Page 11 - NH Guide
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Dental
Our dental plan makes dental care more affordable for employees and
their families. Taking care of your mouth, teeth, and gums is a big part
of making sure you feel your best. Healthy habits like brushing, lossing,
and seeing your dentist for regular cleanings help prevent problems.
Remember to choose an in-network dentist to ensure you’re receiving the
deepest level of discounted services.
Dental coverage is administered by Cigna. You are encouraged to seek
services from Cigna Dental PPO providers. Non-participating dentists
will be reimbursed at the 90th percentile of usual and customary and you
may be balance billed for the amount above Cigna’s reimbursement.
Core Plan In-
Network High Plan In-Network
Deductible/Maximum
Individual deductible $50 $50
Family deductible $150 $150
Calendar year maximum $1,250 $2,500
Coinsurance
Preventive services 100% 100%
(Exams, x-rays, cleanings)
Basic services 80% 80%
(Fillings, root canals, oral surgery)
Major services 50% 50%
(Bridges, crowns, dentures)
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,000 $2,500
Eligibility Adults and children
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description, the
terms of the SPD will prevail.
Dental Bi-Weekly Contributions—Paid By You on a Pre-Tax
Basis
Coverage Tier Core Plan High Plan
Employee only $4.95 $8.67
Employee + spouse $18.63 $21.60
Employee + child or children $11.28 $17.88
Family $23.16 $31.99
2016 New Hire Guide
Dental
Our dental plan makes dental care more affordable for employees and
their families. Taking care of your mouth, teeth, and gums is a big part
of making sure you feel your best. Healthy habits like brushing, lossing,
and seeing your dentist for regular cleanings help prevent problems.
Remember to choose an in-network dentist to ensure you’re receiving the
deepest level of discounted services.
Dental coverage is administered by Cigna. You are encouraged to seek
services from Cigna Dental PPO providers. Non-participating dentists
will be reimbursed at the 90th percentile of usual and customary and you
may be balance billed for the amount above Cigna’s reimbursement.
Core Plan In-
Network High Plan In-Network
Deductible/Maximum
Individual deductible $50 $50
Family deductible $150 $150
Calendar year maximum $1,250 $2,500
Coinsurance
Preventive services 100% 100%
(Exams, x-rays, cleanings)
Basic services 80% 80%
(Fillings, root canals, oral surgery)
Major services 50% 50%
(Bridges, crowns, dentures)
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,000 $2,500
Eligibility Adults and children
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description, the
terms of the SPD will prevail.
Dental Bi-Weekly Contributions—Paid By You on a Pre-Tax
Basis
Coverage Tier Core Plan High Plan
Employee only $4.95 $8.67
Employee + spouse $18.63 $21.60
Employee + child or children $11.28 $17.88
Family $23.16 $31.99
2016 New Hire Guide
