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CIGNA
PPO PLAN - Under the CIGNA Traditional Dental Plan you
may receive services from any licensed dentist of your choice.
Features
of the PPO Plan are:
1. CALENDAR YEAR MAXIMUM INCREASED TO $1500.00
PER PERSON EFFECTIVE 7-1-08.
2. 100% for Preventive-Diagnostic Services.
3. $1000.00 lifetime maximum benefit for child orthodontia.
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. An extensive network of dentists to choose from.
2. Each family member may choose a different dentist.
3. No cost for preventive dental care; $15 copay per tooth for children's
sealants.
4. Low copayments for general, major and orthodontic services.
5. No calendar year or lifetime maximum benefit limits.
CIGNA
HMO AND PPO DENTAL PLAN BENEFITS FOR RETIRED MEMBERS IN TEXAS AND
MISSISSIPPI - EFFECTIVE JULY 1, 2009
| Service |
HMO
Plan Co-Pays (T1R-04) |
Traditional
Plan |
| NEED
TO USE NETWORK PROVIDER? |
Yes |
N/A |
| CALENDAR
YEAR MAXIMUM |
None |
$1,500 |
| Deductible |
HMO
Plan Co-Pays |
Traditional
Plan |
| -Individual
|
None
|
$25 |
| -Family |
None |
$75 |
| DEDUCTIBLE
APPLIES TO CLASS I SERVICES |
N/A |
No |
| Class
I Services |
HMO
Plan Co-Pays |
Traditional
Plan |
| PREVENTIVE-DIAGNOSTIC |
$0 |
100% |
| -Cleaning
|
$0 |
100%
|
| -Exams
|
$0 |
100%
|
| -X-ray
|
$0 |
100%
|
| -Sealant |
$15/tooth
|
100%
|
| Class
II Services |
HMO
Plan Co-Pays |
Traditional
Plan |
| BASIC
SERVICES |
|
|
| -Routine
Extractions |
$0 |
80%
|
| -Fillings
- Basics |
$0 |
80%
|
| -Root
Canal Therapy |
$75
to $180 per tooth |
80%
|
| -Osseus
Surgery |
$285
per quadrant |
80%
|
| -Oral
Surgery |
$0
to $205 per tooth |
80%
|
| Class
III Services |
HMO
Plan Co-Pays |
Traditional
Plan |
| MAJOR
SERVICES |
|
|
| -Crowns
|
$100
to $180 per tooth |
50%
|
| -Bridges |
$100
to $180 per tooth |
50%
|
| -Dentures |
$140-160
per denture |
50%
|
| Class
IV Services |
HMO
Plan Co-Pays |
Traditional
Plan |
| ORTHODONTIA |
|
Covers
Adults and children to age 19(Age 25 if a full-time student) |
| -Co-payments
|
Multiple
co-pays totaling
$1,930 for children to age 19
$1,930 for adult
|
50%
|
| -Lifetime
maximum |
24
month maximum |
$1,000
|
MONTHLY
CONTRIBUTIONS
Note:
L.A. City Subsidy varies as Determined by age and years of
service. |
Single
= $24.94
Two Party = $50.27
Family = $75.62
|
Single
= $50.60
Two Party without ortho= $79.65
Member+child with ortho=$85.19
Family without ortho= $123.52
Family with ortho= $139.05
|
| ACCOUNT/GROUP
NUMBER |
10038602 |
3214764
|
| TOLL
FREE 800-NUMBER FOR INJURIES |
800-367-1037 |
888-336-8258 |
| ADDRESS
FOR CLAIMS OR INQURIES |
|
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. |
