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City of Cocoa I Employee Benefit Highlights 12020-20210 <br /> Cigna Dental PPO Plan At-A-Glance <br /> q <br /> Network Total Cigna DPPO <br /> Calendar Year Deductible(CYD) In-Network Out-of-Network* Locate a Provider <br /> Per Member 1 $25 To search for a participating provider, <br /> contact Cigna's customer service or visit <br /> Per Family $50 www.mycigna.com.When completing <br /> EWaived for Class I Services? Yes the necessary search criteria,select <br /> - Total Cigna DPPO or Advantage <br /> Calendar Year Benefit Maximum network. <br /> Per Member $1,500 <br /> Class I Services:Diagnostic&Preventive Care , 0 1 <br /> Routine Oral Exam(2 Per Calendar Year) <br /> 1 [Routine Cleanings(2 Per Calendar Year) i Plan Pays:100% Plan Pays:100% Plan References <br /> DeducObleWaived Deductible Waived <br /> •CompleteX-rays(Per 36 Months) (Subjearo8alanceBilling) Out-Of-Network Balance Billing: <br /> [Bitewing X-rays(2 Sets Per Calendar Year) For information regarding out-of- <br /> _ network balance billing that may be <br /> Class II Services:Basic Restorative Care charged by an out-of-network provider, <br /> please refer to the Out-of-Network <br /> Fillings Benefits section on the previous page. <br /> Simple Extractions <br /> [Endodontics(Root Canal Therapy) _1 Plan Pays:80%After CYD <br /> Oral Surgery Plan Pays:80%After CYD j Billing) <br /> (Subject to Balance Billin) <br /> ^Periodontal Services <br /> [Anesthetics — Important Notes <br /> •Each covered family member may <br /> Class III Services:Major Restorative Care receive up to two(2)routine cleanings <br /> per calendar year covered under the <br /> LCrowns <br /> • <br /> _Bridges Plan Pays:50%After CYD <br /> Plan Pays:50%After CYD preventive benefit <br /> __ – -- — — --— (Subject to Balance Billing) •For any dental work expected to cost <br /> 1 Dentures $200 or more,the plan will provide a <br /> "Pre-Determination of Benefits"upon <br /> Class IV Services:Orthodontia the request of the dental provider. <br /> • <br /> [Lifetime Maximum $2,000 This will assist with determining <br /> approximate out-of-pocket costs <br /> { Plan Pays:50% should employee have the dental work <br /> Benefit(Dependent Children and Adults) Plan Pays:50% <br /> (Subject to Balance Billing) performed. <br /> Deductible Waived DeductibleWaived <br /> �_ J •Waiting periods and age limitations <br /> may apply. <br /> •Benefit frequency limitations may apply <br /> to certain services. <br /> 18 <br /> 10 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved <br />