Page 10 - L'Abri Management 2020 Benefits Guide

Dental Benefits

Cypress |Voluntary DHMO Dental Plan

With the Dental Health Maintenance Organization (DHMO) plan through Cypress, 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 DHMO copay schedule. Please keep a copy of
your copay schedule 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.
Cypress| Voluntary PPO Dental Plan

With the Cypress 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 Cypress Exclusive (CEN) or 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.

Cypress Cypress
Plan Name DHMO PPO
Network Name Liberty Dental Cypress Exclusive Dental PPO Non-Network
LDP-400 Network (CEN) Network Network
Dental Benefits
Office Visit Copay No Charge N/A

Calendar Year Maximum Unlimited $1,500 $1,500 $1,000
Deductible (Annual)
- Individual / Family None $25 / $75 $50 / $150 $75 / $225
Preventive (Plan Pays) 100% for Most Services 100%, ded waived 100%, ded waived Deductible, 80%,
Exams, X-Rays, Cleanings
Basic Services (Plan Pays)
Fillings, Oral Surgery, See Copay Schedule Deductible, 90% Deductible, 80% Deductible, 80%
Endodontics, Periodontics

Major Services (Plan Pays) See Copay Schedule Deductible, 60% Deductible, 50% Deductible, 50%
Crowns, Prosthetics

Orthodontia Children & Adults
- Covered Members $1,775 Child Not Covered
- Copay $1,950 Adult

Finding a Dental Provider
DHMO Providers:
Go to https://client.libertydentalplan.com/cypress/FindADentist or call (888) 703-6999.
DHMO participants should refer to Benefit Plan LDP-400 when prompted.
PPO Providers:
Go to cypressadmin.com or call (800) 350-3989. Click “Find a Dentist”
PPO participants should refer to the “Cypress Exclusive Network (CEN)” or “PPO” 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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