Page 11 - Razer Benefits Guide 1-18 So CA_PRINT

DENTAL INSURANCE

CIGNA | DHMO DENTAL PLAN
With the Dental Health Maintenance Organization (DHMO) plan through Cigna, you are required to select a general
dentist who is a member of the HMO network 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 the DHMO copay schedule. Please keep a copy of the 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.

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. You may also be responsible for filing claims. Your dental benefits
may be accessed by giving your provider your name and your social security number (you will not receive an ID card
in the mail).

CIGNA CIGNA
DHMO PPO

NETWORK HMO DPPO Advantage Cigna DPPO &
Non-Network (UCR*)
DENTAL BENEFITS
Calendar Year Benefit Maximum Unlimited $1,500
Annual Deductible
• Individual None None $50
• Family None None $150
Preventive Services (Plan Pays) See Copay Schedule No Cost No Cost
• Deductible Waived N/A Yes
Basic Services (Plan Pays) See Copay Schedule 90% 75%
Major Services (Plan Pays) See Copay Schedule 60% 50%
Orthodontia Children / Adults Children / Adults
$1,224 / $1,728 Copay 50% with $1,500 Lifetime Benefit Maximum

*UCR refers to the non-network reimbursement schedule. Your dental benefits will pay based off of a fee that Cigna
deems ‘Usual, Customary, and Reasonable’.

FINDING A DENTAL PROVIDER:
• Cigna: Go to www.cigna.com. Once you select ‘Find a Doctor’, select ‘For Plans Offered Through
Work or School’. Click ‘Dentist’, then enter your location and select a plan:
• Cigna DHMO: Click ‘Cigna Dental Care HMO’ or call (800) 244-6224
• Cigna PPO: Click ‘Cigna Dental PPO or EPO’, and refer to ‘Cigna DPPO Advantage’ dentists
or call (800) 244-6224

11