Ricoh - Dental Coverage

Both PPO and DMO options are available. Make sure you understand the differences so that you can choose the type that’s best for you and your family.

Cigna Dental PPO Options

Cigna will be the dental plan administrator for the dental PPO options. You’ll pay the cost of dental coverage with before-tax dollars. In an effort to provide team members with both choice and flexibility, Ricoh will offer two dental PPO options—the Dental PPO Plus and the Dental PPO preventive option—both of which are administered by Cigna. By taking advantage of discounted rates through Cigna network dentists, the dental PPO allows Ricoh and team members to more effectively manage dental costs. Under these “active” PPO dental options, receiving care from a Cigna dentist results in lower out-of-pocket costs for you due to higher coinsurance percentages paid by the insurance carrier and in-network discounted rates. Although you may still choose to receive dental care from any dentist, if you receive care from an out-of-network dentist, you will pay higher out-of-pocket costs. Like your medical coverage, choosing dental coverage is a personal decision. As you make this decision, take a look at the highlights and the different deductibles and coinsurance amounts of the dental PPO options.

	CIGNA DENTAL PPO
	In-Network (Total Cigna DPPO)	Out-of-Network
Individual deductible	You pay $50	You pay $100
Family deductible	You pay $150	You pay $300
Calendar Year Benefits Maximum*	Year 1: $1,000 Year 2: $1,125 Year 3: $1,250 Year 4: $1,375	Year 1: $1,000 Year 2: $1,125 Year 3: $1,250 Year 4: $1,375
Preventive & Diagnostic services	You pay 0%	You pay 10% after deductible
Basic Restorative	You pay 20% after deductible	You pay 30% after deductible
Major Restorative	You pay 70% after deductible	You pay 75% after deductible
Orthodontia	Not covered
Orthodontia deductible	Not applicable
Orthodontia lifetime maximum the plan will pay	Not applicable

*Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1.
*Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 & 2.
*Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 1, 2 & 3.

	CIGNA DENTAL PPO PLUS
	In-Network (Total Cigna DPPO)	Out-of-Network
Individual deductible	You pay $50	You pay $100
Family deductible	You pay $150	You pay $300
Calendar Year Benefits Maximum*	Year 1: $1,500 Year 2: $1,625 Year 3: $1,750 Year 4: $1,875	Year 1: $1,500 Year 2: $1,625 Year 3: $1,750 Year 4: $1,875
Preventive & Diagnostic services	You pay 0%	You pay 10% after deductible
Basic Restorative	You pay 20% after deductible	You pay 30% after deductible
Major Restorative	You pay 50% after deductible	You pay 60% after deductible
Orthodontia	You pay 50% after deductible	You pay 60% after deductible
Orthodontia deductible	Refer to individual/Family deductible
Orthodontia lifetime maximum the plan will pay	$1,500

Preventive & Diagnostic Services

Oral Evaluations
Prophylaxis: routine cleanings
X-rays: routine
X-rays: non-routine
Fluoride Application
Sealants: per tooth
Space Maintainers: non-orthodontic
Emergency Care to Relieve Pain

Basic Services

Restorative: fillings
Endodontics: minor and major
Periodontics: minor and major
Oral Surgery: minor and major
Anesthesia: general and IV sedation
Repairs: Bridges, Crowns and Inlays
Inlays and Onlays

Major Services

Prosthesis Over Implant
Crowns: prefabricated stainless steel / resin
Crowns: permanent cast and porcelain
Bridges and Dentures
Repairs: Dentures
Denture Relines, Rebases and Adjustments

Orthodontia

Orthodontia, up to lifetime maximum

For Children

One fluoride treatment annually; sealants

You are encouraged to submit a pre-treatment estimate if you expect to have dental work for which charges are anticipated to exceed $250.

Both dental PPO options allow you to take advantage of network discounts and get more benefit for theannual maximum by using a Cigna network dentist. You are not required to use a Cigna network dentist; however, if you do not, you will pay more in out-of-pocket expenses under either of the dental PPO options.

The Cigna network of dentists is extensive and includes over 72,000 dentists across the country. Detailed access studies indicate that over 90% of Ricoh’s team members live within 10 miles of at least two dentists in the Cigna network. To locate a Cigna dentist in your area, you can access the Cigna website at www.cigna.com. Click on “Find a Doctor” and be sure to search under "Dental: Total Cigna DPPO Network”. You can also find providers using Provider Direct on the Your Benefits Resources website.

ID Cards will not be provided to members of the Cigna dental plans. When visiting your dentist, provide them with a Cigna dental claim form, which includes Ricoh’s Cigna plan number. This Cigna claim form is available on RWorld and on http://mycigna.com.

Aetna Dental DMO Option

Aetna will be the carrier for the Dental DMO option. The Aetna Dental DMO option provides benefits for the same services that are covered under the Dental PPO options, but at a significantly lower out-of-pocket cost as long as you use a dentist that participates in the Aetna Dental DMO network.

FEATURE	IN-NETWORK	OUT-OF-NETWORK
Deductible	$0	Not Covered
Annual maximum	$0	Not Covered
Preventive services	Covered 100%	Not Covered
Basic services	Covered 100%	Not Covered
Major services	You pay 40%	Not Covered
Orthodontia	You pay 50%	Not Covered

The Aetna Dental DMO may be available to you depending on where you live. When you log in to Your Benefits Resources (YBR), you will see if the Aetna Dental DMO is available to you in your area. To locate an Aetna dentist in your area, you can access the Aetna website at https://www.aetna.com/ or call them at 1.855.496.6289.

Like a medical HMO option, if you elect coverage under the Aetna Dental DMO option you must seek dental care only from a dentist that participates in the Aetna Dental DMO network. In addition, you must elect a Primary Care Dentist (PCD) for each covered member of your family in order to access dental care. Failure to elect a PCD may result in claims being denied. Before you choose the Aetna Dental DMO option, you should check Aetna’s online dental provider directory for a list of local participating dentists.

When you enroll in the Aetna Dental DMO, you must select a primary dentist. If you do not, you will not receive an ID card and claims may be denied.

If you select a dentist when you enroll, you will receive an ID card in the mail within the first few weeks of January.

No out-of-network benefits are paid through the Aetna Dental DMO.

The summary above describes only the Aetna Dental DMO option. A few other non-Aetna dental DMOs with slightly different plan designs are available in different locations across the U.S. For information on these other DMO options, please refer to the specific information listed on the Your Benefits Resources website.

This overview serves as a summary on various Ricoh 2024 benefit plans. It is intended to provide an overview of information about some of the benefits you may be eligible for through Ricoh. If there is a discrepancy between the information displayed and the official plan documents, the official plan documents will govern.