The Plan offers three dental care plans for active employees:
The Cigna Dental
The Dental Health Maintenance Organization (DHMO) consists of a network of dentists and dental care providers. If you opt for dental coverage through Cigna Dental DHMO, you must choose a dental care provider within the DHMO network to receive benefits. This selected dentist will act as your primary dental provider, overseeing your care. The DHMO covers preventive services, such as exams and cleanings, at no charge. For other procedures, there is a Co-payment required (please refer to the “Patient Charge Schedule” in your Cigna DHMO booklet for exact amounts). Additionally, you won’t need to file any claim forms as your network dentist will handle claim submissions on your behalf.
There is no annual limit (annual benefit maximum) on the services provided under the DHMO. Orthodontia benefits are available for both children and adults. Adults are responsible for a Co-payment of $2,328 for a 24-month treatment plan, while for children, the Co-payment is $1,584 for the same duration. Retainers and related orthodontic expenses are covered in accordance with the Patient Charge Schedule.
| Annual Deductible | None |
| Annual Benefit Maximum | $0 |
| Preventive Services (Exams Cleanings) | $0 |
| Basic Restorative Services | $0 |
| Major Restorative Services (Crowns Porcelain/Ceramic) | $245 |
| Root Canal Bicuspid | $31 |
| Extraction Single Tooth Partial Bony Impaction | Single Tooth $12 Partial Bony Impaction $21 |
| Dentures | Co-Pay |
| Orthodontia 24-month treatment Adult/Child | Adult $2,328 -Child $1,584 |
| Crown and Bridges | 5-year replacement |
CareFirst Dental
The CareFirst Dental plan provides you with the flexibility to visit any dental care provider of your choice and still receive benefits for covered services. However, opting for a participating CareFirst dental provider within the network can lead to greater savings.
Most covered services are reimbursed at 80% of the allowance set by CareFirst with its providers. You are responsible for paying the remaining 20% of the program allowance. Additionally, if you opt for a non-participating dentist, you are responsible for any charges that exceed the network allowance.
The Plan will cover dental services up to $1,500 per individual annually (annual benefit maximum). Once this limit is reached, you will be fully responsible for any remaining charges for the remainder of the year.
Before undergoing a major dental procedure, we strongly recommend that you and your dentist obtain an estimate of eligible benefits from CareFirst. This will help you understand the cost of the service and your share of the expenses.
| Annual Deductible | None |
| Annual Benefit Maximum | $1,500 |
| Preventive Services (Exams Cleanings) | No charge if a participating dentist renders a service |
| Basic Restorative Services | The plan pays 100% of the Allowance. |
| Major Restorative Services (Crowns Porcelain/Ceramic) | The plan pays 80% of the Allowance |
| Root Canal Bicuspid | The plan pays 80% of the Allowance. |
| Extraction Single Tooth Partial Bony Impaction | The plan pays 80% of the Allowance |
| Dentures | The plan pays 80% of the Allowance every 5 Years. |
| Orthodontia 24-month treatment Adult/Child | Not Covered |
| Crown and Bridges | 5-year replacement |
CareFirst Dental with Orthodontia
You have the option to enroll in orthodontic coverage through CareFirst Dental. CareFirst covers 50% of the expenses, with a separate lifetime maximum benefit of $1,000 per participant.
| Annual Deductible | None |
| Annual Benefit Maximum | $1,500 Individual (for non-orthodontic services) |
| Preventive Services (Exams Cleanings) | No charge to you if participating dentist renders a service |
| Basic Restorative Services | The plan pays 100% of the Allowance. |
| Major Restorative Services (Crowns Porcelain/Ceramic) | The plan pays 80% of the Allowance |
| Root Canal Bicuspid | The plan pays 80% of the Allowance |
| Extraction Single Tooth Partial Bony Impaction | The plan pays 80% of the Allowance |
| Dentures | The plan pays 80% of the Allowance every 5 Years |
| Orthodontia 24-month treatment Adult/Child | Pays 50% of Allowance to a lifetime maximum of $1,000 |
| Crown and Bridges | 5-year replacement |
Delta Dental (Retirees Only)
Delta Dental serves as the administrator for the retiree dental plan, handling claim payments and overseeing the network of participating dentists. Before proceeding with any treatment that exceeds $300 in cost, please ensure that your dentist submits the claim form to Delta Dental for predetermination.
Under Delta Dental, there is an annual deductible of $100 per individual with a family maximum of $300. Additionally, the yearly benefit maximum stands at $1,500 per individual.
| Annual Deductible | $100 per individual and up to $300 per family |
| Annual Benefit Maximum | $1,500 per person |
| Preventive Services (Exams Cleanings) | 60% of reasonable and customary, no deductible |
| Basic Restorative Services (fillings) | The plan pays 60% of the Allowance |
| Major Restorative Services Crown (porcelain/Ceramic) | The plan pays 60% of the Allowance |
| Root Canal Bicuspid | The plan pays 50% of the Allowance |
| Extraction Single Tooth Partial Bony Impaction | The plan pays 50% of the Allowance |
| Dentures | The plan pays 50% of the Allowance |
| Orthodontia 24-month treatment Adult/Child | Not Covered |
| Crowns and Bridges | 30% of reasonable and Customary |
*Non-participating dentist, you pay any amount in excess of reasonable and customary allowance.
Limitation and Exclusions
Covered services must meet the carrier’s criteria for medical necessity. Generally, cosmetic and experimental procedures are not covered. Certain procedures and appliances may require prior authorization based on medical necessity, or they may be subject to limitations or exclusions. For instance, dentures or other devices may only be replaced after a specified number of years, depending on the reason for replacement. Typically, up to two routine dental exams are covered per year. Experimental procedures are also typically excluded. For more information, consult your carrier’s benefits booklet or contact them directly.
