Page 13 - 2015 Enrollment Guide
P. 13
AIP Aerospace Holdings, LLC
Cigna DMO—Dental Care Plan
Similar to a medical HMO plan, the Cigna DMO is a network of dental Dental
providers who manage dental care for its members. You must designate a
Primary Care Dentist that will coordinate your coverage and refer you to AIP Aerospace offers
Specialists when needed. There are no deductibles or coinsurances under two dental plan options
through Cigna to meet
the Dental Care plan and you pay a lat fee for services based on the plan’s your dental care needs.
patient charge schedule.
The information at
Cigna DPPO Advantage Plan right is a summary
Cigna’s DPPO Advantage plan features a network of dentists that have only. Please refer
to your Evidence of
agreed to a discount payment schedule. You are not required to designate Coverage for complete
a primary care dentist, and you have the choice to select any participating details of plan benefits,
Cigna DPPO Advantage dentist. You may choose to obtain services from limitations, and
a non-preferred provider; however, your out-of-pocket costs will be higher exclusions.
and your annual maximum beneit will be lower.
Cigna DMO Cigna DPPO Advantage
Out-of- In- Out-of-
In-Network Network * Network Network *
Deductible (Calendar Year)
Individual None Not covered $50 $100
Family $150 $300
Coinsurance
Preventive services: No charge Not covered No charge
exams, x-rays,
prophylaxis
Basic services: Many services paid Not covered 10% * 20% *
illings, oral surgery, at 100%; some
root canals subject to copays
Major services: Subject to copays Not covered 40% * 50% *
bridges, crowns,
dentures, and
implants (NEW)
Primary dentist Required Not covered Not required
designation
Calendar Year Maximum
N/A Not covered $1,500
Orthodontist Services
Dependent children Subject to copays Not covered 50% *
Adults Subject to copays Not covered
Orthodontist lifetime N/A Not covered $1,500
maximum
* Subject to calendar year deductible; accumulates towards calendar-year maximum (CY Max
does not apply to routine preventive dental exams or cleanings)
** For Texas residents only, the Cigna DPPO Advantage Plan features no differential in beneit
levels (deductible, coinsurance, limits, etc.) between services rendered in-network or out-of-
network. The In-Network beneits will apply to all covered services for Texas residents.
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Cigna DMO—Dental Care Plan
Similar to a medical HMO plan, the Cigna DMO is a network of dental Dental
providers who manage dental care for its members. You must designate a
Primary Care Dentist that will coordinate your coverage and refer you to AIP Aerospace offers
Specialists when needed. There are no deductibles or coinsurances under two dental plan options
through Cigna to meet
the Dental Care plan and you pay a lat fee for services based on the plan’s your dental care needs.
patient charge schedule.
The information at
Cigna DPPO Advantage Plan right is a summary
Cigna’s DPPO Advantage plan features a network of dentists that have only. Please refer
to your Evidence of
agreed to a discount payment schedule. You are not required to designate Coverage for complete
a primary care dentist, and you have the choice to select any participating details of plan benefits,
Cigna DPPO Advantage dentist. You may choose to obtain services from limitations, and
a non-preferred provider; however, your out-of-pocket costs will be higher exclusions.
and your annual maximum beneit will be lower.
Cigna DMO Cigna DPPO Advantage
Out-of- In- Out-of-
In-Network Network * Network Network *
Deductible (Calendar Year)
Individual None Not covered $50 $100
Family $150 $300
Coinsurance
Preventive services: No charge Not covered No charge
exams, x-rays,
prophylaxis
Basic services: Many services paid Not covered 10% * 20% *
illings, oral surgery, at 100%; some
root canals subject to copays
Major services: Subject to copays Not covered 40% * 50% *
bridges, crowns,
dentures, and
implants (NEW)
Primary dentist Required Not covered Not required
designation
Calendar Year Maximum
N/A Not covered $1,500
Orthodontist Services
Dependent children Subject to copays Not covered 50% *
Adults Subject to copays Not covered
Orthodontist lifetime N/A Not covered $1,500
maximum
* Subject to calendar year deductible; accumulates towards calendar-year maximum (CY Max
does not apply to routine preventive dental exams or cleanings)
** For Texas residents only, the Cigna DPPO Advantage Plan features no differential in beneit
levels (deductible, coinsurance, limits, etc.) between services rendered in-network or out-of-
network. The In-Network beneits will apply to all covered services for Texas residents.
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