Comparing The Dental Plans

 
 

Benefits Summary Plan Description

Comparing The Dental Plans

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Comparing the Dental Plans

The chart below provides an overview of covered dental services in the Leidos Dental PPO Plan and the DHMOs. For a complete list of DHMO benefits, a participant should refer to the plan's certificate of coverage. Download the Leidos Dental Plans Table for a PDF version of the table below.

  Leidos DENTAL PPO PLAN
(Administered by Aetna)
AETNA DMO
- Plan 58
CIGNA DENTAL
- Plan F1-09
CIGNA INTERNATIONAL DENTAL

Group Number

698685-50

698685-51

3174168

00666

Member Services Phone Number

800-843-9126

877-238-6200

800-244-6224

800-441-2668 or 302-797-3100 (collect)

Plan Web Site Address

Aetna

Aetna

CIGNA

CIGNA International Expatriates

Availability

Nationwide

Nationwide except for Alabama, Alaska, Arkansas, Louisiana, Maine, Mississippi, New Hampshire, North Dakota, South Carolina, South Dakota Vermont and Wyoming. Service area based on dental plan's zip code eligibility criteria.

Nationwide except for Alaska, Hawaii, Maine, North Dakota, New Mexico, South Dakota, and Wyoming. Service area based on dental plan's zip code eligibility criteria.

Available for participants on International Assignments of 6 months or more.

Choice of Dentist

Any dentist. Using a PPO dentist results in higher benefit levels.

Select a dentist from a list of participating dentists in your area.

Select a dentist from a list of participating dentists in your area.

Any Dentist - Online directory available to search for Dentists in 450+ countries.

COVERED SERVICES

NETWORK*

OUT-OF-NETWORK**

 

Annual deductible

$50 per person

No deductible

No deductible

$50 per person/$150 per family

Annual maximum benefit

$1,500 per person

No maximum

No maximum

$1,500 per person

Preventive Services***

Plan pays:

Plan pays 100% after:

Periodic oral examination

100% Not subject to deductible (2 per participant per calendar year)

100% of R&C Not subject to deductible (2 per participant per calendar year)

$0 copay

$0 copay

$0 copay (2 per participant per calendar year)

Prophylaxis/Cleanings, Adult/Child including scaling and polishing (2 per year)

100% (2 per participant per calendar year)

100% of R&C (2 per participant per calendar year)

$0 copay (1 per participant every six months)

$0 copay (2 per participant every calendar year; routine cleaning with no active periodontal disease; age frequency)

$0 copay (2 per participant per calendar year)

X-rays - Complete series

100% (1 per participant every 3 years)

100% of R&C (1 per participant every 3 years)

$0 copay (1 per participant every 3 years)

$0 copay (1 per participant every 3 years)

$0 copay (1 per participant every 3 years)

X-rays - One set of bitewings

100% (2 per participant per calendar year)

100% of R&C (2 per participant per calendar year)

$0 copay (1 per year)

$0 copay (1 per participant every 3 years)

$0 copay (2 per participant per calendar year)

Topical application of sodium or stannous fluoride

100% (ages 18 and younger; 1 per participant per calendar year)

100% of R&C (ages 18 and younger; 1 per participant per calendar year)

$0 copay

$0 copay (Limit 2 per calendar year; To age 19)

$0 copay (To age 18, 1 per participant per calendar year)

Diagnostic Services

Plan pays:

Plan pays 100% after:

Diagnostic X-rays

90%

80% of R&C

$0 copay

$0 copay

$0 copay

Single film

90%

80% of R&C

$0 copay

$0 copay

$0 copay

Fissure sealant, per tooth

90% (ages 13 and younger; once every 3 calendar years)

80% of R&C (ages 13 and younger; once every 3 calendar years)

$5 copay (under age 15)

$0 copay (ages 13 and younger)

$0 copay (ages 13 and younger, 1 per participant every 3 years)

Oral Surgery

Simple extraction

90%

80% of R&C

$0 copay (Extraction, erupted, exposed root)

$12 copay

Plan pays 80%

Surgical extraction

90%

80% of R&C

$28 copay

$21 copay

Plan pays 80%

Impactions

90%

80% of R&C

$46 soft tissue; $58 partially; $100 completely

$15 - $100 copay

Plan pays 80%

General Anesthesia (only for surgical extractions)

90%

80% of R&C

General Anesthesia (deep sedation) or Conscious IV Sedation (first 30 min.): $165 copay, $70 copay for each additional 15 minutes

When medically necessary $190 copay (first 30 minutes); $84 copay (each additional 15 minutes)

Plan pays 80% when determined to be medically necessary

Fillings

Amalgam restoration of Primary Teeth/Permanent Teeth

90%

80% of R&C

$0 copay

$0 copay

Plan pays 80%

Composite restoration

90%

80% of R&C

$0-$50 copay depending on type. Contact Plan for specifics

$0 - $115 copay

Plan pays 80%

Endodontics

Root canal therapy

90%

80% of R&C

Anterior: $70 copay. Bicuspid: $85 copay. Molar: $240 copay.

