Page 16 - Saddleback EE Guide 07-20 v.7 FINAL

Dental Plan Choices

Cigna | DHMO Plan Cigna | DPPO Plan
This plan requires you to select a general dentist who is The Cigna Preferred Provider Organization (PPO) Dental
a member of the Cigna Dental Care HMO network to plan offers you the freedom and flexibility to use the
provide your dental care. You will contact your general dentist of your choice. You may visit a DPPO Advantage
dentist for all of your dental needs, such as routine dentist or a DPPO dentist and benefit from the negotiated
check-ups and emergency situations. If specialty care is rate, or you may visit a non-network dentist. When you
needed, your general dentist will provide the necessary utilize a DPPO Advantage or a DPPO dentist, your out-of-
referral. For covered procedures, you'll pay the pre-set pocket expenses will be less. If you obtain services using a
copay or coinsurance fee described in your DHMO plan non-network dentist, you will be responsible for the
booklet. Please keep a copy of your booklet to refer to difference between the covered amount and the actual
when utilizing your dental care. This will show the charges and you may be responsible for filing claims. The
applicable copays that apply to all of the dental services chart below provides a high-level overview of the DPPO
that are covered under this plan. dental plan.

Please note that our Dental and Vision plans are bundled and thus, if you elect one, you must elect the other.
Cigna Cigna
Plan Name DHMO Plan DPPO Plan

Cigna Dental DPPO
Network Name Care HMO Advantage DPPO Non-Network
Dental Benefits
Maximum Plan Year Benefit Unlimited $1,500 $1,000 $1,000
Annual Deductible
- Per Covered Person $0 $50 $100 $100
- Per Family Unit $0 $150 $300 $300
Preventive Services
- Exams, Cleanings, Fluoride, No Charge for No Charge No Charge No Charge*
Sealants, Diagnostic X-Rays Most Services
- Exam/Cleaning Limit 2/Calendar Year 2/Policy Year 2/Policy Year 2/Policy Year
Basic Services
- Fillings, Extractions, Endodontics, Copays Apply Deductible, 20% Deductible, 50% Deductible, 50%*
Periodontics
Major Services
- Crowns, Bridges, Dentures, Implants Copays Apply Deductible, 50% Deductible, 50% Deductible, 50%*
Orthodontia (Adult / Child) $2,108 / $1,604 50% / $1,000 Lifetime Benefit Maximum
*Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference between what Cigna
pays them and what the dentist usually charges.

Note:
We strongly recommend you ask your Finding a Dental Provider
dentist for a predetermination if total Go to www.cigna.com.
charges are expected to exceed $300. • DHMO: Refer to the “Cigna Dental Care HMO”
Predetermination enables you and your Network when prompted.
dentist to know in advance what the • PPO: Refer to the “DPPO Advantage” or the “DPPO”
payment will be for any service that may network when prompted.
be in question.

16 Employee Benefits