Page 13 - Excelligence 2022 Benefit Guide

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 two dental plan options through Cigna.
Annual Deductible
(Individual/Family)
Calendar Year Maximum
Orthodontia Lifetime Maximum
Diagnostic and Preventive Services
(e.g., X-rays, cleanings, exams)
Basic and Restorative Services
(e.g., fillings, extractions, root canals)
Major Services
(e.g., dentures, crowns, bridges)
Orthodontia
*For Out-of-Network services, members pay applicable coinsurance plus any amount that exceeds the usual, customary, and reasonable charge.
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.
Plan Provisions
Dental PPO* High Plan
In-Network
$50/$150
Out-of-Network
$50/$150
Dental PPO* Low Plan
In-Network
$50/$150 $50/$150
Out-of-Network
Dental HMO Plan
In-Network Only
$0
$1,500
$1,500
$1,500 $1,500
$0
$1,500 per individual
Not covered
Not covered
Covered at 100%
Covered at 100%
Covered at Covered at 100% 100%
$0-$50 copay
10%
20%
20% 20%
$0-$95 copay
40%
50%
50% 50%
$0-$720 copay
50%* for children and adults
Not covered
Covered
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