Page 14 - QSC Benefit Summary 7-18 COLORADO

DENTAL INSURANCE

Option 1 - DMO

As a Cigna DMO member, you are required to select a general dentist 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.

Option 2 - Base PPO
The Cigna Base PPO plan is a Preferred Provider dental plan. The benefits cover a wide range of dental services. You may
visit a PPO dentist who is a member of the “Cigna DPPO Advantage” network 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. When using the PPO plan, all deductibles, plan maximums, and service
specific maximums (dollar and occurrence) cross accumulate between the network and non-network tiers of the plan.

Option 3 - Premier PPO
The Cigna Premier PPO plan works just like the Cigna Base PPO plan, but the Premier plan has the additional Cigna DPPO
total network of providers. When you visit a “Cigna DPPO Advantage” or a “Cigna DPPO” dentist you will benefit from the
negotiated rate.

Cigna Cigna Cigna
Plan Features Option 1 DMO Option 2 Base PPO Option 3 Premier PPO
Plan / Network Cigna Dental Cigna DPPO Non-Network Cigna DPPO Cigna DPPO /
Name Care HMO Advantage Advantage Non-Network
DENTAL BENEFITS You Pay You Pay You Pay You Pay You Pay
Calendar Year None $2,000 (Plan $500 (Plan Pays $2,000 (Plan $2,000 (Plan
Benefit Maximum Pays Per Member Per Member Pays Per Member Pays Per Member
Covered) Covered) Covered) Covered)
Annual Deductible Deductible Waived for Preventive Deductible Waived for Preventive
Individual None $25 $100 $25 $50
Family None $75 $300 $75 $150
Preventive Services Copays Apply No Charge 75%* No Charge No Charge

Basic Services Copays Apply No Charge 75%* No Charge 20%
Oral Surgery Copays Apply No Charge 75%* No Charge 20%
Major Services Copays Apply 40% 75%* 40% 50%
Orthodontia 24-Month
Treatment Fee** 50% up to
Adult $3,000 $1,500 Lifetime Not Covered 50% up to $2,000 Lifetime
Child $2,280 Maximum Not Covered Maximum
*Based on maximum allowable charge
**Charge per month for 24 months: Child $95 / Adult $125, other copays may apply

FINDING A DENTAL PROVIDER:
Go to www.cigna.com or call (800) 244-6224 to find a provider near you. DMO participants should
refer to the “Cigna Dental Care HMO” plan and PPO participants should refer to the “Cigna Dental
PPO or EPO“ plan and then the “Cigna DPPO Advantage” network for the Base PPO plan and the
“Cigna DPPO Advantage” or “Cigna DPPO” network for the Premier PPO plan when prompted.

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