Benefit Guide - Stripes

DENTAL DPPO BENEFITS

HOW TO FIND A DPPO DENTAL PROVIDER

All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between In and Out-of-network. Your DPPO plan allows you to see any licensed dentist, but using an In-Network dentist may minimize your out-of-pocket expenses.

1. Go to www.Cigna.com . 2. Click on “Find a Doctor”. 3. Under “How are you Covered?” click on “Employer or School” . 4. Enter the location of the area you want to search then click “Doctor by Type” . 5. Select the type of dentist from the dropdown menu and click “Search” . 6. Click “Continue as guest” (if you are already a Cigna member go to www.myCigna.com and enter your username and password or click “Register” ). 7. Verify your search location then click “Continue” . 8. Under “Please Select a Plan” click “DPPO/EPO” .

DPPO ADVANTAGE

DPPO

BENEFIT

IN-NETWORK

IN-NEWORK

OUT-OF-NETWORK

Annual Deductible

Individual: $50 Family: $150

Individual: $50 Family: $150

Individual: $50 Family: $150

Annual Benefit Maximum

$1,500

$1,500

$1,500

Dental Plans Reimbursement Level

90th percentile of submitted charges

Contracted Fees

Contracted Fees

Diagnostic & Preventive Services Oral Examinations, Cleanings, Routine X-rays, Fluoride Application, Sealants, Space Maintainers, Non-Routine X-rays, Emergency care to relieve pain, Basic Services Filings, Oral Surgery, Periodontics, Root Canal Therapy/Endodontics, Relines, Rebases, and Adjustments, Repairs - Bridges, Crowns, and Inlays, Stainless Steel/Resin Crowns, Brush Biopsy Major Services Surgical Extraction of Impacted Teeth, Anesthetics, Repairs - Dentures, Bridges

100%

100%

100%

80%

60%

60%

50%

50%

50%

Orthodontic Services (adults & children)

Not Covered

Not Covered

Not Covered

Bi-Weekly Contributions Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$12.90 $24.91 $24.28 $36.30

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