to offer you and your family members dental Remember to visit in-network
insurance. Visit www.cigna.com to ind in-network providers who dentists to receive the deepest
participate in the Cigna Dental PPO network and access a variety level of discount on your services .
of online tools and programs. You have the choice of Cigna DPPO
Advantage and Cigna DPPO providers for in-network services. While the To find a participating in-
network dentist in your area
plan will pay for services from non-participating dentists, you will receive go to www.cigna.com or call
deeper discounts and maximum reimbursement if you seek services from 866.494.2111.
participating dentists.
Basic* Buy-Up** Orthodontia
Calendar Year Deductible—In-Network Services Note
Individual $50 $50 The lifetime maximum illustrated
Family $150 $150 is different from the calendar
Calendar Year Maximum year maximum . For orthodontia
$1,000 $5,000 services, this limit does not
Coinsurance reset each year, this is the most
Preventive 100% no deductible 100% no deductible your plan will cover for your
Basic 50% after deductible 80% after deductible services for the lifetime of your
Major 50% after deductible 50% after deductible participation in this program .
Orthodontia
Coinsurance Not covered 50% after deductible
Lifetime Maximum $1,000 Examples of
Benefit Applies to Adults and children Services
X Preventive—exams, cleanings,
* Non-participating services reimbursed at the 80th percentile fluoride, x-rays, and sealants
** Non-participating services reimbursed at the 90th percentile
This is a high level summary of your benefit coverage . Full coverage details are X Basic—fillings, extractions,
available in your summary plan description (SPD) . In the event there is a discrepancy periodontics, repairs, and oral
between what is reflected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail . surgery
Employee Pretax Dental Contributions X Major—crowns, inlays,
dentures, and dental impacts
Dental
Full-Time Bi-Weekly Weekly Contributions
Basic
Employee $0 .00 $0 .00
Employee/Spouse $13 .62 $6 .81
Employee/Child(ren) $16 .58 $8 .29
Family $27 .40 $13 .70
Buy-Up
Employee $0 .00 $0 .00
Employee/Spouse $23 .06 $11 .53
Employee/Child(ren) $28 .06 $14 .03
Family $46 .38 $23 .19
Dawson 19
Providers
We partner with Cigna to offer you and your family members dental Remember to visit in-network
insurance. Visit www.cigna.com to ind in-network providers who dentists to receive the deepest
participate in the Cigna Dental PPO network and access a variety level of discount on your services .
of online tools and programs. You have the choice of Cigna DPPO
Advantage and Cigna DPPO providers for in-network services. While the To find a participating in-
network dentist in your area
plan will pay for services from non-participating dentists, you will receive go to www.cigna.com or call
deeper discounts and maximum reimbursement if you seek services from 866.494.2111.
participating dentists.
Basic* Buy-Up** Orthodontia
Calendar Year Deductible—In-Network Services Note
Individual $50 $50 The lifetime maximum illustrated
Family $150 $150 is different from the calendar
Calendar Year Maximum year maximum . For orthodontia
$1,000 $5,000 services, this limit does not
Coinsurance reset each year, this is the most
Preventive 100% no deductible 100% no deductible your plan will cover for your
Basic 50% after deductible 80% after deductible services for the lifetime of your
Major 50% after deductible 50% after deductible participation in this program .
Orthodontia
Coinsurance Not covered 50% after deductible
Lifetime Maximum $1,000 Examples of
Benefit Applies to Adults and children Services
X Preventive—exams, cleanings,
* Non-participating services reimbursed at the 80th percentile fluoride, x-rays, and sealants
** Non-participating services reimbursed at the 90th percentile
This is a high level summary of your benefit coverage . Full coverage details are X Basic—fillings, extractions,
available in your summary plan description (SPD) . In the event there is a discrepancy periodontics, repairs, and oral
between what is reflected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail . surgery
Employee Pretax Dental Contributions X Major—crowns, inlays,
dentures, and dental impacts
Dental
Full-Time Bi-Weekly Weekly Contributions
Basic
Employee $0 .00 $0 .00
Employee/Spouse $13 .62 $6 .81
Employee/Child(ren) $16 .58 $8 .29
Family $27 .40 $13 .70
Buy-Up
Employee $0 .00 $0 .00
Employee/Spouse $23 .06 $11 .53
Employee/Child(ren) $28 .06 $14 .03
Family $46 .38 $23 .19
Dawson 19
