Cigna Global Health Dental Plan

2021 and 2022 Plan Year Information

Cigna Global Health Dental Plan: In-Network and Out-of-Network
Note

The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums, which employees pay.

Individual Annual Deductible

$50

Family Annual Deductible

$150

Diagnostic and Preventive Care

100% of R&C; deductible waived

Restorative Services

80% of R&C, after annual deductible

Prosthodontics

50% of R&C, after annual deductible

Orthodontics

50% of R&C after separate $50 deductible, up to a $3,000 lifetime maximum per person (children to age 19)

Annual Benefit Maximum per Person

$2,000

Out-of-Network Charges for Dental Services

Out-of-network reimbursements and maximums are based on Reasonable and Customary (R&C) charges as determined by the health plan administrator.

Orthodontics Lifetime Maximum Benefit

The orthodontics lifetime benefit maximum is combined across plan options.

A Note About Annual Benefit Maximums

In no event can any one person receive more than the annual benefit maximum during a calendar year (excluding orthodontics), even if provided by an in-network or PDP dentist.

Flexible Spending Account

Learn how a Health Care FSA or Limited Purpose FSA can save you 20% to 40% (depending on your tax bracket) on your health care costs, including dental expenses.

Dental Contributions

You and the Firm share the cost of your Dental Plan coverage. Your contributions are deducted from your pay on a before-tax basis.

Note: Your location and salary band are used to calculate only your medical contribution rates.
The costs shown below are per paycheck contributions. For the monthly cost, double the amounts shown.

 Yourself OnlyYourself + Spouse/Domestic PartnerYourself + Children Yourself + Family
Cigna Global Dental Plan$33.33$66.58$66.58$99.92

If you are covering a domestic partner or the children of a domestic partner, the IRS determines the tax status of a dependent and may impose a tax on the value of coverage. Consult your tax advisor for more information.