$14 - $370 copay (varies by tooth type)

Plan pays 80%

Pulpotomy

90%

80% of R&C

$14 copay

$21 copay

Plan pays 80%

Apicoectomy and retro fill

90%

80% of R&C

Anterior: $85 copay. Bicuspid (1 root): $85 copay. Molar (1st root): $90 copay. Each additional root: $55 copay

$58 - $220 copay

Plan pays 80%

Periodontics

Periodontal planning and root scaling

90%

80% of R&C

$55 copay

$80 - $165 copay

Plan pays 80%

Gingivectomy (per quadrant)

90%

80% of R&C

$100 copay (Limit 1 per quadrant every 3 years)

$105 - $220 copay per quadrant

Plan pays 80%

Restorative Services

Plan pays:

Plan pays 100% after:

Crowns - per unit

60%

50% of R&C

$180-$220 copay depending on type.

$335 - $415 copay

Plan pays 50%

Bridges - per unit

60%

50% of R&C

$210 copay per unit

$345 - $380 copay

Plan pays 50%

Stainless steel crowns

90%

80% of R&C

$50 copay

$12 copay

Plan pays 50%

Recementation

Inlay

90%

80% of R&C

$10 copay

$12 copay

Plan pays 50%

Crown

60%

50% of R&C

$10 copay

$12 copay

Plan pays 50%

Bridge

60%

50% of R&C

$15 copay

$12 copay

Plan pays 50%

Prosthetics (Dentures)

Complete upper or lower denture

60%

50% of R&C

$275 copay

$500 copay

Plan pays 50% (1 per participant every 5 years

Partial upper or lower denture

60%

50% of R&C

$275 copay

$370 copay

Plan pays 50%

Denture and Partial Adjustment

60%

50% of R&C

$10 copay

$39 copay

Plan pays 50%

Denture Reline

90%

80% of R&C

$45 copay (chairside) $85 copay (laboratory)

$14 copay (chairside)

Plan pays 50%

Denture Duplication

60%

50% of R&C

Not covered

Not covered

Not covered

Denture and Partial Repairs

90%

80% of R&C

$25 - $86 copay

$65 copay

Plan pays 80%

Adding Teeth or Clasps to Partial Denture - per unit

90%

80% of R&C

$35 - $40 copay

$65 - $85 copay

Plan pays 80%

Orthodontia

Plan pays:

Plan pays 100% after:

Full banded case

50% up to a separate $1,500 lifetime maximum per participant; annual deductible applies; includes invisible braces

50% up to a separate $1,500 lifetime maximum per participant; annual deductible applies; includes invisible braces

$1,545 copay, plus $30 orthodontic screening exam; $150 diagnostic records; $275 retention fee. Other fees may apply per Aetna's Dental Care Schedule. ****

$2,194 (child) to $2,904 (adult) copay, plus $345 retention fee; $68 pre-orthodontic treatment visit; $195 orthodontic treatment plan & records $480 (child) - $500 (adults); Other fees may apply per CIGNA's patient charge schedule.

50% after separate $50 lifetime deductible; $1500 lifetime maximum; includes invisible braces

Partial banded case

50% up to a separate $1,500 lifetime maximum per participant

50% up to a separate $1,500 lifetime maximum per participant

Not covered

Varies

50% after separate $50 lifetime deductible; $1500 lifetime maximum; includes invisible braces

Annual maximum benefit

$1,500 per person

No maximum

No maximum

No maximum

* Covered services received from a network provider will be paid based on the negotiated rate.

** Covered services received from an out-of-network provider will be paid based on the reasonable and customary (R&C) limit.

*** Preventive services are not subject to the annual deductible.

**** Participants are advised to refer to the Evidence of Coverage, contact the individual dental plan carrier and obtain a predetermination of benefits for services in excess of $150.