Dental plan comparison at a glance

Plan features DPPO (current plan) DHMO (new plan)
In-network Out-of-network In-network only
Deductible (individual/family) $0/$0 $50/$150 No deductible
Annual benefit maximum (per person) $2,000 $2,000 No maximum
Orthodontia lifetime maximum (per person) $1,500 $1,500 No maximum
Preventive and Diagnostic

  • Cleanings
  • Oral examinations
  • Fluoride
  • X-rays
  • Space maintainers for dependent children up to age 19
  • Sealants
 100% of the DPPO fee 100% of the reasonable and customary (R&C) fee 100%
Basic Care

  • Fillings
  • Simple extractions
  • Crown, denture, bridge repair/recommendations
  • General anesthesia (when in connection with oral surgery, extraction or other covered services)
  • Periodontal maintenance
 80% of the DPPO fee 80% of the R&C fee, after deductible The DHMO sets the cost for services based on a Patient Charge Schedule (PCS)3
Major Care

  • Implants
  • Bridges and dentures
  • Crowns, inlays, onlays
  • Endodontics
  • Oral surgery
  • Periodontal surgery
 60% of the DPPO fee 60% of the R&C fee, after deductible See the PCS
Orthodontia Services 60% of the DPPO fee 60% of the R&C Fee, after deductible
Dental Card No Yes

1 DPPO in-network services are based on the fee amount the DPPO provider has agreed to charge for covered services. A provider
will not bill you for charges in excess of the in-network negotiated fees. Visit www.mycigna.com to find the closest DPPO provider.
2 DPPO out-of-network services are based on the reasonable and customary (R&C) amount that Cigna determines using the lowest
of either the dentist’s actual charge, the dentist’s usual charge, or the charge of most dentists in the same geographic area for the
same/similar service. Out-of-network dentists may bill you for amounts that exceed the R&C fee limit.
3 Under the DHMO, Cigna allows your network dentist to charge a certain amount. Then, you pay a [fixed portion/percentage] of
that cost, as listed in the Patient Charge Schedule (PCS), which can be found on www.mycignaplans.com. The DHMO pays the rest.

Note: This is a brief summary of the Allscripts associate benefits. Coverage is subject to the insurance policy terms and conditions and government statutes. Allscripts reserves the right to change, suspend or terminate any employee benefit at any time.