BL Companies | 2022 Benefits Brochure

CIGNA DENTAL COVERAGE

PLAN PROVISIONS

CIGNA PPO DENTAL IN-NETWORk

Calendar Year Deductible (Individual/Family)

$50/$150

Calendar Year Maximum

$1,500 per individual

Orthodontia Lifetime Maximum Diagnostic and Preventive Services (e.g., X-rays, cleanings, exams) Basic and Restorative Services (e.g., fillings)

$1,000 lifetime maximum

Covered at 100%

80%*

50%*

Major Services (e.g., dentures, crowns, bridges)

Orthodontia (coverage for dependent children to age 19)

50%

*after deductible

Benefit Plan Provisions IN-NETWORK REIMBURSEMENT: For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. NON-NETWORK REIMBURSEMENT: For services provided by a non- network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 80th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees.

CALENDAR YEAR BENEFITS MAXIMUM: The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. CALENDAR YEAR DEDUCTIBLE: This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. ORTHODONTIA: Coverage for Dependent Children to age 19, Lifetime Benefits Maximum: $1,000

BENEFITS OF USING IN-NETWORK DENTAL PROVIDERS While you have the option of choosing any provider, you will save money when you use in-network dentists. When using an out-of- network dental provider, you will pay more because the provider has not agreed to charge you a negotiated rate.

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