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Dental Finding In-
We partner with Cigna to offer you and your family members dental Network Providers
insurance. Visit www.cigna.com to ind in-network providers who Remember to visit in-network
participate in the Cigna Dental PPO network and access a variety dentists to receive the
of online tools and programs. You have the choice of Cigna DPPO deepest level of discount on
Advantage and Cigna DPPO providers for in-network services. While the your services.
plan will pay for services from non-participating dentists, you will receive To find a participating in-
deeper discounts and maximum reimbursement if you seek services from network dentist in your area,
participating dentists. go to www.cigna.com or call
866.494.2111.
Basic* Buy-Up**
Calendar Year Deductible—In-Network Orthodontia
Individual $50 $50
Family $150 $150 Services Note
Calendar Year Maximum The lifetime maximum
$1,500 $3,000 illustrated is different from
Coinsurance the calendar year maximum.
Preventive 100% no deductible 100% no deductible For orthodontia services, this
Basic 50% after deductible 80% after deductible
Major 50% after deductible 50% after deductible limit does not reset each year,
Orthodontia this is the most your plan will
Coinsurance 50% after deductible 50% after deductible cover for your services for the
Lifetime Maximum $1,000 $1,000 lifetime of your participation in
Beneit Applies to Children to age 19 Adults and children this program.
* Non-participating services reimbursed at the 80th percentile Examples of
** Non-participating services reimbursed at the 90th percentile Services
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in X Preventive—exams,
this guide and what is communicated in your SPD, the terms of your SPD will prevail. cleanings, fluoride, x-rays,
and sealants
Employee Pretax Dental Contributions
Dental X Basic—fillings, extractions,
Full-Time Bi-Weekly* Weekly Contributions periodontics, repairs, and
Basic oral surgery
Employee $0.00 $0.00
Employee/Spouse $10.05 $4.64 X Major—crowns,
Employee/Child(ren) $12.13 $5.60 inlays, dentures, and
Family $19.62 $9.05 dental impacts
Buy-Up
Employee $10.00 $4.62
Employee/Spouse $30.11 $13.90
Employee/Child(ren) $39.45 $18.21
Family $63.23 $29.18
* During the two months in a year that have three pay periods (January and July), beneits will
only be deducted from the irst two paychecks.
Dawson 19
We partner with Cigna to offer you and your family members dental Network Providers
insurance. Visit www.cigna.com to ind in-network providers who Remember to visit in-network
participate in the Cigna Dental PPO network and access a variety dentists to receive the
of online tools and programs. You have the choice of Cigna DPPO deepest level of discount on
Advantage and Cigna DPPO providers for in-network services. While the your services.
plan will pay for services from non-participating dentists, you will receive To find a participating in-
deeper discounts and maximum reimbursement if you seek services from network dentist in your area,
participating dentists. go to www.cigna.com or call
866.494.2111.
Basic* Buy-Up**
Calendar Year Deductible—In-Network Orthodontia
Individual $50 $50
Family $150 $150 Services Note
Calendar Year Maximum The lifetime maximum
$1,500 $3,000 illustrated is different from
Coinsurance the calendar year maximum.
Preventive 100% no deductible 100% no deductible For orthodontia services, this
Basic 50% after deductible 80% after deductible
Major 50% after deductible 50% after deductible limit does not reset each year,
Orthodontia this is the most your plan will
Coinsurance 50% after deductible 50% after deductible cover for your services for the
Lifetime Maximum $1,000 $1,000 lifetime of your participation in
Beneit Applies to Children to age 19 Adults and children this program.
* Non-participating services reimbursed at the 80th percentile Examples of
** Non-participating services reimbursed at the 90th percentile Services
This is a high level summary of your beneit coverage. Full coverage details are available in your
summary plan description (SPD). In the event there is a discrepancy between what is relected in X Preventive—exams,
this guide and what is communicated in your SPD, the terms of your SPD will prevail. cleanings, fluoride, x-rays,
and sealants
Employee Pretax Dental Contributions
Dental X Basic—fillings, extractions,
Full-Time Bi-Weekly* Weekly Contributions periodontics, repairs, and
Basic oral surgery
Employee $0.00 $0.00
Employee/Spouse $10.05 $4.64 X Major—crowns,
Employee/Child(ren) $12.13 $5.60 inlays, dentures, and
Family $19.62 $9.05 dental impacts
Buy-Up
Employee $10.00 $4.62
Employee/Spouse $30.11 $13.90
Employee/Child(ren) $39.45 $18.21
Family $63.23 $29.18
* During the two months in a year that have three pay periods (January and July), beneits will
only be deducted from the irst two paychecks.
Dawson 19
