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CIGNA
PPO PLAN - Under the Cigna PPO Plan you may receive services
from any licensed dentist of your choice. If you choose to use a
PPO provider you will receive a higher level of benefit coverage
than if you use a non-PPO
Features
of the PPO Plan are:
1.
Member coverage at no cost to you.
2. Calendar year maximum of $1750.00 per person.
3. 100% PPO Provider and out-of-Network for preventive Diagnostic
Services.
4. Lifetime maximum for orthodontia services
of $1500.00
CIGNA
HMO Plan - Under the CIGNA HMO plan you must select a primary
care dentist from the plan's network of dentists and receive services
only from that dentist in order to receive coverage, except in an
emergency. You must receive a referral from your primary care dentist
to see a specialist in order to receive coverage.
Features
of the HMO Plan are:
1. Member and dependent coverage at no cost to you.
2. An extensive network of dentists to choose from.
3. Each family member may choose a different dentist.
4. No cost for preventive dental care; $0 copay per tooth for children's
sealants.
5. Low copayments for general, major and orthodontic services.
6. No calendar year or lifetime maximum benefit limits.
CIGNA
GROUP DENTAL PROGRAM HMO AND PPO DENTAL INSURANCE BENEFITS
FOR ACTIVE MEMBERS - EFFECTIVE JULY 1, 2009
NEW IMPROVED PPO BENEFITS AND LOWER
MEMBER PREMIUMS
| Service |
HMO
Plan Co-Pays (B1R-04) |
PPO |
| NEED
TO USE NETWORK PROVIDER? |
Yes |
Optional |
| CALENDAR
YEAR MAXIMUM |
None |
$1,750 |
| Deductible |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| -Individual
|
None
|
$0 |
$25 |
-Family
DEDUCTIBLE
APPLIES TO CLASS I SERVICES |
|
|
|
| Class
I Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| PREVENTITIVE-DIAGNOSTIC |
$0 |
100% |
100% |
| -Cleaning
|
$0 |
100% |
100% |
| -Exams
|
$0 |
100% |
100% |
| -X-ray
|
$0 |
100% |
100% |
| -Sealant |
$0 |
100% |
100% |
| Class
II Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| BASIC
SERVICES |
|
|
|
| -Routine
Extractions |
$0 |
90% |
80% |
| -Fillings
- Basics |
$0 |
90% |
80% |
| -Root
Canal Therapy |
$0
to $130 per tooth |
90% |
80% |
| -Osseus
Surgery |
$80
Per Quandrant |
90% |
80% |
| -Oral
Surgery |
$0
to $45 per tooth |
90% |
80% |
| Class
III Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| MAJOR
SERVICES
|
|
|
|
| -Crowns
|
$140
to $220 per tooth |
60% |
60% |
| -Bridges |
$140
to $220 per tooth |
60% |
60% |
| -Dentures |
$180-$260
per denture |
60% |
60% |
| Class
IV Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| ORTHODONTIA |
|
Covers
Adults and Children to age 19 (age 25 if a full time student) |
| -Co-payments
|
Multiple
co-pays totaling
$1,890 for children to age 19
$2,490 for adult
|
50% |
50% |
| -Lifetime
maximum |
24
month maximum |
$1,500
|
| BI-WEEKLY
CONTRIBUTIONS |
Single
= $0.00
Two Party = $0.00
Family = $0.00
|
Single
= $0.00
Two Party = $6.00
Family = $11.00
|
| ACCOUNT/GROUP
NUMBER |
10038598 |
3214764
|
| TOLL
FREE 800-NUMBER FOR INQUIRIES |
800-367-1037 |
800-336-8258 |
| ADDRESS
FOR CLAIMS |
|
CIGNA
P. O. Box 1888037
Chattanooga, TN 37422-8037
|
THE
FOREGOING BRIEF DESCRIPTION OF BENEFITS IS PROVIDED FOR YOUR CONVENIENCE
AND IS SUBJECT TO ALL TERMS, CONDITIONS, LIMITATIONS AND EXCLUSIONS
OF THE GROUP INSURANCE CONTRACTS, PLEASE REFER TO THE EXPLANATION
OF COVERAGE FOR DETAILS ON BENEFITS.
|
