Dental Benefits

Offers three affordable plan options for routine care and beyond: two DPPO plans that allow for in-network and out-of-network coverage and one DHMO plan that allows for in-network only coverage.

Dental Benefits

Covered Services

Services	Base Plan In-Network	Base Plan Out-of-Network	Buy-Up Plan In-Network	Buy-Up Plan Out-of-Network	DHMO In-Network
Calendar Year Deductible - Individual	$50	$50	$50	$50	$0
Calendar Year Deductible - Family	$150	$150	$150	$150	$0
Calendar Year Maximum - Per Person	$1,500	$1,500	$1,500	$1,500	N/A
Preventive Services	Covered in full	10%	Covered in full	10%	Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992
Basic Services	50%*	50%*	20%*	30%*	Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992
Major Services	50%*	50%*	50%*	50%*	Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992
Orthodontics	Not covered	Not covered	50%	50%	Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992
Orthodontic Lifetime Maximum	Not applicable	Not applicable	$2,000	$2,000	Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992

Services: Calendar Year Deductible - Individual
Base Plan In-Network: $50
Base Plan Out-of-Network: $50
Buy-Up Plan In-Network: $50
Buy-Up Plan Out-of-Network: $50
DHMO In-Network: $0

Services: Calendar Year Deductible - Family
Base Plan In-Network: $150
Base Plan Out-of-Network: $150
Buy-Up Plan In-Network: $150
Buy-Up Plan Out-of-Network: $150
DHMO In-Network: $0

Services: Calendar Year Maximum - Per Person
Base Plan In-Network: $1,500
Base Plan Out-of-Network: $1,500
Buy-Up Plan In-Network: $1,500
Buy-Up Plan Out-of-Network: $1,500
DHMO In-Network: N/A

Services: Preventive Services
Base Plan In-Network: Covered in full
Base Plan Out-of-Network: 10%
Buy-Up Plan In-Network: Covered in full
Buy-Up Plan Out-of-Network: 10%
DHMO In-Network: Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992

Services: Basic Services
Base Plan In-Network: 50%*
Base Plan Out-of-Network: 50%*
Buy-Up Plan In-Network: 20%*
Buy-Up Plan Out-of-Network: 30%*
DHMO In-Network: Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992

Services: Major Services
Base Plan In-Network: 50%*
Base Plan Out-of-Network: 50%*
Buy-Up Plan In-Network: 50%*
Buy-Up Plan Out-of-Network: 50%*
DHMO In-Network: Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992

Services: Orthodontics
Base Plan In-Network: Not covered
Base Plan Out-of-Network: Not covered
Buy-Up Plan In-Network: 50%
Buy-Up Plan Out-of-Network: 50%
DHMO In-Network: Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992

Services: Orthodontic Lifetime Maximum
Base Plan In-Network: Not applicable
Base Plan Out-of-Network: Not applicable
Buy-Up Plan In-Network: $2,000
Buy-Up Plan Out-of-Network: $2,000
DHMO In-Network: Examples of copays include: Cleaning – $5 copay Sealant – Non Molars $5 copay Root Canal – Anterior $50 copay Orthodontic – Child $1,512 Orthodontic – Adult $1,992

Plan Notes

If you use a dentist who doesn’t participate in your plan’s network, your out-of-pocket costs will be higher, and you are subject to any charges beyond the Maximum Allowable Charge (MAC) and could be balance billed.
To find a Cigna network dentist, visit www.cigna.com, click Find a Doctor, Dentist or Facility.
You may log in or click Plans Through Your Employer or School.
Under Dental Plans, select either the Total DPPO or Access Plus DHMO depending on which dental plan you elect.