Page 21 - 2018 Capgemini Enrollment
P. 21
Dental Plan Comparison Chart What is a maximum
allowable charge?
DMO
Covered Services Enhanced Dental Basic Dental (In-Network Only) The maximum allowable
charge is the amount
Deductible customarily charged for
Individual $25 $50 $0 a given service by other
Family $75 $150 $0 providers in your area as
Maximum Benefit determined by Cigna. If
Dental Services $1,500 per plan year $1,000 per plan year No limit you visit an out-of-network
Orthodontia Services $2,000 per lifetime N/A provider who charges
fees higher than the
Non-Surgical Temporomandibular $1,000 per lifetime N/A maximum allowable
Joint Dysfunction (TMJ)
amount, you will be
Diagnostic & Preventive responsible for paying
Services (deductible waived) the diference.
Co-insurance 1 100% 100% 100%
Oral Exams 2 visits per plan year 2 visits per plan year Service limits, if any, are
Cleaning 2 visits per plan year 2 visits per plan year determined by DMO
X-rays Bite wing – Bite wing –
2 per plan year 2 per plan year
Complete series – Complete series –
1 during any 36 months 1 during any 36 months
Basic Services (co-insurance) 1
Basic Restorations, Endodontics, 80% after deductible 80% after deductible Costs based on patient
Periodontics charge schedule 2
Major Services (co-insurance) 1
Crowns, Inlays/Onlays, Full or Partial 50% after deductible No coverage Costs based on patient
Dentures charge schedule 2
Implants No coverage No coverage Costs based on patient
charge schedule 2
Orthodontic Services 50% after deductible No coverage Costs based on patient
(co-insurance) 1 charge schedule 2
Non-Surgical Temporomandibular 50% after deductible No coverage Costs based on patient
Joint Dysfunction (TMJ) charge schedule 2
(co-insurance) 1
CAPGEMINI 2018 BENEFITS GUIDE 18
allowable charge?
DMO
Covered Services Enhanced Dental Basic Dental (In-Network Only) The maximum allowable
charge is the amount
Deductible customarily charged for
Individual $25 $50 $0 a given service by other
Family $75 $150 $0 providers in your area as
Maximum Benefit determined by Cigna. If
Dental Services $1,500 per plan year $1,000 per plan year No limit you visit an out-of-network
Orthodontia Services $2,000 per lifetime N/A provider who charges
fees higher than the
Non-Surgical Temporomandibular $1,000 per lifetime N/A maximum allowable
Joint Dysfunction (TMJ)
amount, you will be
Diagnostic & Preventive responsible for paying
Services (deductible waived) the diference.
Co-insurance 1 100% 100% 100%
Oral Exams 2 visits per plan year 2 visits per plan year Service limits, if any, are
Cleaning 2 visits per plan year 2 visits per plan year determined by DMO
X-rays Bite wing – Bite wing –
2 per plan year 2 per plan year
Complete series – Complete series –
1 during any 36 months 1 during any 36 months
Basic Services (co-insurance) 1
Basic Restorations, Endodontics, 80% after deductible 80% after deductible Costs based on patient
Periodontics charge schedule 2
Major Services (co-insurance) 1
Crowns, Inlays/Onlays, Full or Partial 50% after deductible No coverage Costs based on patient
Dentures charge schedule 2
Implants No coverage No coverage Costs based on patient
charge schedule 2
Orthodontic Services 50% after deductible No coverage Costs based on patient
(co-insurance) 1 charge schedule 2
Non-Surgical Temporomandibular 50% after deductible No coverage Costs based on patient
Joint Dysfunction (TMJ) charge schedule 2
(co-insurance) 1
CAPGEMINI 2018 BENEFITS GUIDE 18
