Dental Plan

We have selected Cigna as our dental care insurance provider. Cigna's nationwide network of dentists provides you and your family members with the flexibility to choose any dentist that you wish to use.

You may elect dental coverage for yourself and eligible family members. The plan provides coverage for services from any licensed dentist – however, you can optimize your benefits by accessing care from a contracted provider. Non-network dental services are subject to usual, customary, and reasonable (UCR) fees, which may result in additional costs if the dentist charges more than the carrier-contracted fees. This is referred to as balance billing.

Please reference the Cigna Provider Directory to find dentists that are in-network with Cigna, so you can maximize your coverage. Select the DPPO Advantage Network.

Please note: After you have completed your enrollment, eligibility information will be sent to the carriers on the next weekly file, which is scheduled for Friday morning. Dependent eligibility will be sent to the carriers on a weekly Friday morning file following dependent verification document being received and approved. The carriers take approximately 3-4 business days to process the files at which time, you can register with myCigna.com and login to download a digital ID card and also contact Cigna Member services with any questions.

Group Number	Service Number
3346552	800.244.6224

Cigna Provider Directory

Cigna Dental PPO SDBC

Cigna Dental Plan Summary

Cigna Dental Plan Summary (Texas Only)

Cigna Member Resources

CIGNA DENTAL	PPO PLAN
Network	In-Network \| Out-of-Network
Annual Plan Maximum	$1,500
Annual Deductible Individual Family	(waived for preventive & diagnostic) $50 $150
Preventive Services	100%
Basic Services	80%
Major Services	50%
Orthodontia	50%
Ortho Lifetime Max	$1,500 (Adult & Child)
Usual, Customary & Reasonable	Negotiated Fee \| 90th Percentile

For out-of-network providers, Cigna will only pay dentist up to the 90th percentile of the Usual, Customary and Reasonable (UCR) prevailing billed charges in the dentist's zip code. If your dentist charges a rate higher than this benchmark, you are responsible for the additional charges. Ask your dentist for an estimate if you are concerned.

Contributions

PER PAY PERIOD (26)	PPO PLAN EMPLOYEE COST
Employee Only	$3.42
Employee + Spouse	$10.54
Employee + Child(ren)	$15.99
Family	$25.82

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Disclaimer: This presentation is to provide a summary of Alto Pharmacy employee benefit programs. Should any discrepancy arise, please refer to actual plan documents which supersede this presentation. Once enrolled, you will receive a Combined Evidence of Coverage and Disclosure Form that explains the exclusions and limitations, as well as the full range of covered services of your plan, in detail.