Dental
Plan A: High Option
Plan A offers the highest level of dental coverage. This plan stresses preventive care to help you and your family avoid serious dental problems. The plan pays 100% of the covered cost (reasonable and customary charges) of preventive and basic services. It also pays 80% of the covered cost (reasonable and customary charges) of major services and orthodontia care. The maximum benefit you can receive under this plan each year is $2,000 per person. Orthodontia care carries a separate $2,000 per person lifetime maximum.
Plan A also includes a Preferred Provider Organization (PPO) feature, which gives you the option of receiving care from PPO participating dental care providers and paying less out-of-pocket.
Participating dentists agree to charge negotiated rates. These rates are typically lower than the rates charged by non-participating dentists. This means that when you visit a participating dentist, your out-of-pocket costs may be less. Remember, when you visit a non-participating dentist, you are responsible for a percentage of the reasonable and customary charges. In addition, you pay any amount above the reasonable and customary limit. Here’s an example of how you might save money using a participating dentist compared to a non-participating dentist.
Here’s an Example
Let’s assume you need a major procedure that’s covered at 80%:
| Participating Dentist | Non-participating Dentist | |
| Provider’s Regular Fee | $600 | |
| Negotiated Fee | $375 | N/A |
| Reasonable & Customary Limit | N/A | $500 |
| Plan Pays | 80% of $375 = $300 | 80% of $500= $400 |
| You Pay | 20% of $375 = $75 | $200 ($600-$400 = $200) |
| Savings obtained by using a participating provider: $125 | ||
NOTE: This chart is for illustrative purposes only.
To locate a participating provider in your area, visit www.cigna.com or call (800) 345-4511 to request a provider directory.
Plan Option A Benefit Summary:
| Coverage Type | In-Network | Out-of-Network |
| Type A – Preventive | 100% of PDP Fee* | 100% of R&C Fee** |
| Type B – Basic Restorative | 100% of PDP Fee* | 100% of R&C Fee** |
| Type C – Major Restorative | 80% of PDP Fee* | 80% of R&C Fee** |
| Type D – Orthodontia | 80% of PDP Fee* | 80% of R&C Fee** |
| Deductible*** | In-Network | Out-of-Network |
| Individual | None | None |
| Family | None | None |
| Annual Maximum Benefit | In-Network | Out-of-Network |
| Per Person | $2,000 | $2,000 |
| Orthodontia Lifetime Maximum | In-Network | Out-of-Network |
| Per Person | $2,000 | $2,000 |