Page 40 - Benefits-Guide-2020

DENTALPLANS | SummaryOfBenefits
METLIFE PPO
IN-NETWORK
OUT-OF-NETWORK
CIGNA HMO*
IN-NETWORK
Calendar Year Maximum Benefit
$2,000 per person
$2,000 per person
No maximum
Calendar Year Deductible
$60 per person (does not apply
to Class 1 services)
$60 per person (does not apply
to Class 1 services)
$0
Type A Covered Services:
Preventive and Diagnostic Services
100% of the network dentist contracted amount (subject to frequency limits)
100% of reasonable and customary charge
Most preventive services covered with no copay, most other services have copays, see benefit schedule for details*
Type B Covered Services:
Basic and Restorative Services
70% of the network dentist contracted amount after deductible
70% of reasonable and customary charge after deductible
Amalgam fillings covered with no copays, most other services have copays, see benefit schedule for details*
Type C Covered Services:
Major Restorative Services
50% of the network dentist contracted amount after deductible
50% of reasonable and customary charge after deductible
Most services have copays, see benefit schedule for details*
Dentures
Repairs and Adjustments Initial Installation (Full or Partial) Replacement Limit
Covered as
Type B Covered as Type C Once every 60 months
Covered as
Type B Covered as Type C Once every 60 months
Services have copays, see benefit schedule for details* Once every 60 months
Orthodontic Services
Lifetime Maximum
50% of the network dentist contracted amount after deductible $2,500
50% of reasonable and customary charge after deductible $2,500
Services have copays, see benefit schedule for details* Maximum benefit period of 24 months
*Cigna HMO does not cover services provided by out-of-network dental providers. Copies of benefit plan materials are available to you via mail or email, and may be requested by calling Cigna. Please refer to the “Getting Help” pages of the guide for carrier contact information.
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