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Plan Name Cigna DPPO PlanIn Network BenefitsPreventive Services 100% / 2 cleanings per calendar yearBasic Services 90%Major Services 60%Orthodontia $1,250Deductible(Applies to Basic & Major services only)$50/$150Annual Benefit Maximum $1,750Orthodontia Lifetime Maximum 50% of the Maximum of $1,250Out-of-Network BenefitsPreventive Services 100%*Basic Services 90%*Major Services 60%*Orthodontia 50% of the Maximum of $1,250*Deductible (Applies to Basic & Major services only) $50/$150*Annual Benefit Maximum $1,750*Orthodontia Lifetime Maximum $1,250*Dental PlanCigna DPPO PlanEmployee No costEmployee + Spouse No costEmployee + Child(ren) No costFamily No costDental Plan*MAC: The out%u2010of%u2010network percentage of benefits is based on the %u201callowable amount%u201d applicable for the same service that would have been rendered by anetwork provider.**UCR: The out%u2010of%u2010network percentage of benefits is based on the %u201cusual and customary fees%u201d in the geographic areas in which the expenses are incurred.The network percentage of benefits is based on the discounted fees negotiated with the provider. See full plan summary for a more detailed plan explanationalong with a list of exclusions and limitationsRefer to your full plan summary for details on covered services.Dental Insurance Employee Cost Per Pay Period16Cigna dental plan: DPPO | This plan covers 100% of preventive services.