Page 17 - QSC EE Guide 01-20 Remote

Cigna | PPO Plans
Two plan options are available
The PPO plan options offer 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 Cigna 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 Cigna
Plan Name Base PPO Premier PPO
Cigna DPPO /
Network Name Cigna DPPO Non-Network Cigna DPPO Non-Network
Advantage
Advantage
Dental Benefits
Calendar Year $2,000/Member $500/Member $2,000/Member $2,000/Member
Maximum Benefit
Annual Deductible
- Individual $25 $100 $25 $50
- Family $75 $300 $75 $150
Preventive Services No Charge 75%* No Charge No Charge
Basic Services Ded, No Charge Ded, 75%* Ded, No Charge Ded, 20%
Oral Surgery Ded, No Charge Ded, 75%* Ded, No Charge Ded, 20%

Major Services Ded, 40% Ded, 75%* Ded, 40% Ded, 50%
Orthodontia
- Child 50% up to $1,500 Not Covered 50% up to $2,000 50% up to $2,000
- Adult Lifetime Not Covered Lifetime Lifetime
*Based on maximum allowable charge
**Charge per month for 24 months: Child $67 / Adult $75, other copays may apply

Note:
We strongly recommend you ask
your dentist for a predetermination Finding a Dental Provider
if total charges are expected to Go to www.cigna.com.
exceed $300. Predetermination
enables you and your dentist to Refer to the “Cigna Dental PPO or EPO” and the “Cigna
know in advance what the payment DPPO Advantage” network
will be for any service that may be
in question.