Page 17 - Dawson 2021 New Hire Guide
P. 17
2021 Benefits Guide
Dental Finding In-Network Providers
We partner with Cigna to offer you and your family Remember to visit in-network dentists to receive the
members dental insurance. Visit www.cigna.com to deepest level of discount on your services.
ind in-network providers who participate in the Cigna To ind a participating in-network dentist in your area, go to
Dental PPO network and access a variety of online www.cigna.com or call 866.494.2111.
tools and programs. You have the choice of Cigna
DPPO Advantage and Cigna DPPO providers for in- Orthodontia Services Note
network services. While the plan will pay for services The lifetime maximum illustrated is diferent from the
from non-participating dentists, you will receive deeper calendar year maximum. For orthodontia services, this limit
discounts and maximum reimbursement if you seek does not reset each year, this is the most your plan will
services from participating dentists. cover for your services for the lifetime of your participation
in this program.
Basic* Buy-Up**
Calendar Year Deductible—In-Network Examples of Covered Services
Individual $50 $50 Preventive—exams, cleanings, luoride, x-rays, and
Family $150 $150 sealants
Calendar Year Maximum Basic—illings, extractions, periodontics, repairs, and
$1,500 $3,000 oral surgery
Coinsurance Major—crowns, inlays, dentures, and dental implants
Preventive 100% no deductible 100% no deductible
Basic 50% after deductible 80% after deductible
Major 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% no deductible 50% no deductible
Lifetime Maximum $1,000 $1,000
Beneit Applies To Children to age 19 Adults and children
* Non-participating services reimbursed at the 80th percentile
** Non-participating services reimbursed at the 90th percentile
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 this guide and what is
communicated in your SPD, the terms of your SPD will prevail.
Employee Pretax Dental Contributions
Dental
Weekly
Full-Time Bi-Weekly* Contributions
Basic
Employee $0.00 $0.00
Employee/Spouse $10.07 $4.65
Employee/Child(ren) $12.15 $5.61
Family $19.65 $9.07
Buy-Up
Employee $10.02 $4.62
Employee/Spouse $30.17 $13.92
Employee/Child(ren) $39.52 $18.24
Family $63.34 $29.23
* 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.
17
Dental Finding In-Network Providers
We partner with Cigna to offer you and your family Remember to visit in-network dentists to receive the
members dental insurance. Visit www.cigna.com to deepest level of discount on your services.
ind in-network providers who participate in the Cigna To ind a participating in-network dentist in your area, go to
Dental PPO network and access a variety of online www.cigna.com or call 866.494.2111.
tools and programs. You have the choice of Cigna
DPPO Advantage and Cigna DPPO providers for in- Orthodontia Services Note
network services. While the plan will pay for services The lifetime maximum illustrated is diferent from the
from non-participating dentists, you will receive deeper calendar year maximum. For orthodontia services, this limit
discounts and maximum reimbursement if you seek does not reset each year, this is the most your plan will
services from participating dentists. cover for your services for the lifetime of your participation
in this program.
Basic* Buy-Up**
Calendar Year Deductible—In-Network Examples of Covered Services
Individual $50 $50 Preventive—exams, cleanings, luoride, x-rays, and
Family $150 $150 sealants
Calendar Year Maximum Basic—illings, extractions, periodontics, repairs, and
$1,500 $3,000 oral surgery
Coinsurance Major—crowns, inlays, dentures, and dental implants
Preventive 100% no deductible 100% no deductible
Basic 50% after deductible 80% after deductible
Major 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% no deductible 50% no deductible
Lifetime Maximum $1,000 $1,000
Beneit Applies To Children to age 19 Adults and children
* Non-participating services reimbursed at the 80th percentile
** Non-participating services reimbursed at the 90th percentile
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 this guide and what is
communicated in your SPD, the terms of your SPD will prevail.
Employee Pretax Dental Contributions
Dental
Weekly
Full-Time Bi-Weekly* Contributions
Basic
Employee $0.00 $0.00
Employee/Spouse $10.07 $4.65
Employee/Child(ren) $12.15 $5.61
Family $19.65 $9.07
Buy-Up
Employee $10.02 $4.62
Employee/Spouse $30.17 $13.92
Employee/Child(ren) $39.52 $18.24
Family $63.34 $29.23
* 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.
17
