Page 5 - 2022 Fantasea Benefit Guide English_Spanish

Dental Coverage

Regular dental exams Plan Provision Cigna DPPO
can help you and your In-Network Out-of-Network
dentist detect problems
in the early stages when Annual Deductible (Individual/Family) $50/$150
treatment is simpler, and Annual Maximum (Per person) $1,000
costs are lower. Keeping
your teeth and gums Diagnostic and Preventive Care: 100%, no ded
Includes cleanings, fluoride treatments,
clean and healthy will sealants and x-rays 100%, no ded
help prevent most tooth Basic Services: Includes fillings, periodontics,
decay and periodontal scaling and root planning, and oral surgery 70% after ded 70%, after ded
disease, and it is an

important part of Major Services: Includes crowns, bridges and 50% after ded
maintaining your medical full and partial dentures 50% after ded
health. The Cigna Dental Orthodontia Services Not Covered
plan provides
comprehensive coverage.
Dependent Children are
covered until age 26.

Vision Coverage
Benefit In-Network
The Horizon vision plan covers routine eye
exams and also pays for all or a portion of Exam $10 copay
the cost of glasses or contact lenses if you Lenses $25 copay
need them. Members will utilize the Davis Frequency
Vision network of physicians. Exam Once per calendar year
Dependent Children are covered until age Lenses Once per calendar year
26. Frames Once per two calendar years

Frames & Contact $130
Allowance

Single Vision Lenses Included
Bifocal Lenses Included
Trifocal Lenses Included

Elective Contact Lenses in Up to $130
lieu of glasses Plus a 15% discount on any overage

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