AIRES Group Benefits July 1, 2021 - aires-llc
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AIRES Group Benefits
July 1, 2021
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2021 - 06/30/2022
AIRES, LLC: Open Access Plus Coverage for: Individual/Individual + Family | Plan Type: OAP
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is
only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general
definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You
can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-866-494-2111 to request a copy.
Important Questions Answers Why This Matters:
Generally, you must pay all of the costs from providers up to the
For in-network providers: $3,000/individual or
deductible amount before this plan begins to pay. If you have other family
What is the overall $6,000/family
members on the plan, each family member must meet their own individual
deductible? For out-of-network providers: $6,000/individual or
deductible until the total amount of deductible expenses paid by all family
$12,000/family
members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the
deductible amount. But a copayment or coinsurance may apply. For
Are there services covered Yes. In-network preventive care, office visits, diagnostic
example, this plan covers certain preventive services without cost-sharing
before you meet your test, prescription drugs, emergency room visits, in-
and before you meet your deductible. See a list of covered preventive
deductible? network urgent care facility visits.
services at https://www.healthcare.gov/coverage/preventive-care-
benefits/.
Are there other deductibles
No. You don't have to meet deductibles for specific services.
for specific services?
For in-network providers: $6,250/individual or
$12,500/family The out-of-pocket limit is the most you could pay in a year for covered
What is the out-of-pocket For out-of-network providers: $12,500/individual or services. If you have other family members in this plan, they have to meet
limit for this plan? $25,000/family their own out-of-pocket limits until the overall family out-of-pocket limit has
Combined medical/behavioral and pharmacy out-of- been met.
pocket limit
Penalties for failure to obtain pre-authorization for
What is not included in the Even though you pay these expenses, they don't count toward the out-of-
services, premiums, balance-billing charges, and health
out-of-pocket limit? pocket limit.
care this plan doesn’t cover.
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Important Questions Answers Why This Matters:
This plan uses a provider network. You will pay less if you use a provider
in the plan’s network. You will pay the most if you use an out-of-network
provider, and you might receive a bill from a provider for the difference
Will you pay less if you use a Yes. See www.cigna.com or call 1-866-494-2111 for a
between the provider’s charge and what your plan pays (balance billing).
network provider? list of network providers.
Be aware your network provider might use an out-of-network provider for
some services (such as lab work). Check with your provider before you
get services.
Do you need a referral to see
No. You can see the specialist you choose without a referral.
a specialist?
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an $30 copay/visit
50% coinsurance None
injury or illness Deductible does not apply
$60 copay/visit
Specialist visit 50% coinsurance None
Deductible does not apply
If you visit a health care No charge/visit** Not covered/visit You may have to pay for services that
provider's office or clinic No charge/other services** Not covered/other services aren’t preventive. Ask your provider if
Preventive care/ No charge/immunizations** Not covered/immunizations the services needed are preventive.
screening/immunization Then check what your plan will pay
for.
**Deductible does not apply
Diagnostic test (x-ray, blood No charge
50% coinsurance None
work) Deductible does not apply
If you have a test 30% coinsurance at an 50% coinsurance at an
Imaging (CT/PET scans, $750 penalty for no out-of-network
outpatient facility outpatient facility
MRIs) precertification.
30% coinsurance in the office 50% coinsurance in the office
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What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
$10 copay/prescription (retail Coverage is limited up to a 90-day
30 days), $25 supply (retail and home delivery); up
Generic drugs (Tier 1) copay/prescription (retail & Not covered to a 30-day supply (retail and home
home delivery 90 days) delivery) for Specialty drugs.
If you need drugs to treat Deductible does not apply Certain limitations may apply,
your illness or condition $35 copay/prescription (retail including, for example: prior
30 days), $88 authorization, step therapy, quantity
Preferred brand drugs (Tier
More information about copay/prescription (retail & Not covered limits.
2)
prescription drug coverage home delivery 90 days) For drugs in the Cigna Patient
is available at Deductible does not apply Assurance Program you may pay less
www.cigna.com $70 copay/prescription (retail than the noted retail or home delivery
30 days), $175 cost share amounts.
Non-preferred brand drugs In-network Federally required
copay/prescription (retail & Not covered
(Tier 3) preventive drugs will be provided at
home delivery 90 days)
Deductible does not apply no charge.
