Page 6 - Bobit Benefit Guide 2018 FINAL

Benefits

Dental Insurance CIGNA

HMO Dental Plan (State Categories 1 & 2 — See page 10)
Cigna Dental HMO (DHMO) members must select a general dentist to handle all their dental needs (from routine check‐ups to
emergency situations). General dentists provide necessary referrals in cases where specialty care is required. Pre‐set copays and
any coinsurance fees for covered procedures are described in DHMO plan documents.

PPO Dental Plan (All States)
Cigna's Dental PPO (DPPO) is a preferred provider plan which allows members to visit both network and non‐network dentists.
Utilizing PPO network dentists helps lessen out-of-pocket expenses as rates are pre-negotiated with Cigna. When members obtain
services from a non-network dentist they are responsible for the monetary difference between Cigna's Usual and Customary
charges (UCR) and the actual fees charged by the non-network dentist. Members are responsible for filing claims when utilizing non
-network services.

Cigna Cigna
DHMO Plan PPO Plan

Cigna Dental Care HMO Cigna Dental PPO Non-Network
Dental Benefits
Cal. Yr. Max. (plan will pay) Unlimited $1,500
Deductible (you pay) Waived for Preventive Services
- Individual $0 $50
- Family $0 $150
Preventive (plan pays) 100% for Most Services 100% 100%
Exams, X-Rays, Cleanings

Basic Services (plan pays) See Copay Schedule 80% 80%
Fillings, Oral Surgery,
Endodontics, Periodontics
Major Services (plan pays) See Copay Schedule 50% 50%
Crowns, Prosthetics

Orthodontia
- Covered Members Children & Adults Not Covered
- Copay $1,512 Child / $1,992 Adult N/A

Finding a Dental Provider (cigna.com or 800-244-6224)
Refer to the following network names under “dental plans” when prompted
• DHMO: “Cigna Dental Care HMO”
• PPO: “Cigna Dental PPO”

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

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