Page 10 - Confie Retail Benefits Guide

Benefits

Dental Insurance

Option 1
Cigna | DMO Dental Plan

With the Dental Maintenance Organization (DMO) plan through Cigna, you are required to select a general dentist to provide your
dental care. You will contact your general dentist for all of your dental needs, such as routine check‐ups and emergency situations.
If specialty care is needed, your general dentist will provide the necessary referral. For covered procedures, you'll pay the pre‐set
copay or coinsurance fee described in your DMO plan booklet. Please keep a copy of your booklet to refer to when utilizing your
dental care. This will show the applicable copays that apply to all of the dental services that are covered under this plan. You will
be receiving an ID card for this plan.

Option 2
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. You will not be receiving an ID card for this plan. For services provided
by a non-network dentist, Cigna Dental will reimburse the dentist according to the Maximum Allowable Charge which is less than
the contracted fee schedule. This will allow the non-network dentist to balance bill you up to their usual fee.

Cigna Cigna
Plan Name DMO PPO
Network Name Cigna Dental Care DMO Cigna Dental PPO Non-Network
Advantage
Dental Benefits Based on Scheduled of Copays Based on Contracted Based on Maximum
Fees Allowable Charge

Office Visit Copay $5 Copay N/A N/A
Calendar Year Maximum Unlimited $1,750 $1,500
Deductible (Annual)
- Individual $0 $25 $50
- Family $0 $50 $100

Preventive Covered 100% for Most Services No Charge 10%
Exams, X-Rays, Cleanings
Basic Services See Copay Schedule Deductible, 10% Deductible, 30%
Fillings, Oral Surgery,
Endodontics, Periodontics
Major Services See Copay Schedule Deductible, 40% Deductible, 50%
Crowns, Prosthetics

Orthodontia
- Covered Members Children & Adults Children & Adults
- Copay $1,600 Child / $2,600 Adult N/A
- Coinsurance N/A 50%
- Lifetime Benefit Maximum N/A $1,500

Finding a Dental Provider
Go to www.mycigna.com.
• Option 1 DMO: Refer to the “Cigna Dental Care DMO” network when prompted.
• Option 2 PPO: Refer to the “Cigna Dental PPO Advantage” network when prompted.

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