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
Anti-Reflective Standard Progressive Standard Premium High Index Polarized Plastic Photosensitive Intermediate Up to $45 copay Up to $65 copay 20% discount 20% discount 20% discount 20% discount 20% discount Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Frames $130 credit/allowance + 20% discount (20% savings on amount that exceeds frame allowance) Up to $30 allowance Contact Lenses Medically Necessary Elective $20 exam copay, then 100% $20 exam copay, $150 credit/allowance includes fitting and evaluation Up to $225 allowance Up to $75 allowance Other Services LASIK Vision Services Up to 15% discount or 5% off promotional 20% savings Not Covered POST-65 RETIREE MEDICAL BENEFITS – CIGNA Benefit Description Medicare Surround & Part D Prescription Drug Plan Medicare Advantage Plan Annual Plan Deductible Same as Medicare Part B $0 Annual Out-of-Pocket Maximum $0 $1,500 Medicare Part A/B Expenses Retiree Pays Retiree Pays Outpatient Physician Services No referrals or authorizations required to see a specialist Referral from the PCP is required to see a specialist* Primary Care Physician Office Visit 0% $5 Specialty Care Physician Office Visit 0% $10 copay
PRE-65 RETIREE CONTRIBUTIONS Pre-65 Retiree Medical Plan Monthly Premiums OAP IN-NETWORK PLUS Option Retiree Retiree + 1 Family $299.56 $599.11 $835.76 OAP BASIC Option Retiree Retiree + 1 Family $271.87 $543.73 $758.49 CHOICE FUND HRA Option Retiree Retiree + 1 Family $246.27 $492.52 $687.07 Dental Plan Monthly Premiums DPPO ($1,500) Option Retiree Retiree + 1 Family $25.79 $54.17 $77.38 Vision Plan Monthly Premiums Retiree Retiree + 1 Family $5.10 $9.77 $15.84 POST-65 RETIREE CONTRIBUTIONS Medicare Surround & Part D Prescription Drug Plan - Monthly Premiums Classified or Less than 15 Years of Service 15-19 Years of Service ($25 credit) 20 – 29 Years of Service ($37.50 credit) 30 Plus of Service ($50 credit) Retiree with Medicare $195.48 $170.48 $157.98 $145.48