Page 12 - United Capital EE Guide 2019-2020

DENTAL INSURANCE

CIGNA | DHMO DENTAL PLAN
AVAILABLE STATES: AR, AZ, CA, CO, CT, DC, FL, GA, IL, IN, LA, MA, MD, MI, NC, NJ, NV, NY, OH, OK, OR, PA, SC, TN, TX, VA, WA
With the Dental Health Maintenance Organization (DHMO) plan through Cigna, you are required to select a general dentist who
is a member of the 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 your DHMO plan booklet. Please keep a copy of
your booklet 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 PLANS
With the Cigna Preferred Provider Organization (PPO) dental plans, 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 and you may be responsible for filing claims.

CIGNA CIGNA CIGNA
DHMO LOW PPO HIGH PPO
Network Name Network Network Non-Network Network Non-Network
DENTAL BENEFITS
Office Visit Copay $5 Copay N/A N/A N/A N/A
Calendar Year Maximum Benefit Unlimited $1,000 $1,000 $1,500 $1,200
Annual Deductible
• Individual $0 $50 $75 $50 $75
• Family $0 $150 $225 $150 $225
Preventive Services 100% Covered for 100% Covered 20% 100% Covered 100% Covered
• Deductible Waived Most Services Yes No Yes No
Basic Services See Schedule 20% 40% 10% 25%
Major Services See Schedule 50% 60% 40% 50%
ORTHODONTIA BENEFITS
Covered Family Members Child | Adult Child Only Child Only Child Only Child Only
Copay $1,460 | $2,160 N/A N/A N/A N/A
Coinsurance N/A 50% 50% 50% 50%
Lifetime Benefit Maximum N/A $1,000 $1,000 $1,250 $1,250

FINDING A DENTAL PROVIDER:
Go to www.cigna.com or call (800) 244-6224. DHMO participants should refer to the “Cigna Dental Care
HMO” network and PPO participants should refer to the “Cigna Dental PPO or EPO” network when prompted.

12 UNITED CAPITAL 2019-2020