Page 15 - TCM EE Guide 2019 v2 Non CA FINAL

Dental Plan Choices

Cigna | PPO Plan
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your
benefits and reduce your out-of-pocket costs if you choose a dentist who participates in the Cigna network. When
you utilize a network dentist, your out-of-pocket expenses will be less, however, you will usually pay the lowest
amount for services when you visit a PPO dentist. If you obtain services using a non-network dentist, you will be
responsible for the difference between the covered amount and the actual charges and you may be responsible
for filing claims. The chart below provides a high-level overview of your dental plan.

Cigna
Plan Name PPO

Network Name Cigna DPPO DPPO Non-Network
Advantage

Dental Benefits
Office Visit Copay None

Calendar Year Maximum Benefit $1,500
Annual Deductible
- Individual $50
- Family $150
Preventive Services No Charge 20% 20%*

Basic Services Deductible, 10% Deductible, 20% Deductible, 20%*

Major Services Deductible, 50% Deductible, 50% Deductible, 50%*
Orthodontia
- Child 50% / $1,500 Lifetime Benefit Maximum
- Adult 50% / $1,500 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. Cigna’s reimbursement is based on 90th UCR.

Note:
We strongly recommend you ask your
dentist for a predetermination if total Finding a Dental Provider
charges are expected to exceed $300.
Predetermination enables you and your Go to www.mycigna.com or call (800) 244-6224.
dentist to know in advance what the Refer to the “Cigna DPPO Advantage” network
payment will be for any service that may
be in question.

Employee Benefits 15