The Plan offers three dental care plans for active employees:
The Cigna Dental
Dental Health Maintenance Organization (DHMO) is a network of dentists and dental care providers. If you elect dental coverage through the Cigna Dental DHMO, you must select a dental care provider from within the DHMO network to receive benefits. This dentist will serve as your primary dental provider and coordinate your care. The DHMO provides preventive services, like exams and cleanings, at no charge. Other procedures require a Co-payment (refer to the “Patient Charge Schedule” in your Cigna DHMO booklet for exact amounts). Also, there are no claim forms to file- your network dentist will submit your claims for you.
There is no annual limit (annual benefit maximum) on the services you can receive when using the DHMO. The DHMO provides orthodontia benefits for both children and adults. Adults are responsible for a Co-payment of $2,328 for a 24-month treatment plan. For children, the Co-payment is $1,584 for a 24-month treatment plan. Retainers and related Orthodontic expenses are covered according to 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 offers you the freedom to visit any dental care provider you would like and still receive benefits for covered services. However, if you take advantage of the network and use a participating CareFirst dental provider, your savings will be more significant.
Most covered services are paid at 80% of the Allowance established by CareFirst with its providers. You pay 20% of the program Allowance. If you use a non-participating dentist, you are also responsible for charges over the network Allowance.
The Plan will pay up to $1,500 per individual for dental services (annual benefit maximum). If you reach that limit, you will be fully responsible for the remainder of the charges you incur for the rest of the year.
Before you have major dental procedures performed, we encourage you and your dentist to obtain an estimate of eligible benefits from CareFirst. You know what the cost of the service and your share of the cost will be.
| 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 can elect coverage for orthodontia through CareFirst Dental. CareFirst pays 50% with a separate $ 1,000-lifetime maximum benefit 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 is the administrator for the retiree dental plan and is responsible for paying claims and maintaining the networks of participating dentists. Have your dentist submit the claim form to Delta Dental for predetermination before completing treatment for any care exceeding $300.
Delta Dental has an annual deductible of $100 per individual and up to $300 family maximum. The yearly benefit maximum is $1,500 per individual.
| Annual Deductible | $100 per induvial and up to $300 per family |
| Annual Benefit Maximum | $1,500 |
| 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 be medically necessary as determined under the carrier’s rules. Cosmetic procedures and experimental procedures are generally not covered. In addition, specific procedures and appliances may be subject to prior authorization for medical necessity or to limitations or exclusions. For example, dentures or other devices can typically only be replace after a certain number of years, depending on the reason for the replacement. Up to two routine dental exams are generally covered per year. Experimental procedures are also generally excluded. Refer to the benefits booklet from your carrier or contact your carrier for more details.