2021 Plan Year Information
If you are a U.S. benefits-eligible expatriate or U.S. benefits-eligible international employee and your medical plan administrator is Cigna Global Health Medical, your dental benefits are provided under Cigna Global Health Dental.
| Cigna Global Health Dental Plan: In-Network and Out-of-Network |
|---|
| Note |
The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums. |
| Individual Deductible |
$50 |
| Family Annual Deductible |
$150 |
| Diagnostic and Preventive Care |
100% of R&C; deductible waived |
| Restorative Services |
80% of R&C, after annual deductible |
| Prosthodontics |
50% of R&C, after annual deductible |
| Orthodontics |
50% of R&C after separate $50 deductible, up to a $3,000 lifetime maximum per person (children to age 19) |
| Annual Benefit Maximum per Person |
$2,000 |
Out-of-network reimbursements and maximums are based on Reasonable and Customary (R&C) charges as determined by the health plan administrator.
The orthodontics lifetime benefit maximum is combined across plan options.
In no event can any one person receive more than the annual benefit maximum during a calendar year (excluding orthodontics), even if provided by an in-network or PDP dentist.
Flexible Spending Accounts (FSAs) allow you to set aside before-tax money to use for certain eligible expenses not covered by your health plans or to pay for certain dependent day care expenses. Using an FSA can save you from 20% to 40% depending on your tax bracket.
The Firm offers three types of FSAs: a Health Care FSA, a Limited Purpose FSA* and a Dependent Day Care FSA. The Health Care and Dependent Day Care FSAs are administered by UnitedHealthcare (UHC). The Limited Purpose FSA is administered by Your Savings Account.
*The Limited Purpose FSA is only available to employees enrolled in Medical Plan Option C and can only be used for eligible dental and vision expenses.
You and the Firm share the cost of your Dental Plan coverage. Your contributions are deducted from your pay on a before-tax basis.
Note: Your location and salary band are used to calculate only your medical contribution rates.
The costs shown below are per paycheck contributions. For the monthly cost, double the amounts shown.
| Yourself Only | Yourself + Spouse/Domestic Partner | Yourself + Children | Yourself + Family | |
|---|---|---|---|---|
| Delta Dental | $13.67 | $27.38 | $27.38 | $41.04 |
| MetLife Dental Plan — Option A | $13.67 | $27.38 | $27.38 | $41.04 |
| MetLife Dental Plan — Option B | $7.75 | $15.50 | $15.50 | $23.50 |
If you are covering a domestic partner or the children of a domestic partner, the IRS determines the tax status of a dependent and may impose a tax on the value of coverage.
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Group Number: 00519A
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