Page 20 - 2018 Capgemini Enrollment
P. 20
Dental HMO (DMO) Moving from Enhanced Dental or
Basic Dental Plan to DMO?
The Dental HMO (DMO) covers the same basic and major dental services, as well as orthodontic
services, that are covered by the Enhanced Dental Plan, as long as those services are performed If you switch from the Enhanced Dental
by in-network providers. You pay a co-payment at the time the service is received and there is no Plan or the Basic Dental Plan to the
annual maximum on the beneits you can receive from this plan. DMO, be sure you understand how any
When you enroll in the DMO, you select a primary care dentist for yourself and each covered major dental or orthodontia care you may
be undergoing will transition to the new
dependent. Your primary care dentist provides routine, basic care and refers you to specialty plan. Generally, major dental treatment
dentists when necessary. If your dentist leaves the network during the year, you must select a plans (e.g., root canal treatment, dentures,
new in-network general dentist to have care covered by the plan. or crown and bridge treatment) should
The plan pays beneits only when your in-network general dentist provides or coordinates be completed under your current plan.
your care. If you seek care on your own, you pay the entire cost. Payment for services is Ongoing orthodontia treatment may
based on a predetermined patient charge schedule, which is available on the FS benergy be able to transition to the DMO. For
site at www.capgeminiFS.benergy.com (User ID: CapgeminiFS; password: benefits). simplicity, you might want to postpone
Procedures not listed on the patient charge schedule are not covered. any upcoming new major dental or
The DMO is available only if you live in the plan’s network area. When you access the ADP Beneits orthodontia care until the new plan year
Self-Service site, you will only have the option to enroll in the plan options for which you are eligible. begins. If you have any questions about
the transition of care, contact Cigna at
Choose Your Dentist 1-800-771-0046 .
Locate a participating dental provider in your area in the Find a Dentist section of Cigna’s
website at www.mycigna.com .
Dental Plan Semi-Monthly Employee Contributions
Coverage Level Enhanced Plan Basic Plan DMO Plan
You Only $5.51 $3.31 $2.72
You + Spouse/Domestic Partner $11.02 $6.62 $4.90
You + Child(ren) $12.68 $7.61 $6.20
You + Family $18.74 $11.24 $9.18
Coverage levels can include any eligible dependents defined under the Benefits Eligibility section.
The rates shown do not apply to COBRA participants.
CAPGEMINI 2018 BENEFITS GUIDE 17
Basic Dental Plan to DMO?
The Dental HMO (DMO) covers the same basic and major dental services, as well as orthodontic
services, that are covered by the Enhanced Dental Plan, as long as those services are performed If you switch from the Enhanced Dental
by in-network providers. You pay a co-payment at the time the service is received and there is no Plan or the Basic Dental Plan to the
annual maximum on the beneits you can receive from this plan. DMO, be sure you understand how any
When you enroll in the DMO, you select a primary care dentist for yourself and each covered major dental or orthodontia care you may
be undergoing will transition to the new
dependent. Your primary care dentist provides routine, basic care and refers you to specialty plan. Generally, major dental treatment
dentists when necessary. If your dentist leaves the network during the year, you must select a plans (e.g., root canal treatment, dentures,
new in-network general dentist to have care covered by the plan. or crown and bridge treatment) should
The plan pays beneits only when your in-network general dentist provides or coordinates be completed under your current plan.
your care. If you seek care on your own, you pay the entire cost. Payment for services is Ongoing orthodontia treatment may
based on a predetermined patient charge schedule, which is available on the FS benergy be able to transition to the DMO. For
site at www.capgeminiFS.benergy.com (User ID: CapgeminiFS; password: benefits). simplicity, you might want to postpone
Procedures not listed on the patient charge schedule are not covered. any upcoming new major dental or
The DMO is available only if you live in the plan’s network area. When you access the ADP Beneits orthodontia care until the new plan year
Self-Service site, you will only have the option to enroll in the plan options for which you are eligible. begins. If you have any questions about
the transition of care, contact Cigna at
Choose Your Dentist 1-800-771-0046 .
Locate a participating dental provider in your area in the Find a Dentist section of Cigna’s
website at www.mycigna.com .
Dental Plan Semi-Monthly Employee Contributions
Coverage Level Enhanced Plan Basic Plan DMO Plan
You Only $5.51 $3.31 $2.72
You + Spouse/Domestic Partner $11.02 $6.62 $4.90
You + Child(ren) $12.68 $7.61 $6.20
You + Family $18.74 $11.24 $9.18
Coverage levels can include any eligible dependents defined under the Benefits Eligibility section.
The rates shown do not apply to COBRA participants.
CAPGEMINI 2018 BENEFITS GUIDE 17
