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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 provider.
Features
of the PPO Plan are:
1.
CALENDAR YEAR MAXIMUM INCREASED TO $1500.00
PER PERSON EFFECTIVE 7-1-08.
2. $1000.00 lifetime maximum benefit for child orthodontia.
3. 100% PPO Provider and 80% Out-of-network for Preventive-Diagnostic
Services.
CIGNA
HMO Plan - Under the CIGNA HMO plan you must select a primary
care dentist from the plan's network of dentist 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 from which to choose.
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 - EFFECTIVE
JULY 1, 2008
| Service |
HMO
Plan Co-Pays (T1R-04) |
PPO |
| NEED
TO USE NETWORK PROVIDER? |
Yes |
Optional |
| CALENDAR
YEAR MAXIMUM |
None |
$1,500 |
| Deductible |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| -Individual
|
None
|
$25 |
$25 |
-Family
DEDUCTIBLE
APPLIES TO CLASS I SERVICES |
|
|
$75
|
| Class
I Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| PREVENTIVE-DIAGNOSTIC |
|
|
|
| -Cleaning
|
$0 |
100% |
80% |
| -Exams
|
$0 |
100% |
80% |
| -X-ray
|
$0 |
100% |
80% |
| -Sealant |
$15/tooth
|
100% |
80% |
| Class
II Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| BASIC
SERVICES |
|
|
|
| -Routine
Extractions |
$0 |
80% |
70% |
| -Fillings
- Basics |
$0 |
80% |
70% |
| -Root
Canal Therapy |
$75
to $180 per tooth |
80% |
70% |
| -Osseus
Surgery |
$285
per quadrant |
80% |
70% |
| -Oral
Surgery |
$0
to $205 per tooth |
80% |
70% |
| Class
III Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| MAJOR
SERVICES |
|
|
|
| -Crowns
|
$100
to $180 per tooth |
50% |
40% |
| -Bridges |
$100
to $180 per tooth |
50% |
40% |
| -Dentures |
$140-$160
per denture |
50% |
40% |
| Class
IV Services |
HMO
Plan Co-Pays |
PPO |
Out-of-Network |
| ORTHODONTIA |
|
Covers
Adults and Children to age 19 (age 25 if fulltime student) |
| -Co-payments
|
Multiple
co-pays totaling
$1,930 for children to age 19
$1,930 for adult
|
50% |
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 INQUIRES |
800-367-1037 |
888-336-8258 |
| ADDRESS
FOR CLAIMS |
|
CIGNA
P. O. Box 1888037
Chattanooga, TN 37422-8037 |
|
