Page 10 - AAG Benefits Guide OOS (Non-CA) Employees

9 OUR FAMILY CARING FOR YOURS

DENTAL COVERAGE

In order to provide you with the level of dental coverage
that best fits the needs of you and your family, AAG
offers one dental plan option: CIGNA DPPO.

To help you understand the features and coverage
available to you, we have provided the following brief
summary of benefits. Please refer to plan documents
for details, including important coverage exclusions
and limitations.

CIGNA DPPO

COVERAGE IN-NETWORK OUT-OF-NETWORK
Deductible (Single/ Family) $50 / $100 $50 / $100

Calendar Year Maximum $2,000 $2,000
Texas
Preventative & Diagnostic Care No charge deductible waived No charge deductible waived
(Cleanings, Exams, X-rays, etc.) Other States
80%
Texas
Basic Care (Fillings, extractions, Plan pays 80% after Plan pays 80% after deductible
Root canal, etc.) deductible Other States
Plan pays 60% after deductible
Texas
Major Services Plan pays 50% after Plan pays 50% after deductible
(Crowns, Bridges, Dentures, etc.) deductible Other States
Plan pays 40% after deductible
Texas
Plan pays 50% after Plan pays 50% after deductible
Coverage: Implants
deductible Other States
Plan Pays 40% after deductible
Orthodontia 50% to a Lifetime maximum 50% to a Lifetime maximum benefit
(Adult and Children) benefit of $2,000 of $2,000
Reimbursements Contracted MRC 80 percentile
th

WHAT ARE YOUR 2021 DENTAL PLAN RATES?

CIGNA DENTAL PLAN OPTIONS - PER PAY PERIOD COST
PLAN EMPLOYEE ONLY EMPLOYEE & EMPLOYEE & EMPLOYEE & FAMILY
SPOUSE
CHILDREN
PPO $29.04 $58.72 $62.46 $94.82