2024 Benefits Guide - San Francisco Deluxe + Dental

Dental & Vision Plans

Help keep your teeth white and your eyes sharp with our amazing plans!

Plan Comparison

Not Sure Which Plan to Pick?
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If you have questions about the plans, reach out to benefitshelpdesk@epicbrokers.com or 877-373-6535 (5am–5pm Monday through Friday PT) to help you navigate the health care system and make the most of your health benefits and program.

Dental Plans

You can choose between two Cigna dental plans to keep you and your family smiling bright. With the PPO you have the freedom to choose any provider, but will typically save money in-network. With the HMO Plan, you only have in-network coverage and must choose a primary care dentist to coordinate all your dental care.

The information below is a summary of coverage only.

Annual Deductible & Orthodontia

	Cigna Dental HMO (CA Only)	Cigna Dental PPO
	In-Network	In-Network	Out-of-Network

Annual Deductible

Individual	n/a	$25
Family	n/a	$75
Annual Benefit Maximum	n/a	$1,500
Preventive Care Cleanings, Oral Examinations, Fluoride Treatments, etc.	No Charge	No Charge	Plan pays 90% after deductible
Basic Care Fillings, Simple Extractions, Root Canals, etc.	See Copay Schedule	Plan pays 80% after deductible	Plan pays 80% after deductible
Major Care Crowns, Inlays, Bridges, etc.	See Copay Schedule	Plan pays 50% after deductible	Plan pays 50% after deductible

Orthodontia

Coverage	Certain Procedures Covered	Child only to age 19
Benefit	See Copay Schedule	Plan pays 50% after deductible	Plan pays 50% after deductible
Lifetime Maximum	See Copay Schedule	$1,000

Find a Cigna Provider

Go to cigna.com and click on the Find a Doctor, Dentist or Facility (blue button)
Select the button Covered by Employer or School
Enter address, city or zip into the search bar, and choose Doctor by Type or Doctor by Name
Select by type, click Dentist or Child’s Dentist or enter your current Dentist’s name to search Doctor by Name
You will then be prompted to login or search as a guest
Select Cigna Dental Care Access for the HMO plan or Total Cigna DPPO for the PPO plan.

Cost &
Benefit Frequency

VSP Vision Plan - VSP Choice Network
	In-Network	Out-of-Network

Cost

Exam	$10 Copay	Up to $45 reimbursement
Materials	$10 Copay	Materials up to $200

Benefit Frequency

Exams	Once per 12 months
Lenses	Once per 12 months
Frames	Once per 12 months
Contacts	Once per 12 months

Covered Services

VSP Vision Plan - VSP Choice Network
	In-Network	Out-of-Network

Lenses

Singles Lenses	No charge after copay	Up to $30 reimbursement
Lined Bifocals	No charge after copay	Up to $50 reimbursement
Lined Trifocals	No charge after copay	Up to $65 reimbursement
Frames	No charge after copay	Up to $70 reimbursement

Contacts (Contacts in lieu of Frames/Lenses)

Contacts - Elective

Up to $130 allowance

Up to $105 reimbursement

Employee Only	$0.39	$1.38
Employee + Spouse	$0.73	$2.78
Employee + Child(ren)	$0.81	$3.39
Employee + Family	$1.08	$4.98

Employee Only	$2.23
Employee + Spouse	$4.46
Employee + Child(ren)	$4.77
Employee + Family	$7.62

2024 Benefits Guide - San Francisco Deluxe + Dental

Dental & Vision Plans

Plan Comparison

Not Sure Which Plan to Pick? We're Here to Help!

Dental Plans

Weekly Dental Costs

Tier

Cigna Dental HMO (CA Only)

Cigna Dental PPO

Employee Only

Employee + Spouse

Employee + Child(ren)

Employee + Family

Coverage may be terminated for failure to timely pay premiums via payroll.

Annual Deductible & Orthodontia

Cigna Dental HMO (CA Only)

Cigna Dental PPO

In-Network

In-Network

Out-of-Network

Annual Deductible

Individual

Family

Annual Benefit Maximum

Preventive Care

Basic Care

Major Care

Orthodontia

Coverage

Benefit

Lifetime Maximum

Need More Information?

Find a Cigna Provider

Vison Plans

Weekly Vision Costs

Tier

VSP Vision Plan

Employee Only

Employee + Spouse

Employee + Child(ren)

Employee + Family

Coverage may be terminated for failure to timely pay premiums via payroll.

Cost & Benefit Frequency

VSP Vision Plan - VSP Choice Network

In-Network

Out-of-Network

Cost

Exam

Materials

Benefit Frequency

Exams

Lenses

Frames

Contacts

Covered Services

VSP Vision Plan - VSP Choice Network

In-Network

Out-of-Network

Lenses

Singles Lenses

Lined Bifocals

Lined Trifocals

Frames

Contacts (Contacts in lieu of Frames/Lenses)

Contacts - Elective

Need More Information?

Find a VSP Provider

Check Out the Full Benefits Guide

Not Sure Which Plan to Pick?
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Cigna Dental HMO
(CA Only)

Cost &
Benefit Frequency