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Benefits

Dental Insurance

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 and you may be responsible for filing claims.

Cigna
PPO
Network Non-Network
Dental Benefits

Calendar Year Maximum Benefit $2,000
Calendar Year Deductible*
- Individual $50
- Family $150
Preventive (Plan Pays)
Diagnostic Oral Examinations, 2 Cleanings/Year, 100% 80%
X-Rays, Sealants and Fluoride treatments up to the Deductible Waived Deductible Waived
age of 15
Basic Services (Plan Pays)
Fillings, Dentures, Anesthesia, Extractions,
Oral Surgery, Pathology, Injections, Sealants, Space 90% 80%
Maintainers, Endodontics, Periodontics, Palliatives,
Repairs
Major Services (Plan Pays)
Crowns, Implants, Inlays, Onlays, Gold Fillings, 50% 50%
Bridgework
Orthodontia
Child only 50%
Ortho Lifetime Maximum $1,500

*Eligible expenses incurred in the last 3 months of a calendar year and applied toward that year's deductible can be carried for-
ward and applied toward your deductible for the next calendar year.

Finding a Dental Provider
Go to www.mycoresource.com or call CoreSource at (866) 280-4120.
- When logged in to your account, go to My Links, then Find a Provider.
- Click on Cigna Dental SA Plus Providers.

Note
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300. Predetermina-
tion enables you and your dentist to know in advance what the payment will be for any service that may be in question.

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