Online Benefits Directory

DENTAL

Policy # 3343404

Eligibility

You and your legal dependents are eligible for on the first day of the month following 30 days of employment.

Coverage Amount

PLAN DESIGN	TOTAL CIGNA DPPO	OUT-OF-NETWORK
Calendar Year Maximum	Progressive Plan	Progressive Plan
(Class I, II, III Expenses)	Class I applies	Class I applies
	Year 1: $1500, Year 2: $1750, Year 3: $2000, Year 4: $2250	Year 1: $1500, Year 2: $1750, Year 3: $2000, Year 4: $2250
Calendar Year Deductible
Per Individual	$50	$50
Per Family	$150	$150
Class I Expenses - Preventive & Diagnostic Care
Oral Exams. Cleanings, Routine X-rays, Fluoride Application, Sealants, Space Maintainers (limited to non-orthodontic treatment), Non-Routine X-rays, Emergency Care to Relieve Pain	100%, No Deductible	100%, No Deductible
Class II Expenses - Basic Restorative Care
Fillings (Amalgam and composite on all teeth), Oral Surgery - Simple Extractions, Oral Surgery - All Except Simple Extraction, Surgical Extraction of Impacted Teeth, Minor Periodontics, Major Periodontics, Root Canal Therapy / Endodontics, Brush Biopsy	100%, No Deductible	80%, No Deductible
Class III Expenses - Major Restorative Care
Anesthetics, Relines, Rebases, and Adjustments, Repairs - Bridges, Crowns, and Inlays, Repairs - Dentures, Crowns/Inlays/Onlays, Stainless Steel/Resin Crowns, Dentures, Bridges	60%, After Deductible	50%, After Deductible
Class IV Expenses - Orthodontia
Coverage for Eligible Children Only	50%, No Ortho Deductible	50%, No Ortho Deductible
Lifetime Maximum	$1500	$1500
Dental Plan Reimbursement Levels	Based on contracted fees	90th percentile
Additional Member Responsibility in excess of Coinsurance	None	Yes, the difference between Billed Charges and the plan reimbursement.
Student/Dependent Age	26/26	26/26

Procedure Exclusions & Limitations

Exams Two per calendar year
Prophylaxis (cleanings) Two per calendar year
Fluoride 1 per calendar year for people under 19
X-Rays (routine) Bitewings: 2 per calendar year
X-Rays (non-routine) Full mouth: 1 every 3 calendar years. Panorex: 1 every 3 calendar years

For additional coverage information check the Dental Benefit Summary

Progression

Members progress to the next level by utilizing Class I services in the prior year.

Finding a Provider

Visit the Cigna provider directory to find a dentist near you.

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How do I check on a claim?

Login to your Cigna account to see a list of your most recent claims, their status, and reimbursements.

Cost of benefit

Benefit	Employee	Employee & Spouse	Employee & Children	Employee & Family
DENTAL	$9.00	$18.00	$22.00	$33.00

Continuing Coverage after I stop working.

Benefit	Employee Only	Employee & Spouse	Employee & Child(ren)	Employee & Family
COBRA Monthly Costs	$36.72	$ 78.54	$98.94	$149.94

Online Forms & Documents

Cigna Dental Claim Form
Cigna Enrollment Change Form
2024 Cigna Dental Benefit Summary
How to Find a Dentist
A Guide to Your Dental PPO Coverage