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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 overall health. We offer three dental plans through Cigna.

Passive PPO
Incentive PPO Dental Plan Dental HMO Plan**
Dental Plan
In-Network/
In-Network Out-of-Network Network Only
Plan Provisions Out-of-Network
Annual Deductible
(Individual/Family) $50/$100 $100/$300 $50/$300 No deductibles
Calendar Year Maximum $1,000 per individual $1,000 per person Unlimited

Member pays
Orthodontia Lifetime Maximum Not covered $1,500 per person
scheduled copay
Diagnostic and Preventive Services Member pays 20%; Member pays
Covered at 100% Covered at 100%
(e.g., X-rays, cleanings, exams) deductible waived scheduled copay
Basic and Restorative Services Member pays
25%* 50%* 50%*
(e.g., fillings) scheduled copay
Major Services 40%* 50%* 50%* Member pays
(e.g., dentures, crowns, bridges) scheduled copay
50%* for children Member pays
Orthodontia Not covered
up to age 19 scheduled copay
*After deductible
**Must choose network general dentist to manage overall care. The DHMO is not available in all states.

Using in-network dental providers

While you have the option of choosing any provider, you will
save money when you use in-network dentists. When using an
out-of-network dental provider, you will pay more because
the provider has not agreed to charge you a negotiated rate.

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