GHO - 2024 Employee Benefit Guide (FINAL 6.26.2024) SP

DENTAL BENEFITS

DENTAL PPO PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual:

$50

Individual:

$50

Family:

$150

Family:

$150

Benefit Maximum

$2,000

$2,000

Preventive Services Include Oral Examinations; Cleanings Routine X-rays Fluoride Application ; Sealants; Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-rays Emergency Care to Relieve Pain Basic Services Include Fillings (Amalgam and composite on all teeth) Oral Surgery - Simple Extractions Oral Surgery - All Except Simple Extractions Surgical Extraction of Impacted Teeth Anesthetics Minor Periodontics; Major Periodontics Root Canal Therapy / Endodontics Relines, Rebases, and Adjustments Repairs - Bridges, Crowns, and Inlay; Dentures Brush Biopsy

100% coinsurance Deductible waived

100% coinsurance Deductible waived

80% coinsurance After deductible

80% coinsurance After deductible

Major Services Include Crowns/Inlays/Inlays Stainless Steel/Resign Crowns Dentures Bridges

50% coinsurance After deductible

50% coinsurance After deductible

Certain services may be covered under the Medical Plan.

Understand How Your Plan Works When you choose an In-Network dentist, your coverage includes a wide range of services after you satisfy any potential waiting period. Your plan includes coverage for preventive dental care services, including cleanings, x-rays and more, at no additional cost or at a reduced cost to you. Additional Programs For Our Dental PPO Participants x Enjoy discounts on health-related products and services through Cigna Healthy Rewards ® x The Cigna Dental Oral Health Integration Program ® offers enhanced dental coverage and more for individuals with any of the following medical conditions: Diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program. Individuals who qualify get reimbursed 100% of coinsurance for certain related dental procedures and are eligible for other perks, as well.

For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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QUESTIONS? Call BenefitsVIP at 866.284.2053