Facility fee (e.g., $750 penalty for no out-of-network
30% coinsurance 50% coinsurance
If you have outpatient ambulatory surgery center) precertification.
surgery $750 penalty for no out-of-network
Physician/surgeon fees 30% coinsurance 50% coinsurance
precertification.
$300 copay/visit $300 copay/visit
Emergency room care Per visit copay is waived if admitted
Deductible does not apply Deductible does not apply
If you need immediate Emergency medical
30% coinsurance 30% coinsurance None
medical attention transportation
$50 copay/visit
Urgent care 50% coinsurance None
Deductible does not apply
Facility fee (e.g., hospital $750 penalty for no out-of-network
30% coinsurance 50% coinsurance
room) precertification.
If you have a hospital stay
$750 penalty for no out-of-network
Physician/surgeon fees 30% coinsurance 50% coinsurance
precertification.
3 of 8
What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
$60 copay/office visit**
50% coinsurance/office visit $750 penalty if no precert of out-of-
30% coinsurance/all other
If you need mental health, Outpatient services 50% coinsurance/all other network non-routine services (i.e.,
services
behavioral health, or services partial hospitalization, etc.).
**Deductible does not apply
substance abuse services
$750 penalty for no out-of-network
Inpatient services 30% coinsurance 50% coinsurance
precertification.
Office visits 30% coinsurance 50% coinsurance Primary Care or Specialist benefit
Childbirth/delivery levels apply for initial visit to confirm
30% coinsurance 50% coinsurance pregnancy. Cost sharing does not
professional services
apply for preventive services.
Depending on the type of services, a
If you are pregnant
copayment, coinsurance or deductible
Childbirth/delivery facility may apply. Maternity care may
30% coinsurance 50% coinsurance
services include tests and services described
elsewhere in the SBC (i.e.
ultrasound).
4 of 8
What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
$750 penalty for no out-of-network
precertification. Coverage is limited to
Home health care 30% coinsurance 50% coinsurance 60 visits annual max. (The limit is not
applicable to mental health and
substance use disorder conditions.)
$750 penalty for failure to precertify
out-of-network speech therapy.
Coverage is limited to an annual max
$60 copay/visit for Physical,
50% coinsurance/visit for of 40 visits for Physical therapy and
Speech, Hearing &
Physical, Speech, Hearing & 20 visits for Speech, Hearing &
Occupational therapy**
Occupational therapy Occupational therapy and 20 visits
Rehabilitation services
annual max for Chiropractic care
$60 copay/visit for Chiropractic
50% coinsurance/visit for services.
care**
Chiropractic care
**Deductible does not apply
Limits are not applicable to mental
If you need help health conditions for Physical, Speech
recovering or have other and Occupational therapies.
special health needs
Services are covered when Medically
$60 copay/visit for Physical, Necessary to treat a mental health
50% coinsurance/visit for
Speech, Hearing & condition (e.g. autism).
Physical, Speech, Hearing &
Occupational therapy**
Occupational therapy
Habilitation services
$60 copay/visit for Chiropractic
50% coinsurance/visit for
care** Limits are not applicable to mental
Chiropractic care
**Deductible does not apply health conditions for Physical, Speech
and Occupational therapies.
$750 penalty for no out-of-network
precertification.
Skilled nursing care 30% coinsurance 50% coinsurance
Coverage is limited to 60 days annual
max.
$750 penalty for no out-of-network
Durable medical equipment No charge 50% coinsurance
precertification.
5 of 8
What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
$750 penalty for no out-of-network
Hospice services 30% coinsurance 50% coinsurance
precertification.
Children's eye exam Not covered Not covered None
If your child needs dental
Children's glasses Not covered Not covered None
or eye care
Children's dental check-up Not covered Not covered None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture Hearing aids
Routine eye care (Adult)
Bariatric surgery Infertility treatment
Routine eye care (Children)
Cosmetic surgery Long-term care
Routine foot care
Dental care (Adult) Non-emergency care when traveling outside of the U.S.
Weight loss programs
Dental care (Children) Private-duty nursing
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Chiropractic care (20 visits)
6 of 8
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee
Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you, too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-
2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information
about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a
claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-866-
494-2111. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-494-2111.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-494-2111.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-866-494-2111.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-494-2111.
