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III <br /> Dental - Cigna yCigna <br /> Dental coverage is key to your overall health. The District offers employees three dental plan options through <br /> Cigna. For more information about your plan and to find a Cigna dentist near your, visit www.cigna.com, or <br /> call 800-244-6224. <br /> Your dental plan covers four main types of expenses: <br /> • Preventive and diagnostic services like exams and cleanings,fluoride treatments, and sealants <br /> • Basic services such a simple fillings, root canals, oral surgery, and gum disease treatment <br /> • Major services such as crowns and dentures <br /> • Orthodontia (DHMO Only)* <br /> Benefit PPOOblag) PPO L'p DHMO <br /> Annual Calendar Year Maximum (Per Enrollee) $1,000 $1,000 N/A <br /> Calendar Year Deductible (Per Enrollee) $50 $50 N/A <br /> Preventive Services No Charge No Charge No Charge <br /> Basic Services No Charge 20% $0-$345 <br /> Major Services 40% 50% $20-$415 <br /> Semi-Monthly - Paycheck Deductions <br /> Employee Only $17.25 $14.80 $10.04 <br /> Employee+Spouse $36.94 $31.70 $17.24 <br /> Employee + Child(ren) $34.57 $29.67 $17.36 <br /> Family $54.38 $46.67 $25.01 <br /> Note:Coinsurance shown is member paid for In-Network providers. Non-contracted providers would include balance billing. Members can see dentists <br /> that are part of the Advantage network;which is the highest tier providing coverage at the full in-network benefit level,DPPO network which still offers a <br /> discount on the services however benefits are paid based on the out of network benefit levels,and full Out of network,your benefits may be lower and you <br /> may have to file your own claims.DHMO plan members are encouraged to select a dentist. <br /> *Maximum benefit of 24 months of interceptive orthodontics and/or comprehensive treatment. Atypical <br /> cases or cases beyond 24 months require an additional payment by the patient. <br /> Atirt '.-N,,, , ( 1 <br /> \----' -----, ./ <br /> I <br /> all. 401-25.4 <br /> .--.., A i AI, , !,...\ ' <br /> *� `it r <br /> .t Z t <br /> 1� <br /> vm <br /> l'i I <br /> il" it - V . tilr <br /> 20 <br />