Page 16 - Harvard Maintenance Executive 2022 Benefits Guide
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Calendar Year 2022
Benefits Enrollment
Dental Coverage—Cigna PPO
Plan Highlights In-Network Out-of-Network
Annual Calendar Year Deductible (excludes orthodontia services)
Individual $50 $100
Family $150 $300
Annual Maximum Beneit
$1,000 per person
Preventive Services
Oral Examinations (1) 100% (deductible waived) 80%
Bitewing Images (1)
Cleanings (once every six months) (1)
Topical Fluoride Treatment (1)
Sealants (1)
Basic Services
General Anesthesia* 90% 80%
Amalgam and Composite Fillings (anterior teeth only)
Incision and Drainage of Abscess*
Surgical Removal of Erupted Tooth*
Repair and Maintenance of Dentures
Simple Extractions
Surgical Extractions
Major Services
Root Canal 50% 50%
Dentures
Inlays and Onlays
Crowns
Pontics
Orthodontia Lifetime Maximum
$1,000 per person
Dependent Age Limit
30
Reward Provisions
Required Service for Annual Maximum Increase in the Following Year Any preventive service
Annual Maximum Reward Increase** $300
Maximum Number of Increases 3
Annual Maximum Impact if No Visit Reduced to original plan level
* Certain services may be covered under the Medical Plan . Contact Member Services for more details .
** Increase does not apply to Orthodontia .
(1) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certiicate.
Out-of-network reimbursement based on schedule of maximum allowable charge . Network dentists agreed to accept the allowances as payment in
full for covered services. Out-of-network dentists may bill member for any diference between the allowed amount and their fee.
The above information is a summary only. Please refer to your evidence of coverage for complete details of plan beneits, limitations, and exclusions.
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Benefits Enrollment
Dental Coverage—Cigna PPO
Plan Highlights In-Network Out-of-Network
Annual Calendar Year Deductible (excludes orthodontia services)
Individual $50 $100
Family $150 $300
Annual Maximum Beneit
$1,000 per person
Preventive Services
Oral Examinations (1) 100% (deductible waived) 80%
Bitewing Images (1)
Cleanings (once every six months) (1)
Topical Fluoride Treatment (1)
Sealants (1)
Basic Services
General Anesthesia* 90% 80%
Amalgam and Composite Fillings (anterior teeth only)
Incision and Drainage of Abscess*
Surgical Removal of Erupted Tooth*
Repair and Maintenance of Dentures
Simple Extractions
Surgical Extractions
Major Services
Root Canal 50% 50%
Dentures
Inlays and Onlays
Crowns
Pontics
Orthodontia Lifetime Maximum
$1,000 per person
Dependent Age Limit
30
Reward Provisions
Required Service for Annual Maximum Increase in the Following Year Any preventive service
Annual Maximum Reward Increase** $300
Maximum Number of Increases 3
Annual Maximum Impact if No Visit Reduced to original plan level
* Certain services may be covered under the Medical Plan . Contact Member Services for more details .
** Increase does not apply to Orthodontia .
(1) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certiicate.
Out-of-network reimbursement based on schedule of maximum allowable charge . Network dentists agreed to accept the allowances as payment in
full for covered services. Out-of-network dentists may bill member for any diference between the allowed amount and their fee.
The above information is a summary only. Please refer to your evidence of coverage for complete details of plan beneits, limitations, and exclusions.
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