Page 17 - 2022 Benegit Guide

Dental Coverage

Cigna offers a choice of two dental plan options: Cigna Dental PPO and Cigna Dental Care DHMO.

DPPO DHMO
Benefit Plan Features
Network* Non-Network Network Non-Network
Individual/Family $50/$150 None No coverage
Deductible
Class I – Preventive 1 100% 90% 100% No coverage
Class II – 80%, after 70%, after N/A, see Patient No coverage
Basic Restorative deductible deductible Charge Schedule
Coinsurance
Class III – 60%, after 50%, after N/A, see Patient No coverage
Major Restorative deductible deductible Charge Schedule
Annual Maximum $1,500 $1,000 N/A, see Patient No coverage
(Non-orthodontia services) Charge Schedule
Class IV – Orthodontia
Class IV Orthodontia applies only 60% after plan 50% after plan N/A, see Patient No coverage
to dependent children 18 years of deductible is met deductible is met Charge Schedule
age and younger
N/A, see Patient
Lifetime Maximum Coverage $1,500 $1,200 No coverage
Charge Schedule
• Clinical oral exam • Periodontal maintenance
• Palliative (emergency) treatment procedures
of dental pain • Topical flouride (up to age 19)
Diagnostic and Preventive Services
• X-rays and bitewing x-rays • Sealants (up to age 14)
• Prophylaxis cleanings • Space maintainer fixed
unilateral (non-ortho)
• Fillings • Replacement bridge
• Root canal therapy • Routine extractions
Basic Restorative Services • Osseous surgery • Surgical removal of tooth
• Periodontal scaling and root planing • Local and general
• Adjustments anesthetics, I.V. sedation
Crowns Bridges
Major Restorative Services
Dentures Prothesis over implant
*In-Network DPPO dental care is provided by a Cigna Advantage provider.
1 Cigna rewards you for getting preventive dental care, your plan maximum will increase by $200 the following year.

Your Weekly Cost for Coverage DPPO DHMO

Team Member Only $5.90 $3.90
Team Member + Child(ren) $11.85 $9.07
Team Member + Spouse $14.03 $7.16
Team Member + Family $22.52 $13.22

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2022 Health and Benefits Guide 17