Dental PPO

Summary of Benefits

BENEFITSa	IN-NETWORKb		OUT-OF-NETWORKb
Plan Year Maximum - 1 July 2008-30 June 2009 (Class I, II and III expenses)	$2,250		$2,250
Plan Year Deductible - 1 July 2008-30 June 2009	None		$50 per person $150 per family
Reimbursement Levels	Based on reduced contracted fees		Based on reasonable and customary allowance
	Plan Pays	You Pay	Plan Pays	You Pay
Class I - Preventive & Diagnostic Care Oral Exams (two per year) Cleanings (two per year) Full Mouth X-Rays (one complete set every three years) Bitewing X-Rays (two per year) Panoramic X-Ray (one every three years) Fluoride Application (one per year for persons under 19) Sealants (Limited to posterior tooth for a person less than 14. One treatment per tooth every three years) Space Maintainers (Limited to non-orthodontic treatment) Emergency Care to relieve pain	100%	No Charge	90%	10%
Class II - Basic Restorative Carec Fillings Root Canal therapy Osseous Surgery Periodontal Scaling and Root Planing Denture Adjustments and Repairs Extractions Oral Surgery	100%	No Charge	80%d	20%d
Class III - Major Restorative Carec Crowns Dentures Bridges	100%	No Charge	80%d	20%d
Class IV - Orthodontia Lifetime Maximum (in addition to the Class I, II and III maximum)	100% $2250 Dependent children up to age 19d	No Charge	100% of in-network contracted fee $2250 Dependent children up to age 19d	30%d

a Pre-treatment review (pre-determination of benefits) is strongly recommended when dental work in excess of $300 is proposed. The dentist deals directly with CIGNA in this regard.
b The $2,250 maximum is for the plan year, whether the provider is in-network or out-of-network, or a combination of the two.
c Some dental procedures involving costly materials may require additional payment by the participant to the provider.
d The orthodontia benefit ends on the dependent child's 19th birthday.