----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section.-----------
7 of 8
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe's type 2 Diabetes Mia's Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
■ The plan's overall deductible $3,000 ■ The plan's overall deductible $3,000 ■ The plan's overall deductible $3,000
■ Specialist copayment $60 ■ Specialist copayment $60 ■ Specialist copayment $60
■ Hospital (facility) coinsurance 30% ■ Hospital (facility) coinsurance 30% ■ Hospital (facility) coinsurance 30%
■ Other coinsurance 30% ■ Other coinsurance 30% ■ Other coinsurance 30%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $3,000 Deductibles $0 Deductibles $980
Copayments $40 Copayments $800 Copayments $600
Coinsurance $2,400 Coinsurance $0 Coinsurance $0
What isn't covered What isn't covered What isn't covered
Limits or exclusions $20 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $5,460 The total Joe would pay is $820 The total Mia would pay is $1,580
The plan would be responsible for the other costs of these EXAMPLE covered services.
Plan Name: OAP Ben Ver: 21 Plan ID: 12469844
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DISCRIMINATION IS AGAINST THE LAW
Medical coverage
Cigna complies with applicable Federal civil rights laws and a grievance by sending an email to ACAGrievance@Cigna.com or by
does not discriminate on the basis of race, color, national writing to the following address:
origin, age, disability, or sex. Cigna does not exclude people Cigna
or treat them differently because of race, color, national Nondiscrimination Complaint Coordinator
origin, age, disability, or sex.
PO Box 188016
Cigna: Chattanooga, TN 37422
• Provides free aids and services to people with If you need assistance filing a written grievance, please call
disabilities to communicate effectively with us, such as: the number on the back of your ID card or send an email to
– Qualified sign language interpreters ACAGrievance@Cigna.com. You can also file a civil rights
– Written information in other formats (large print, complaint with the U.S. Department of Health and Human
audio, accessible electronic formats, other formats) Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at
• Provides free language services to people whose
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
primary language is not English, such as:
– Qualified interpreters U.S. Department of Health and Human Services
– Information written in other languages 200 Independence Avenue, SW
Room 509F, HHH Building
If you need these services, contact customer service at
Washington, DC 20201
the toll-free number shown on your ID card, and ask a
1.800.368.1019, 800.537.7697 (TDD)
Customer Service Associate for assistance.
Complaint forms are available at
If you believe that Cigna has failed to provide these services http://www.hhs.gov/ocr/office/file/index.html.
or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life
Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service
company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna
Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For
current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma
que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el
reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
896375a 05/17 © 2017 Cigna.Proficiency of Language Assistance Services
English – ATTENTION: Language assistance services, free of French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis
charge, are available to you. For current Cigna customers, pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele
call the number on the back of your ID card. Otherwise, call nimewo 1.800.244.6224 (TTY: Rele 711).
1.800.244.6224 (TTY: Dial 711).
French – ATTENTION: Des services d’aide linguistique vous sont
Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, proposés gratuitement. Si vous êtes un client actuel de Cigna,
sin cargo, a su disposición. Si es un cliente actual de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité.
llame al número que figura en el reverso de su tarjeta de Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le
identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios numéro 711).
de TTY deben llamar al 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência
Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o
的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 número que se encontra no verso do seu cartão de identificação. Caso
1.800.244.6224 （聽障專線：請撥 711）。 contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).
Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy
ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany
lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o
1.800.244.6224 (TTY: Quay số 711). skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).
Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利
무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電
카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）
1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오. まで、お電話にてご連絡ください。
Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica
tulong sa wika nang libre. Para sa mga kasalukuyang customer gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della
ng Cigna, tawagan ang numero sa likuran ng iyong ID card. tessera di identificazione. In caso contrario, chiamare il numero
O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). 1.800.244.6224 (utenti TTY: chiamare il numero 711).
Russian – ВНИМАНИЕ: вам могут предоставить бесплатные German – ACHTUNG: Die Leistungen der Sprachunterstützung
услуги перевода. Если вы уже участвуете в плане Cigna, stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger
позвоните по номеру, указанному на обратной стороне Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer
вашей идентификационной карточки участника плана. Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an
Если вы не являетесь участником одного из наших (TTY: Wählen Sie 711).
