1/1/08 CIGNA DENTAL PPO BENEFIT SUMMARY
Calendar Year Maximum
(Class I, ll, and III Expenses) $1,000
Caldendar Year Deductible
Per Individual $50
Per Family $150
Class I Expenses - Preventive & Diagnostic Care 100%, No Deductible
Oral Exams,Cleanings,Bitewing X-rays, Fluoride Application, Sealants, Space Maintainers (limited to non-orthodontic treatment), Full Mouth X-rays, Panoramic X-Rays, Emergency Care to Relieve Pain, Histopathologic Exams
Class II Expenses - Basic Restorative Care 100% After Deductible
Fillings, Oral Surgery - Simple Extractions, Oral Surgery - All Except Simple Extraction, Surgical Extraction of Impacted Teeth, Anesthetics, Major Periodontics, Minor Periodonics, Root Canal/Therapy, Relines, Rebases, and Adjustments, Repairs - Bridges, Crowns, and Inlays, Repairs - Dentures
Class III Expenses - Major Restorative Care 50%, After Deductible
Crowns, Dentures, Bridges
Class IV Expenses - Orthodontia 50%, No Separate Deductible
Lifetime Maximum $1,500
Missing Tooth Provision This amount payable is 50% of the amount otherwise payable until insured for 24 months,thereafter, considered a Class III expense.
Pretreatment Review Available on a voluntary basis when extensive work in excess of $200 is proposed.
Progressive Preventive Care $100/yr added to $1000 maximum total $1500
Student Age 19-25
Late Entry Penalties:
New Employees None
Basic Plan 6 Months
Major Plan 12 Months
$
