How the Dental Program works

Important information about how the Dental Program works
mechanic


The Dental Program has two options that are both administered by Cigna:
The options available to you will be reflected on your Personalized Enrollment Worksheet included in your annual enrollment packet each year.

Dental Program at-a-glance

This chart compares how treatments and services are covered under the two dental options:

 
Dental PPO
Dental Health Maintenance Organization (DHMO)
In-network Out-of-network
General information
Plan-year deductible
$25/person
 
$75 family maximum
$100/person
 
$300 family maximum
None
Plan-year maximum benefit
$3,000/person for diagnostic and preventive services and for basic and major restoration services combined (in-network and out-of-network combined)
$1,500/person for diagnostic and preventive services and for basic and major restoration services combined (in-network and out-of-network combined)
None
Lifetime maximum benefit
$2,000/person for orthodontia (in-network and out-of-network combined)
$1,500/person for orthodontia (in-network and out-of-network combined)
None
For the following treatments and services, the dental options pay:
Covered services
Diagnostic and preventive services
(e.g., routine oral exams, preventive cleanings, X-rays, fluoride treatments, periodontal maintenance)
100% with no deductible
 
Note: Participants are eligible for three regular cleanings and one periodontal maintenance per plan year (in-network and out-of-network combined)
100% with no deductible
 
Note: Participants are eligible for three regular cleanings and one periodontal maintenance per plan year (in-network and out-of-network combined)
100% after scheduled preset charge**
 
Note: Participants are eligible for one cleaning every six months (two per plan year). Additional cleanings are available, but are subject to a copay
Basic restoration
(e.g., fillings, extractions, oral surgery, treatment of gums, additional periodontal services, root canal therapy) (In the DHMO, some root canals fall into major restoration group.)
90% after deductible
70% after deductible*
100% after scheduled preset charge**
Major restoration
(e.g., crowns and caps to repair teeth, dentures, bridgework, implants, prosthetics)
70% after deductible
50% after deductible*
100% after scheduled preset charge**
Orthodontia for adults and children
(e.g., braces, retainers, oral exams, X-rays)
50% with no deductible, up to $2,000 per lifetime maximum shown above
50% with no deductible*, up to $1,500 per lifetime maximum shown above
100% after scheduled preset charge**

* Coinsurance benefit levels are subject to maximum allowable charge limits for services or supplies provided by an out-of-network provider.

** Provided in the patient charge schedule from Cigna Dental Health.  

 

Publication date: April 2019

 

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