Dental PPO - High Option Benefits Network Options Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, III, & IX expenses
Cigna Dental PPO - High Option Out-of-Network: In-Network: See Non-Network Total Cigna DPPO Network Reimbursement Based on Contracted Fees
Maximum Reimbursable Charge
$1,000
$1,000
$50 $150
$50 $150
Benefit Highlights
Tier
$35.06
EE + Spouse
$75.68
EE + Family
Plan Pays
You Pay
Plan Pays
You Pay
100% No Deductible
No Charge
100% No Deductible
No Charge
80% After Annual Deductible
20% After Annual Deductible
80% After Annual Deductible
20% After Annual Deductible
50% After Annual Deductible
50% After Annual Deductible
50% After Annual Deductible
50% After Annual Deductible
50% No Deductible
50% No Deductible
50% No Deductible
50% No Deductible
50% After Annual Deductible
50% After Annual Deductible
50% After Annual Deductible
50% After Annual Deductible
Rate
EE Only
EE + 1 Child(ren)
Annual Deductible Individual Family
Monthly PPO Premiums
$84.12 $123.88
Class I: Diagnostic & Preventive Oral Exams Cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic
Class II: Basic Restorative Emergency Care to Relieve Pain Restorative: fillings Endodontics: minor and major Osseous Surgery Periodontics: minor and major Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments
Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns, Bridges and Dentures Stainless Steel/ Resin Crowns
Class IV: Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,500
Class IX: Implants
This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.
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