Dental PPO Insurance
EMPLOYEE BENEFITS
Cigna ABOUT DENTAL Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease.
For full plan details, please visit your benefit website: www.txescbenefits.com
Our dental plan helps you maintain good oral health How to Request a New ID Card through affordable options for preventive care, including You can request your dental id card by contacting Cigna regular checkups and other dental work. Premium directly at 800-244-6224. You can also go to contributions are deducted from your paycheck on a pretax www.mycigna.com and register/login to access your basis. Coverage is provided through Cigna Dental. account. In addition you can download the “MyCigna” app on your smartphone and access your id card right there on DPPO Plan your phone. Two levels of benefits are available with the DPPO plan: innetwork and out-of-network. You may select the dental Dental provider of your choice, but your level of coverage may Employee vary based on the provider you see for services. You could $34.00 pay more if you use an out-of-network provider. Employee + Spouse $60.00
How to Find a Dentist Visit https://hcpdirectory.cigna.com/ or call 800-244-6224 to find an in-network dentist. Dental PPO
Calendar Year Deductible Individual Family Policy Year Benefits Maximum Applies to: Class I, II, & III expenses Reimbursement Levels Class I: Diagnostic & Preventive Oral Evaluations, Prophylaxis: routine cleanings, Xrays: routine, X-rays: non-routine, Fluoride Application, Sealants: per tooth, Space Maintainers: non-orthodontic, Emergency Care to Relieve Pain Class II: Basic Restorative Fillings, Oral Surgery: minor, Anesthesia: general and IV sedation, Repairs: Bridges, Crowns and Inlays, Repairs: Dentures, Denture Relines, Rebases and Adjustments 24
Employee + Child(ren) Family
$69.00 $96.00
In-Network: Total Cigna DPPO Network
Out-of-Network: See Non-Network Reimbursement
$50 $150
$50 $150 $1000
Based on Contracted Fees
Maximum Reimbursable Charge You Pay
0%
Any amount over the Maximum Reimbursable Charge
20% after deductible
20% after deductible
