This plan offered by Group Benefit Associates and insured by Cigna, gives members the opportunity to choose either a Dental PPO Plan or a Dental DHMO Plan. This flexibility allows you to select the plan that best fits your specific needs and budget. The Dental DHMO Plan is offered in California, New York, New Jersey, Illinois, Florida and Texas. The Dental PPO Plan is offered in all 50 states. Both the Dental PPO and the Dental DHMO Plan include a Vision benefit. See this DHMO FLYER for more information on the Cigna DHMO Plan.
The Dental PPO plan allows you to visit any dentist or specialist you choose any time care is needed. If you elect to visit a Cigna network provider, you will receive the highest level of benefits and save on out-of-pocket costs. Best of all, the Cigna Dental PPO Plan features one of the industry’s most extensive nationwide dental networks.
The plan pays a specific amount for each dental service based upon an established fee schedule. If you go to a Cigna Dental PPO provider, the benefits described below apply. If you go to a non-Cigna provider, the amounts charged over the scheduled fees are the patient’s responsibility.
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Cigna PPO Advantage
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Cigna PPO
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Out-Of-Network Providers
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Calendar Year Deductible
(waived for Preventive services)
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$50 Individual
$150 Family
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$75 Individual
$225 Family
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$75 Individual
$225 Family
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Preventive Services
Exams, Cleanings, X-Rays, Fluoride, Sealants, Space Maintainers
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100% of fee schedule, no deductible
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75% of fee schedule, no deductible
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75% of fee schedule, no deductible
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Basic Services
Fillings, Oral Surgery, Anesthetics, Periodontics, Root Canal / Endodontics
Repair Bridge / Crown / Inlays / Dentures
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80% of fee schedule, after deductible
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80% of fee schedule, after deductible
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50% of fee schedule, after deductible
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Major Services
Crowns / Inlays / Onlays, Dentures, Bridges
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50% of fee schedule, after deductible
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50% of fee schedule, after deductible
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50% of fee schedule, after deductible
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Orthodontia
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not an insured benefit
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not an insured benefit
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not an insured benefit
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Implants
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50% of fee schedule, after deductible, $1000 yearly
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50% of fee schedule, after deductible, $1000 yearly
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50% of fee schedule, after deductible, $1000 yearly
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Calendar Year Maximum Benefit
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$1000, $1200, $1400, $1600
Years 1,2,3,4
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$1000, $1200, $1400, $1600
Years 1,2,3,4
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$1000, $1200, $1400, $1600
Years 1,2,3,4
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PRE-DETERMINATION: When a course of treatment is expected to cost $200 or more and is of a non-emergency nature, it is recommended to have your dentist submit a treatment plan before he/she begins.
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This is intended only as a brief summary of benefits. It is not an official statement of those benefits. Please see additional docs under the “Plan Details” Tab above.
The Dental DHMO Plan option (only available in CA, NY, NJ, IL, FL and TX):
The Dental DHMO Plan is designed to provide quality dental care while controlling the cost of such care. To do this, this plan requires participants to seek dental care from dentists that belong to the Cigna Dental DHMO network. All covered services must be provided by the participant’s Primary Care Dentist selected at the time of enrollment.
You are only covered if you go to your assigned Primary Care Dentist
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Specialty Referrals
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Must be coordinated by your Primary Care Dentist
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Calendar Year Deductible
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None
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Office Visit Co-pay
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$5
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Preventive Services
Oral Exams, Cleaning, X-Rays, Sealants, Space Maintainers
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May be an additional fee. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
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Basic Services
Fillings, General Anesthesia, Scaling & Root Planing, Simple Extractions, Endodontics, Periodontics
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Available for a Copayment. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
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Major Services
Dentures, Single Crowns, Prosthodontics
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Available for a Copayment. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
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Orthodontia
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Available for a Copayment. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
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Calendar Year Maximum Benefit
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Unlimited
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DHMO Copayment Schedules are available on the “Plan Details” tab above.
Vision benefits are provided through Cigna Vision and include an annual eye exam for a $10 co-pay, in addition to discounted rates on frames, lenses, and other professional services. This benefit also includes discounts on all covered services such as LASIK.
Our vision plan allows you to visit any eye doctor you wish. However, you save significantly on out-of-pocket costs when network providers are used. You will receive substantial coverage for annual eye exams and discounts on eyewear and contact lens professional services every 12 months.
You can find a provider near you by:
- Clicking Find an Eye Doctor to search the online directory.
- Requesting a provider directory by calling (877) 478-7557.
Covered Services & Value Added Discounts
Eye Exams:
- $10.00 copay, covered in full thereafter
Glasses:
- 20% off lenses, frames and the industry’s most extensive list of “cosmetic extras”, including tints, special lenses (e.g. progressives) and scratch resistant coatings.
- 20% off the retail price of additional glasses after initial pair is purchased.*
Contact Lenses and Professional Services
- 15% off of the network doctor’s evaluation and fitting services.
- 20-25% off laser vision correction, or 5% off the laser surgery center’s best promotional price, whichever is a better deal!**
You should call the provider to schedule an appointment. When calling to schedule the appointment, identify yourself as a Cigna member and give the insured’s social security number.
*The claimant must go within 12 months to the same doctor who provided the exam.
**Laser surgery is not an insured benefit. The surgery is available at a discounted fee. The covered person must pay the entire discounted fee. In addition, the laser surgery discount may not be available in all states. participant’s out-of-pocket costs won’t exceed $1,800 per eye for LASIK and $1,500 per eye for PRK.
