Page 15 - Demo

Plan Name Cigna Dental Care HMO Low Plan Cigna DPPO Advantage High PlanIn Network BenefitsPreventive Services 100% / 2 cleanings per calendar year 100% / 2 cleanings per calendar yearBasic Services Fee schedule 50%Major Services Fee schedule 50%Orthodontia Fee schedule $2,000Deductible(Applies to Basic & Major services only)N/A $50/$100Annual Benefit Maximum Fee schedule $2,000Orthodontia Lifetime Maximum Fee schedule 50% of the Maximum of $2,000Out-of-Network BenefitsPreventive Services Not covered 100%*Basic Services Not covered 90%*Major Services Not covered 50%*Orthodontia Not covered 50% of the Maximum of $2,000*Deductible (Applies to Basic & Majorservices only)Not covered $50/$100*Annual Benefit Maximum Not covered $2,000*Orthodontia Lifetime Maximum Not covered $2,000*Low Plan High PlanCigna Dental Care HMO Low Plan Cigna DPPO Advantage High PlanEmployee $7.59 $9.89Employee + Spouse $16.44 $20.77Employee + Child(ren) $13.91 $19.79Family $21.49 $29.68Dental Plans*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 Period15Ardena offers two Cigna dental plans: Low DHMO and High PPO. Both plans cover100% of preventive services.