DENTAL

Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the Victory Capital’s dental benefit plan.

To find an in-network dentist, visit Cigna Health Care Provider Directory.

Dental	In-Network	Out-of-Network
Annual Deductible (does not apply to Preventive & Diagnostic)	$25/$50	$25/$50
Annual Maximum (per person) (does not apply to Preventive & Diagnostic)	$2,500	$2,500
Preventive & Diagnostic Exams, Cleanings, Bitewing x-rays (each twice in a calendar year) Fluoride Treatment (once in a calendar year, children to age 14) Sealants	100%	100%
Remaining Basic (Fillings, Extractions, Endodontics (root canal), Periodontics, Oral Surgery, Repair of Dentures)	80%	80%
Crowns & Prosthodontics	60%	60%
Orthodontic Benefits (child & adult) (subject to a $2,500 lifetime maximum per person)	50%	50%

Cigna per-pay biweekly deductions
Employee Only	$11.26
Employee + Spouse	$20.74
Employee + Child(ren)	$26.09
Family	$41.50

RESOURCES

Dental Benefit Summary

New Hampshire Dental Summary

Dental DPPO Transition of Care Customer FAQ Flyer

Total DPPO Dentacom Customer Brochure