Dental (chart)

What You Pay For Services

XPO offers two dental plan options — Dental Basic and Dental Choice — and both are administered by Cigna. The table below outlines the features of each plan, which are the same in-network and out-of-network.

You can see any dentist you want. However, in-network dentists agree to accept negotiated fees from Cigna. Out-of-network dentists can bill you for amounts above the negotiated in-network fees.

2023	DENTAL BASIC	DENTAL CHOICE
Annual Deductible (per person)	$50	$50
Preventive (twice a year)	0% of MRC	0% of MRC
Basic (restorative)	20% of MRC after deductible	20% of MRC after deductible
Major (restorative)	50% of MRC after deductible	50% of MRC after deductible
Orthodontia (children to age 19, per person)	Not applicable	50% of MRC, no deductible, up to $1,500 lifetime benefit maximum
Annual Maximum (per person)	$1,000	$2,000

A Note About MRC: Maximum Reimbursable Charge (MRC) fees are based on the 90^th percentile of the customary allowance from a fee schedule selected by Cigna.

Dental (chart)

What You Pay For Services

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