2020 Ensign Benefits Guide

Dental To find a Delta Dental dentist (ID, OR and WA), go to www.deltadentalins.com . To find a Cigna DPPO Advantage or Cigna DPPO dentist (all states except ID, OR and WA) or a Cigna Dental DHMO dentist (most states) go to www.cigna.com . If the charge for any dental treatment is expected to exceed $300, ask your dentist to submit a dental treatment plan to Delta Dental or Cigna for review. This will help you to know expected out-of-pocket costs before any treatment begins. Our dental plans provide coverage for preventive services, as well as benefits to help pay for more expensive dental procedures such as fillings, root canals, crowns, bridges and orthodontia coverage. 16 1) After calendar year deductible. 2) Percentage applies to usual, customary and reasonable charges. 3) DHMO copay schedule available on www.ensignbenefits.com . 4) In-network preventive services do not count toward the annual calendar year maximum. 5) Percentage applies to negotiated rate. 2020 Dental Plans At-a-Glance Dental PPO Plan (Delta Dental in ID,OR & WA or Cigna Dental all other states) Cigna Dental DHMO Feature Delta Dental PPO/Cigna DPPO Advantage Dentist Delta Dental Premier/Cigna DPPO Dentist Out-of-Network Cigna DHMO Dentists Only Calendar Year Deductible Waived for preventive $50 per person, $150 per family None Calendar Year Maximum $1,500 per person Unlimited Preventive Services Routine exams, dental cleanings 100% covered 4 You pay 20% 5 You pay 20% 2 $5 office visit copay Basic Services Fillings, oral surgery You pay 10% 1 You pay 20% 1,5 You pay 20% 1,2 Fixed copays 3 Major Services Crowns, inlays, endodontics, periodontics You pay 40% 1 You pay 50% 1,5 You pay 50% 1,2 Fixed copays 3 Orthodontia You pay 50% 1 You pay 50% 1,5 You pay 50% 1,2 Fixed copays 3 Available to children under age 19 only, up to $1,500 lifetime max For children and adults Temporomandibular Joint (TMJ) $1,000 lifetime max You pay 40% 1 You pay 50% 1,5 You pay 50% 1,2 Fixed copays 3 Dental PPO Plan For the highest level of benefits, use a provider in the Delta Dental PPO network (ID, OR and WA) or the Cigna DPPO Advantage network (all other states). You can also go out-of-network but will save money if you use a provider in the Delta Dental Premier network (ID, OR and WA) or the Cigna DPPO network (all other states) versus dental providers who are not in a Delta Dental or Cigna provider network. Cigna Dental DHMO DHMO stands for Dental Health Maintenance Organization and provides dental services exclusively from Cigna DHMO dentists. There is no deductible and no annual maximum benefit. You pay fixed copays for preventive, basic and major services. You must select a primary care dentist for your care. Go to www.cigna.com/offered-cigna-through-work/dental/dhmo to see if there is a Cigna DHMO provider available in your location (not available in all geographic areas).