Page 13 - Benefit Guide 2022

Dental Plan

It’s important to have regular dental exams and cleanings so Coverage Monthly
problems are detected before they become painful—and Level Premium
expensive. Keeping your teeth and gums clean and healthy
will help prevent most tooth decay and is an important part Individual $22
of maintaining your overall health.
Family $54
Using in-network dental providers

While you have the option of choosing any provider, you will save money when you use in-network
dentists. When using an out-of-network dental provider, you will pay more because that provider has
not agreed to charge you a negotiated rate.

Plan Provisions Cigna Network Dentist Non-Participating Dentist

$50 individual
Annual Deductible
$100 family

Calendar Year Maximum $1,000 per individual

$1,500 per individual
Orthodontia Lifetime Maximum
Diagnostic and Preventative Services Covered at 100%, Covered at 100%,
(e.g., x-rays, cleanings, exams) no deductible no deductible

Basic and Restorative Services 80% after deductible 60% after deductible
(e.g., fillings, extractions, root canals)

Major Services 60% after deductible 50% after deductible
(e.g., dentures, crowns, bridges)

50% for children 50% for children
Orthodontia under age 19 under age 19

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