Provider: Cigna
Group #00629701
Member Service: (800) 244-6224
Website: www.mycigna.com
Northwest Georgia Oncology Centers offers a comprehensive dental plan through Cigna. You may visit any dentist in or out of the Total Cigna DPPO provider network.
Seeing an in network dentist will give you the maximum savings and most coverage. Your out-of-pocket expenses will generally be higher if you visit a dentist out-of-network.
There is a $1,500 plan year maximum for classes I (preventive services), II (basic services) and III (major services).
Cigna's reimbursement amount for out-of-network services will be based 90% Reasonable and Customary (R&C) charges.
The following table is a general overview of your Dental Benefits and Deductible requirements. Please refer to your Summary Plan Description or call customer service for specific benefit details, limitations, and/or exclusions.
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Annual Calendar Year Deductible | $50 Single/ $150 Family | $50 Single/ $150 Family |
| Annual Maximum Benefit | $1,500 per member | $1,500 per member |
| Preventive Services |
Covered 100%, |
Covered 100%, |
| Basic Services | 20% after deductible | 20% after deductible |
| Major Services | 50% after deductible | 50% after deductible |
| Orthodontic Maximum | $1,500 | $1,500 |
*When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of the plan's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what your dentist charges and you are responsible for that difference.
Bi-Weekly Deduction Amounts
| Dental Coverage | Payroll Deduction |
| Employee Only | $21.26 |
| Employee + Spouse | $43.12 |
| Employee + Child(ren) | $49.02 |
| Family | $78.44 |
