Page 12 - 2018 Endeavor Schools Benefit Guide

10

Dental Benefits That

Keep You Smiling

Strong teeth and gums are an important part of good health, which is why
Endeavor Schools is very excited to offer you and your eligible dependents
comprehensive dental coverage through Cigna.
Our dental plans help you pay for most necessary dental services and
supplies, including diagnostic and preventative care (such as exams,
cleanings and x-rays), basic and major restorative services (such as fillings,
crowns and dentures), as well as orthodontic services for children.

Dental Plan Highlights Cigna Silver Plan Cigna Platinum Plan

Summary of Services In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible¹
• Individual $50 $50 $50 $50
• Family $150 $150 $150 $150

MAC* MAC*

Annual Benefit $1,000 $1,000 $1,500 $1,000
Maximum 2

Preventative
• Oral Examinations 0% 0% 0% 0%
• Prophylaxis/Cleaning

Basic
• Minor Restorations
• Endodontics 20% 20% 20% 20%
• Periodontics

Major
• Crowns 50% 50% 50% 50%
• Bridges
• Dentures

Orthodontia
50% 50%
(Lifetime Maximum $1,000 $1,500
Children Up to Age 19)

1 Annual deductible only applies to basic and major services and is waived for preventative services.
2 Annual deductible and maximum are based on calendar year (January 1 through December 31).
*Out-of-Network Coverage is based on the Maximum Allowable Charge, or the same fee that Cigna would pay in-network for a covered service.
The above chart is for illustrative purpose only; actual benefits described in the Certificate of Coverage will prevail.