Benefit Guide - Stripes

DENTAL DHMO BENEFITS

HOW TO FIND A DHMO DENTAL PROVIDER

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist. Not all Network Dentists perform all listed services and it is suggested that you check with your Network Dentist in advance of receiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made by your Network General Dentist to a Network Specialty Endodontist, Periodontist or Oral Surgeon. A referral is not required for Specialty Care at a Network Specialty Pediatric Dentist or Orthodontist. You may select a Network Pediatric Dentist for your child under the age of 13 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 13th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 13th birthday.

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 “Cigna Dental Care DHMO” .

DMO PLAN 57

BENEFIT

IN-NETWORK

Annual Deductible

Individual: None Family: None

Annual Benefit Maximum

None

Office Visit Fee

$5

Diagnostic & Preventive Services

See Fee Schedule

Basic Services

See Fee Schedule

Major Services

See Fee Schedule

Orthodontic Services (adults & children)

See Fee Schedule

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

$3.27 $5.96 $6.87 $10.35

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