Page 15 - Palomar EE Guide 01-19 FINAL

Health & Wellness

Dental Benefits Plan Name Dental
In-Network Non-Network

Cigna administers our DPPO Dental plan. Good health includes Dental Benefits
healthy teeth and gums. With Palomar Health benefits, you have a
great deal of flexibility when you choose dental coverage. You can Calendar Year Deductible
choose to receive your care from a preferred dental provider - Individual $50 $75
through Cigna or any dentist you choose. You will receive a higher - Family (maximum) $150 $225
level of coverage when seeing a Cigna dentist. Practice prevention
and take advantage of the plan’s NO COST preventive care services Diagnostic Preventive Care 100% 80%
when you visit an in-network dental provider. Most dental offices - 2 exams per calendar year
will file a claim for you. However, if your dental office does not file (oral exams, cleanings, bite
claims on your behalf, you will need to submit your dental claims to wing x-rays)
Cigna directly. - 4 cleanings per calendar year
(2 regular and 2 periodontal)
Dental cards are not required and will not be provided, but are - 1 sealant treatment per tooth
available on the Cigna website. every three years (up to age 15)
Basic Restorative Care After deductible, After deductible,
How the Cigna DPPO Advantage Dental Plan - Extractions, fillings, 90% coverage 70% coverage
works endodontic/periodontal,
repair of crowns, bridges,
Whether you choose a dentist in the Cigna DPPO Advantage Dentures
Dental Network or outside the network, your coverage includes
a wide range of eligible services covered at no or low cost to Major Restorative Care After deductible, After deductible,
you. For other services, you will pay a percentage of the cost – - Crowns, jackets, and cast 60% coverage 50% coverage
or coinsurance amount – to the dentist at the time of service. If restorations, fixed bridges,
you visit a dentist or specialist for a second opinion, Cigna will partial & complete dentures
reimburse you according to our plan coverage. A deductible will

apply for Basic and Major Restorative Care services. Maximum Benefit per Year $2,000
- Per Individual (excluding
• Diagnostic Preventive Care - cleanings, x-rays and more Orthodontia)
(deductible does not apply)
• Basic Restorative Care - fillings, root canals and basic Orthodontic Benefits
restorative work Maximum Lifetime Orthodontic
• Major Restorative Care - bridges, crowns and more Benefit
• Orthodontics - our plan includes orthodontic coverage for - Per individual 50% up to a $1,500 Benefit
children and adults
• You don’t need to select a primary care dentist Overview of Dental Premiums
• You don’t need a referral to receive care from a specialist Cost to You (Per Pay Period Rate, Pre-Tax Employee Contribution)

What else can the Cigna DPPO Advantage Dental
Plan do for you? Full-Time Part Time II Part Time I
• Use www.mycigna.com to view your dental claims,
Explanation of Benefits (EOB’s) or call 800-244-6224 to find
Employee Only $1.92 $3.11 $3.90
out what you need to know about your dental plan
$9.43
$8.36
• Estimate your dental care costs and measure your risk for Employee & Sp or DP* $11.74 $13.31 $11.77
$16.63
Employee & Child(ren)
cavities and gum disease with easy-to-use tools available Employee & Family* $19.79 $21.31 $26.62
on www.mycigna.com
• Enjoy discounts on health-related products and services *SP=Spouse, DP=Domestic Partner. Premiums for domestic partner or child(ren) of
through Cigna Healthy Rewards domestic partner, if employee has single coverage, are deducted on a post-tax basis.
The amount the employer pays for the domestic partner coverage is taxable income.
An affidavit of Domestic Partnership is required.
**Proof of coverage outside of Palomar Health is required.

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