Page 11 - Success Academy | 21-22 Benefits Summary

Dental Plans
Dental HMO Plan
Cigna Dental Care Plan offers coverage by a Cigna Network General Dentist (NGD), without deductibles, and annual or lifetime maximums, according to a Patient Charge Schedule (employee paid fee schedule). The fee schedule also applies to specialty dental care when a referral is made by your NGD to a network specialty periodontist or oral surgeon.
Visit MyCigna.com for a listing of in-network providers. You must select and assign a NGD to your account by choosing a provider and clicking “Make this Dentist my NGD” prior to beginning your services.
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Preventive & Diagnostic
Basic Services
Major Services
Orthodontia
(up to 24 months)
Molar Root Canal
Crown (Porcelain/Ceramic)
Filling
(Resin Based/Composite)
Dental PPO Plan
In-Network
Cleaning/X-rays/Fluoride: $0
$0–$430
$480–$2,376
Approximately $2,400
$170
$225
$35
Out-of-Network
N/A
The Dental PPO Plan is a point of service plan that offers coverage at a percentage of the reasonable and customary charges. Preventive visits are covered at 100% without a copay or deductible when in-network. For out-of-network providers, you must first pay a $50 deductible, then preventive services are covered at 100%. Visit MyCigna.com for a listing of network providers in the Cigna Dental Care PPO Network.
In-Network Out-of-Network
Maximum Annual Benefit* $1,500–$1,800 $1,500–$1,800
Deductible $0
$50 (Employee Only)
$150 (Employee + Dependents)
Preventative & Diagnostic 100% 100%
Basic Services 90% 80%
Major Services 60% 50%
Orthodontia (up to 24 months) 50% 50% Lifetime Maximum $1,000 $1,000
* Increases by $100 each calendar year that you receive a cleaning.