Page 17 - 2022 DPR Construction Benefit Guide_Administrative Employees

Dental Plan Options

Your dental health is an important part of your overall wellness. Dental insurance gives you a reason to smile — it covers
preventive care (including regular cleanings and preventive exams), as well as fillings, bridges, crowns and orthodontia
services. There are two Cigna dental plans available:
DPPO Dental Plan

With the PPO dental plan, you may visit any dentist of your choice. Keep in mind, you’ll receive the highest coverage when you
use an in-network provider. If you visit an out-of-network provider, you will not benefit from discounted rates and will pay more
out-of-pocket for services. Visit mycigna.com for provider directory.

DHMO Dental Plan

With the DHMO dental plan, you select a primary dentist who will coordinate your dental care needs, including referrals
to specialists. You typically pay a copay for qualified dental services (refer to the benefit schedule). The DHMO plan offers
in-network coverage only. If you visit a provider outside of the plan’s network, you will be responsible for the full cost of services.

Note: DPPO and DHMO are on different networks with the DPPO having a far greater network. Be sure to check if your preferred
dental provider is in either or both of the Cigna networks.
DPPO PLAN DHMO PLAN
IN-NETWORK OUT-OF-NETWORK* IN-NETWORK
CALENDAR YEAR DEDUCTIBLE
Individual $50 $75 $0

Family $150 $225 $0
CALENDAR YEAR PLAN MAXIMUM
Per Individual $2,000 per individual Unlimited

YOU PAY YOU PAY
PREVENTIVE CARE
Exams, Cleanings, X-rays,
Fluoride Treatments No Charge No Charge $0 (two per calendar year)
BASIC SERVICES
Fillings, Space Maintainers,
Sealants, Extractions, Oral Surgery, Various copays apply.
Endodontics, Periodontics, 20%** 20%** See Schedule of Benefits.
Emergency Exams
MAJOR PROCEDURES

Crowns, Inlays/Onlays, Dentures and 50%** 50%** Various copays apply.
Bridgework, Repairs See Schedule of Benefits.
ORTHODONTIA

24-Month Treatment Fee – Additional fees may apply for pre-ortho visits and treatment, banding, records and retention
50% up to a lifetime maximum benefit of Various copays apply.
Adults and Children
$2,500 per individual; deductible waived See Schedule of Benefits.
* Out-of-network reimbursement is based on the 90th percentile of all provider charges in the geographic area. You are responsible for charges above
that amount.
** Deductible applies.

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