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Benefits

Dental Insurance CIGNA

HMO Dental Plan (State Categories 1 & 2 — See page 10)
Cigna Dental HMO (DHMO) members must select a general dentist to handle all their dental needs (from routine check-ups to
emergency situations). General dentists provide necessary referrals in cases where specialty care is required. Pre-set copays and
any coinsurance fees for covered procedures are described in DHMO plan documents.

PPO Dental Plan (All States)
Cigna's Dental PPO (DPPO) is a preferred provider plan which allows members to visit both network and non-network dentists.
Utilizing PPO network dentists helps lessen out-of-pocket expenses as rates are pre-negotiated with Cigna. When members obtain
services from a non-network dentist they are responsible for the monetary difference between Cigna's Usual and Customary
charges (UCR) and the actual fees charged by the non-network dentist. Members are responsible for filing claims when utilizing non
-network services.

Cigna Cigna
DHMO Plan PPO Plan

Cigna Dental Care HMO Cigna Dental PPO Non-Network
Dental Benefits
Cal. Yr. Max. (plan will pay) Unlimited $1,500
Deductible (you pay) Waived for Preventive Services
- Individual $0 $50
- Family $0 $150
Preventive (plan pays) 100% for Most Services 100% 100%
Exams, X-Rays, Cleanings

Basic Services (plan pays) See Copay Schedule 80% 80%
Fillings, Oral Surgery,
Endodontics, Periodontics
Major Services (plan pays) See Copay Schedule 50% 50%
Crowns, Prosthetics

Orthodontia
- Covered Members Children & Adults Not Covered
- Copay $1,512 Child / $1,992 Adult N/A

Finding a Dental Provider (cigna.com or 800-244-6224)
Refer to the following network names under “dental plans” when prompted
• DHMO: “Cigna Dental Care HMO”
• PPO: “Cigna Dental PPO”

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.

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