LM_SW_Benefits Guide 2024

Dental Benefits

Central National Gottesman Inc. offers the choice of two different dental insurance plans. Each plan gives you and your family the dental coverage that works best for you. It’s your choice!

www.deltadentalins.com 800.932.0783

DELTA DENTAL PPO PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible

Individual: $50 Individual + 1: $50 each Family: $150

Annual Maximum with D&P Maximum Waiver (Diagnostic and Preventative dental care do not apply toward annual maximum) Diagnostic & Preventive Services Prophylaxis (Cleanings); Oral Examinations; Topical Fluoride; X-rays; Bitewing; Sealants (up to age 14); Space Maintainers Basic Services Fillings; Extractions; Oral Surgery; Endodontics; Periodontics; Periodontal surgery; Anesthesia; Consultations; Repairs of dentures, crowns, inlays and onlays

$3,000 per person

$3,000 per person

Covered 100%, deductible waived

Covered 100%, deductible waived

80% after deductible

80% after deductible

Major Services Bridge and Dentures; Crowns, Inlays, Onlays Orthodontic Services (children only - up to age 19)

50% after deductible

50% after deductible

50% after deductible

50% after deductible

Orthodontic Lifetime Maximum

$1,000

$1,000

www.myCIGNA.com 800.CIGNA24 (800.244.6224)

CIGNA DENTAL CARE (DHMO) PLAN

BENEFIT

IN-NETWORK ONLY $0 per visit. Services during Office Visit will be based upon the Dental Benefit Schedule.

Office Visit Copay

Diagnostic Care Office visit for oral exam; Emergency exam, Diagnostic cast; Bitewing x-rays; Entire x-ray series; Periapical x-rays; Pulp Vitality tests; Dentist consultations Preventive Care Prophylaxis, including cleaning and polishing; Topical application of fluoride; Sealants; Dietary advice and counseling; Minor occlusal (bite) adjustments Restorative Care Amalgam and Composite restorations & related medications; Retention pins; Sedative filings; Minor denture adjustment

Refer to Dental Benefit Schedule

Refer to Dental Benefit Schedule

Refer to Dental Benefit Schedule

Periodontics Care & Oral Surgery Orthodontics (child and adult)

Refer to Dental Benefit Schedule Refer to Dental Benefit Schedule

All benefits are subject to applicable limitations, exclusions, and copayments.

Log into www.workforcenow.adp.com and click on Resources – Company Information – Tools/Resources – 2024 Benefit Documents for details. In the event of a discrepancy, the carrier Plan Document shall prevail.

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QUESTIONS? Call BenefitsVIP ® at 866.286.5354