Page 13 - FSSI EE Guide 07-20 - OOS

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 Total DPPO Non-Network

Dental Benefits
Office Visit Copay N/A
Calendar Year Maximum Benefit $1,500
Annual Deductible
- Individual $50
- Family $150
Preventive Services No Charge No Charge*

Basic Services Deductible, 20% Deductible, 20%*

Major Services Deductible, 50% Deductible, 50%*
Orthodontia
- Child 50% / $1,000 Lifetime Benefit Maximum
- Adult 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
dentist for a predetermination if total Finding a Dental Provider
charges are expected to exceed $300.
Predetermination enables you and your Go to www.cigna.com.
dentist to know in advance what the • PPO: Refer to the “Total Cigna DPPO” network
payment will be for any service that may
be in question.