Page 11 - 2022 Thrall Benefits Guide

Dental Plan

It’s important to have regular dental exams and cleanings so problems are detected before they become painful — and
expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and is an important part of
maintaining your overallhealth.

While you have the option of choosing any provider, choosing a DPPO Advantage network provider will ensure you receive
the deepest discounts and lowest out-of-pocket costs. The is the preferred network with the DPPO network a close second
choice. Out-of-Network dental providers are not limited to charging you Cigna’s negotiated rate for services and can cost you
substantially more, depending on the service provided.
Look for the CIGNA DPPO ADVANTAGE designation on mycigna.com when searching for recommended providers.

Plan Provisions CIGNA DPPO Advantage CIGNA DPPO Out-of-Network
Annual Deductible $75 / $225 $150 / $450 $150 / $450
(Individual/Family) waived for preventive waived for preventive waived for preventive

Calendar Year Max (Basic) $1,500 per person $1,500 per person $1,500 per person
Calendar Year Max (Buy-Up) $2,000 per person $2,000 per person $2,000 per person

Orthodontia Lifetime Max
$2,000 $2,000 $2,000
(Available on Buy-Up plan only)
Diagnostic & Preventive
Services (e.g., X-rays, Covered at 100% 20% afterDeductible 20% afterDeductible
cleanings, exams)

Amount you pay after deductible
Basic and Restorative 20% afterDeductible 40% afterDeductible 40% afterDeductible
Services (e.g.,fillings)
Major Services (e.g.,
dentures, crowns, bridges) 50% afterDeductible 60% afterDeductible 60% afterDeductible

Orthodontia
(for dependents aged 19 & 50% afterDeductible 50% afterDeductible 50% afterDeductible
under)

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