Page 12 - Castlerock Corporate

DENTAL PLAN

It’s important to have regular dental exams and cleanings so problems are detected before they become
painful — and expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth
decay and is an important part of maintaining your overall health. We offer two dental plan options
through Cigna.

Basic Plan Premium Plan
Dental Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible $50/$150 $50/$150 $50/$150 $50/$150
(Individual/Family)
$1,200 $1,500
Calendar Year Maximum
Per Person, Per Year Per Person, Per Year
Orthodontia Lifetime Maximum N/A $1,500, Up to Age 19

Diagnostic and Preventive Services Covered at 100% 100% of UCR* Covered at 100% 100% of UCR
(x-rays, cleanings, exams)

Amount the plan pays after Deductible

Basic and Restorative Services 80% 80% of UCR* 80% 80% of UCR*
(fillings)

Major Services 50% 50% of UCR 50% 50% of UCR*
(dentures, crowns, bridges)

Orthodontia Not Covered 50%
*UCR – non-network percentage of benefits is based on the schedule of usual and customary fees in the geographic area which the expenses are incurred.

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 the provider has

not agreed to charge you a
negotiated rate.

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