Page 14 - QSC Benefits Guide 7-18 REMOTE

DENTAL INSURANCE

Option 1 - Base PPO

The Cigna Base PPO plan is a Preferred Provider dental plan. The benefits cover a wide range of dental services. You may
visit a PPO dentist who is a member of the “Cigna DPPO Advantage” network 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. When using the PPO plan, all deductibles, plan maximums, and service
specific maximums (dollar and occurrence) cross accumulate between the network and non-network tiers of the plan.

Option 2 - Premier PPO
The Cigna Premier PPO plan works just like the Cigna Base PPO plan, but the Premier plan has the additional Cigna DPPO
total network of providers. When you visit a “Cigna DPPO Advantage” or a “Cigna DPPO” dentist you will benefit from the
negotiated rate.

Cigna Cigna
Plan Features Option 1 Base PPO Option 2 Premier PPO
Plan / Network Name Cigna DPPO Non-Network Cigna DPPO Cigna DPPO /
Advantage Advantage Non-Network
DENTAL BENEFITS You Pay You Pay You Pay You Pay
Calendar Year Benefit $2,000 (Plan $500 (Plan Pays Per $2,000 (Plan $2,000 (Plan
Maximum Pays Per Member Member Covered) Pays Per Member Pays Per Member
Covered) Covered) Covered)
Annual Deductible Deductible Waived for Preventive Deductible Waived for Preventive
Individual $25 $100 $25 $50
Family $75 $300 $75 $150
Preventive Services No Charge 75%* No Charge No Charge

Basic Services No Charge 75%* No Charge 20%
Oral Surgery No Charge 75%* No Charge 20%
Major Services 40% 75%* 40% 50%
Orthodontia
50% up to $1,500
Adult Lifetime Maximum Not Covered 50% up to $2,000 Lifetime Maximum
Child Not Covered
*Based on maximum allowable charge

FINDING A DENTAL PROVIDER:
Go to www.cigna.com or call (800) 244-6224 to find a provider near you. Base PPO participants should
refer to the “Cigna Dental PPO or EPO“ plan and then the “Cigna DPPO Advantage” network, and
Premier PPO participants should refer to the “Cigna DPPO Advantage” or “Cigna DPPO” network
when prompted.

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