Page 5 - AONNH19
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Dental
Maintaining healthy teeth and gums, and seeking professional treatment
when dental problems arise, is important to your overall health.
The dental plan provider is Cigna. To search for providers, visit
www.mycigna.com. When searching for dental providers, please look for
the DPPO Advantage Network.
Cigna DPPO Advantage
In-Network Out-of-Network
Fee Reimbursement Fee schedule 90th% UCR
Preventive Expenses 100% 100%
Benefit
Basic Expenses Benefit * 80% 70%
Major Expenses Benefit 50% 50%
Orthodontia (child only) 100%—$1,000 lifetime maximum to age 19
Deductible (single/family) $50/$100
Deductible Applies to Basic and major services
Endo and Perio Services Basic service
Maximum Benefit per Year $2,000
* Composite filings are covered under basic benefit
Note: when seeing an out-of-network provider you will be held liable for charges over
the allowed amount which is called balance billing .
Dental Payroll Deductions
Dental Plan—Bi-Weekly Dental Plan—Monthly
Deductions Deductions
Employee Only $14 .33 $31 .05
Employee and $30 .10 $65 .21
Spouse/DP
Employee and $27 .23 $59 .00
Child(ren)
Family Coverage $43 .00 $93 .16
Important for new enrollees! If you do not enroll in dental coverage
when you first become eligible, you will be subject to a 12–month waiting
period for some benefits .
American Oncology Network 5
Maintaining healthy teeth and gums, and seeking professional treatment
when dental problems arise, is important to your overall health.
The dental plan provider is Cigna. To search for providers, visit
www.mycigna.com. When searching for dental providers, please look for
the DPPO Advantage Network.
Cigna DPPO Advantage
In-Network Out-of-Network
Fee Reimbursement Fee schedule 90th% UCR
Preventive Expenses 100% 100%
Benefit
Basic Expenses Benefit * 80% 70%
Major Expenses Benefit 50% 50%
Orthodontia (child only) 100%—$1,000 lifetime maximum to age 19
Deductible (single/family) $50/$100
Deductible Applies to Basic and major services
Endo and Perio Services Basic service
Maximum Benefit per Year $2,000
* Composite filings are covered under basic benefit
Note: when seeing an out-of-network provider you will be held liable for charges over
the allowed amount which is called balance billing .
Dental Payroll Deductions
Dental Plan—Bi-Weekly Dental Plan—Monthly
Deductions Deductions
Employee Only $14 .33 $31 .05
Employee and $30 .10 $65 .21
Spouse/DP
Employee and $27 .23 $59 .00
Child(ren)
Family Coverage $43 .00 $93 .16
Important for new enrollees! If you do not enroll in dental coverage
when you first become eligible, you will be subject to a 12–month waiting
period for some benefits .
American Oncology Network 5
