Page 13 - KIPP NYC 2022 Benfits Summary

Cigna Dental Plan Summary
PLAN PROVISIONS
Individual
Family
Waived for Preventive
Benefit Maximum
Calendar Year Maximum
Office Visit Copay
Oral Exams, Cleanings (two per year), Bitewing x-rays
Endodontics, Periodontics, Oral Surgery, Sealants
Root canals, Inlays, Onlays, Crowns
Orthodontia Coinsurance (Adult & Child)
Orthodontia – (Adult & Child) Lifetime Maximum
Refer
Refer
to Fee Schedule
to Fee Schedule
Yes
N/A
$5
to Fee Schedule
$25 $50
$75 $150
N/A Yes
$1,600 $1,600
100% 90%
$25 $50
$75 $150
N/A Yes
DENTAL HMO (DHMO)
In-Network Only
DENTAL PPO LOW
In-Network
Out-of-Network
DENTAL PPO HIGH
In-Network
Out-of-Network
Annual Deductible
Refer
100% 90%
70%
50% 50%
50% 50%
Refer
Refer
to Fee Schedule
to Fee Schedule
50% 50%
Not covered
N/A
$2,100
$2,100
Type A – Preventive Services
Type B – Basic Services
Refer to Fee Schedule
80%
70%
80%
Type C – Major Services
Type D – Orthodonia
$2,000
$2,000
2022 BENEFITS SUMMARY 13