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Dental Insurance

Cigna | PPO Dental Plan
With the Cigna Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the negotiated rate or visit a non-
network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may also obtain services using a non-network
dentist; however, you will be responsible for the difference between the covered amount and the actual charges and you may be responsible for
filing claims.

Cigna
Plan Name PPO
Network Name Total Cigna DPPO Network Non-Network

Dental Benefits You Pay
Calendar Year Maximum $2,000
Deductible (Annual)
- Individual $50
- Family $150
Preventive No Charge (Deductible Waived)
Exams, X-Rays, Cleanings 2 cleanings per year

Basic Services Deductible, 20%
Fillings, Oral Surgery, Endodontics,
Periodontics

Major Services Deductible, 50%
Crowns, Prosthetics, Inlays, Implants
Orthodontia
- Covered Members Children & Adults
- Coinsurance Deductible, 50%
- Lifetime Benefit Maximum $2,000
Contributions Your Pay Per Pay Period

Employee Only $5.21
Employee + Spouse $10.42
Employee + Child(ren) $11.84
Employee + Family $15.63

Finding a Dental Provider
Go to www.mycigna.com or call (800) 244-6224. Refer to the Total Cigna DPPO Network when prompted.

Note
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300. Predetermination
enables you and your dentist to know in advance what the payment will be for any service that may be in question.

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