планов, позвоните по номеру 1.800.244.6224 (TTY: 711). برای. به صورت رایگان به شما ارائه میشود٬ خدمات کمک زبانی: – توجهPersian (Farsi)
در غیر. لطفا ً با شمارهای که در پشت کارت شناسایی شماست تماس بگیرید٬Cigna مشتریان فعلی
Cigna لعمالء. – برجاء االنتباه خدمات الترجمة المجانية متاحة لكمArabic
را711 شماره: تماس بگیرید (شماره تلفن ویژه ناشنوایان1.800.244.6224 اینصورت با شماره
او اتصل ب.الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية .)شمارهگیری کنید
.)711 اتصل ب:TTY( 1.800.244.6224
896375a 05/17AIRES, LLC - DPPO
Effective Date: July 01, 2021
This is a summary of benefits for your dental plan.
All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network.
Your DPPO plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-of-pocket expenses.
Plan Design Total Cigna DPPO Out-of-Network
Calendar Year Maximum
(Class I, II, III Expenses) $1500, Class I Applies $1000, Class I Applies
Calendar Year Deductible
Per Individual $50 $50
Per Family $150 $150
Class I Expenses - Preventive & Diagnostic Care
Oral Exams 100%, No Deductible 100%, No Deductible
Cleanings
Routine X-rays
Fluoride Application
Sealants
Space Maintainers (limited to non-orthodontic treatment)
Non-Routine X-rays
Class II Expenses - Basic Restorative Care
Emergency Care to Relieve Pain 80%, After Deductible 80%, After Deductible
Fillings
Oral Surgery - Simple Extractions
Oral Surgery - All Except Simple Extraction
Surgical Extraction of Impacted Teeth
Class III Expenses - Major Restorative Care
Anesthetics 50%, After Deductible 50%, After Deductible
Minor Periodontics
Major Periodontics
Root Canal Therapy / Endodontics
Relines, Rebases, and Adjustments
Repairs - Bridges, Crowns, and Inlays
Repairs - Dentures
Crowns/Inlays/Onlays
Stainless Steel/Resin Crowns
Dentures
Bridges
Brush Biopsy
Class IV Expenses - Orthodontia
Coverage for Eligible Children Only 50%, No Ortho Deductible 50%, No Ortho Deductible
Lifetime Maximum $1000 $1000
Dental Plan Reimbursement Levels Based on Contracted Fees 90th Percentile of Allowed Charges***
Yes, the difference between the
Additional Member Responsibility in
None member's dentist's billed charges and
excess of Coinsurance the dental plan reimbursement level***
Student/Dependent Age 26/26
P0010 Network. Prepared by Underwriting. 05/12/2021 01:08 PMAIRES, LLC - DPPO
Effective Date: July 01, 2021
Cigna Dental PPO / Indemnity Exclusions and Limitations:
Procedure Exclusions & Limitations
Exams 1 per 6-month consecutive period
Prophylaxis (cleanings) 1 routine prophy or perio maintenance procedure per 6-month consecutive period
Fluoride Treatments 1 per consecutive 12 months for participants younger than age 14
X-Rays (routine) Bitewings: 1 set in any consecutive 12 month period. Limited to a maximum of 4 films per set.
X-Rays (non-routine) Full mouth or Panorex: 1 per 60 consecutive months
Periapical X-rays: 4 in 12 consecutive months if not performed in conjunction with an operative procedure
Intraoral Occlusal X-rays: 2 in 12 consecutive months
Models Not covered
Space Maintainers No frequency limit for participants under age 14.
Fillings 1 per tooth per 12 consecutive months (applies to replacement of identical surface fillings only). No white-colored fillings on bicuspid
or molar teeth.
Sealants 1 treatment per tooth per lifetime up to age 14. Payable on unrestored permanent bicuspid or molar teeth only
Minor Perio (non-surgical) Root planing-1 per quadrant per 36 consecutive months
Perio Surgery 1 per 36 consecutive months per area of the mouth (same service)
Crowns and Inlays Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for non-precious metals. No porcelain
or white/tooth-colored material on molar crowns or bridges. Replacement must be indicated by major decay. For participants younger
than age 16, benefits are limited to resin or stainless steel.
Stainless Steel & Resin Crowns 1 per 36 consecutive months for participants younger than age 16, primary teeth will be treated with Stainless Steel Crowns.
