Page 13 - Venafi - 2021 Benefit Guide - CA

dental plan

Cigna is the carrier for our PPO PLAN - TOTAL CIGNA DPPO NETWORK
In-Network
dental plan. Annual Deductible $50 per individual
January 1 - December 31 $150 per family
Visit mycigna.com to find a network provider. Annual Maximum
January 1 - December 31 $2,000 per individual
Predetermination
Waiting Period None
Cigna recommends that you have your dentist
submit a request for a pre-treatment estimate Preventive Services
Cleanings, routine exams, Plan pays 100% of covered services, Deductible Waived
for services in excess of $250. This often applies fluoride, and x-rays
to services such as: crowns, bridges, inlays and Basic Services
Fillings, extractions, oral
periodontics. When your dentist suggests surgery, endodontics, and You pay 20% AD
periodontics
treatment, have him or her send an updated
Major Services
claim form along with the proposed treatment Crowns, bridges, dentures, You pay 50% AD
and implants, TMJ
plan to Cigna. A pre-treament estimate will be
Orthodontic Services
sent to you and the dentist detailing an estimate Children and Adults Plan pays up to 50%
of what services CIGNA will cover and at what
Orthodontic Lifetime $1,500 per member
payment level. Maximum

AD: After Deductible
Benefits are paid for out-of-network providers. However, deductibles, out-of-pocket maximums and coinsurance can be up to
two times the in-network levels. Additionally, members will likely be balance-billed for any gap between what the plan pays
for in-network providers and what an out-of-network provider charges. Please refer to plan documents in UltiPro for out-of-
network information.

This information is designed to help you choose a benefit plan for 2021 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. 10
If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.