Page 10 - 2019 Benefit Guide Non-CA

DENTAL COVERAGE

In order to provide you with the level of dental coverage that best fits the needs of you and your family,
AAG offers two dental plan options; CIGNA DPPO Low and CIGNA DPPO High.
To help you understand the features and coverage available to you, we have provided the following brief
summary of benefits. Please refer to plan documents for details, including important coverage exclusions
and limitations.

CIGNA DPPO - HIGH AND LOW OPTION

COVERAGE CIGNA – HIGH OPTION CIGNA – LOW OPTION
In-Network Out-of-Network In-Network Out-of-Network

Deductible (Single/ Family) $50 / $100 $50 / $100 $100 / $300 $100 / $300
Calendar Year Maximum $2,000 $2,000 $1,500 $750
Preventative & Diagnostic Care Texas Texas
(Cleanings, Exams, X-rays, etc.) No charge No charge
No charge No charge
deductible waived deductible waived deductible waived deductible waived
Other States Other States
80% 80%
Basic Care Plan pays 80% after Plan pays 60% after Plan pays 80% after Plan pays 80% after
(Fillings, extractions, Root canal, deductible deductible deductible deductible
etc.)
Major Services Plan pays 50% after Plan pays 40% after Plan pays 50% after Plan pays 50% after
(Crowns, Bridges, Dentures, etc.) deductible deductible deductible deductible
Orthodontia 50% to a Lifetime 50% to a Lifetime
(Adult and Children) maximum benefit maximum benefit Not covered Not covered
of $2,000 of $2,000
Reimbursements Contracted MRC 80th percentile Contracted MRC 80th percentile

*Implants on both High and Low options are covered at 50% In-Network after deductible.

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