Diagnostic and Preventive 100% 100% Basic Services Basic 80%** 80%** Periodontic Treatment 50%** 50%** Re-lining/Re-basing of Existing Removable Dentures 50%** 50%** Repair or Re-cementing of Crowns, Inlays, Onlays, 50%** 50%** Dentures or Bridgework Major Services 50%** 50%** Crowns, Jackets and Cast Restoration Benefits 50%** 50%** Prosthodontic Benefits 50%** 50%** TMJ and Implants Not covered Not covered Orthodontia Services 50% 50% Deductible None None Dependent Children Up to age 26 Up to age 26 Adults Not covered Not covered Lifetime Maximum for Orthodontia $1,500 $1,500 *For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. **After Deductible PRE-65 AND POST-65 RETIREE VISION BENEFITS – Cigna Benefit Network Out-of-Network Benefit Frequency Exam/Lenses/Contacts 12 months 12 months Frames 24 months 24 months Exam $10 Up to $30 allowance Lenses Single Vision $20 copay Up to $25 allowance Bifocal $20 Up to $35 allowance Trifocal $20 copay Up to $45 allowance Lenticular $20 Up to $60 allowance Lens Options UV Coating Up to $17 copay Not Covered Tint/Scratch Resistance Up to $17 copay Not Covered Basic Polycarbonate Up to $40 copay under age 18 Not Covered
Diagnostic and Preventive 100% 100% Basic Services Basic Periodontic Treatment Re-lining/Re-basing of Existing Removable Dentures Repair or Re-cementing of Crowns, Inlays, Onlays, Dentures or Bridgework 80%** 50%** 50%** 50%** 80%** 50%** 50%** 50%** Major Services Crowns, Jackets and Cast Restoration Benefits Prosthodontic Benefits TMJ and Implants 50%** 50%** 50%** Not covered 50%** 50%** 50%** Not covered Orthodontia Services Deductible Dependent Children Adults 50% None Up to age 26 Not covered 50% None Up to age 26 Not covered Lifetime Maximum for Orthodontia $1,500 $1,500 *For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. **After Deductible PRE-65 AND POST-65 RETIREE VISION BENEFITS – Benefit Cigna Network Out-of-Network Benefit Frequency Exam/Lenses/Contacts Frames 12 months 24 months 12 months 24 months Exam $10 Up to $30 allowance Lenses Single Vision Bifocal Trifocal Lenticular $20 copay $20 $20 copay $20 Up to $25 allowance Up to $35 allowance Up to $45 allowance Up to $60 allowance Lens Options UV Coating Tint/Scratch Resistance Basic Polycarbonate Up to $17 copay Up to $17 copay Up to $40 copay under age 18 Not Covered Not Covered Not Covered
SCS%20Pre%2065%20and%20Post-65%20Retiree%20Booklet%202019%20revised%201.docx