DENTAL PLANS

Buy Up Plan	In-Network	Out-of-Network
Network Options	Total Cigna DDPO Network	Non-Network Reimbursement
Calendar Year Maximum	$1,500	$1,500
Calendar Year Deductible	$50 Individual / $150 Family	$50 Individual / $150 Family
Class I – Preventative & Diagnostic Care (oral exams, cleanings, routine x-rays, fluoride application, sealants)	100%, No Deductible	100% (R&C), No Deductible
Class II – Basic Restorative Care (fillings, simple extractions, anesthetics, periodontics, repairs – bridges, crowns, and inlays; repairs – dentures, etc.)	80%, After Deductible	80% (R&C), After Deductible
Class III – Major Restorative Care (crowns/inlays/onlays, stainless steel/resin crowns, dentures, bridges)	60%, After Deductible	60% (R&C), After Deductible
Class IV – Orthodontia (Child Ortho up to age 19)	50%, After Deductible ($2,000 Limit)	50% (R&C), After Deductible ($2,000 Limit)