Prosthesis over Implants 1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals.
No porcelain or white/tooth colored material on molar crowns or bridges.
Bridges Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired. Benefits are based on the amount
payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.
Dentures and Partials Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired.
Relines, Rebases Covered if more than 12 months after installation; 1 per 36 consecutive months
Adjustments Covered if more than 12 months after installation; 1 per 12 consecutive months
Repairs - Bridges Covered if more than 12 months after installation
Repairs - Dentures Covered if more than 12 months after installation
Endodontics Root canal re-treatment 1 per 24 consecutive months, if necessity demonstrated
Alternate Benefits When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine
the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.
Orthodontia For dependent children, up to age 19
Missing Tooth Provision The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense
Late Entrant Limit No coverage except for Class I (as defined in these plans) for 12 months
Pre-Treatment Review Available on a voluntary basis when extensive work in excess of $500 is proposed
Benefit Exclusions:
* Services performed primarily for cosmetic reasons; Replacement of a lost or stolen appliance;
* Initial placement of a full or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered
under this plan; removal of only a permanent third molar will not quality for an initial or replacement denture or bridge
* Overdentures, personalization, precision or semi-precision attachments;
* Replacement of a bridge, denture or crown within 84 months following its initial date of insertion;
* Replacement of a bridge, denture or crown which can be made useable according to dental standards
* Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ
stabilize periodontally involved teeth, or restore occlusion, the restoration of teeth which have been damaged by erosion, attrition or abrasion; bite registration
or bite analysis;
* Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars
* Core buildup, labial veneers; Precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless
steel or resin for participants under 16 years old;
* Bite registrations; precision or semi-precision attachments; splinting; Surgical implant of any type
* Instruction for plaque control, oral hygiene and diet;
* Dental services that do not meet common dental standards; Services that are deemed to be medical services;
* Services and supplies received from a hospital;
* Procedures for which a charge would not have been made in the absence of coverage, for which the person is not legally required to pay;
* Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military
service;
* Experimental or investigational procedures and treatments; Procedures which are not necessary and which do not have uniform professional
endorsement;
* Any injury resulting from, or in the course of, any employment for wage or profit; Any sickness covered under any workers' compensation or similar law
* Charges in excess of reasonable and customary allowances;
* IV sedation or general anesthesia, except when medically or dentally necessary and when in conjunction with covered complex oral surgery
* Fees charged for broken appointments, claim form submission or sterilization;
* Services not included in the list of covered dental expenses, unless Cigna HealthCare agrees to accept such expense as a covered dental expense
in which case payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result;
* Crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite
resin filling due to major decay or fracture; Replacement of teeth beyond the normal complement of 32
* Prescription drugs; Athletic mouth guards; Myofunctional therapy
* Charges for travel time; transportation costs; or professional advice given on the phone;
* Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents,
children, grandparents, and the spouse’s siblings and parents)
* Any procedure, service, or supply which may not reasonably be expected to successfully correct the covered person’s dental condition for a period
of at least three years, as determined by Cigna HealthCare; Temporary, transitional or interim dental services; Diagnostic casts, diagnostic models, or study models
* Any charge for any treatment performed outside of the United States other than for Emergency Treatment (any benefits for Emergency Treatment
which is performed outside of the United States will be limited to a maximum of ($100.00-$200.00) per 12 consecutive month period)
* Procedures that are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on
an insured basis;
* Any charges, including ancillary charges, made by hospital, ambulatory surgical center or similar facility
* To the extent that payment is unlawful where the person resides when the expenses are incurred;
* For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery
* To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, othe
than Medicaid;
* To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with
a "no-fault" insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustmen
option chosen under such part by you or any one of your Dependents.
* Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared
** In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network.
***Charges are based upon an independent third party organization that is the industry standard. Percentile data is based upon the third party organization's aggregated industry-wide claims data
Did you know that most of Cigna's dental plans include the Cigna Dental Oral Health Integration Program? This program was designed to address research that supports the association
of oral health to overall health and provides reimbursement of copays or coinsurance for customers with qualifying medical conditions for program eligible procedures. Additionally,
registered program members can access articles on behavioral conditions that impact oral health.
Cigna is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries.
All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance
Company, Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries.
Prepared by Underwriting.
Cigna DPPO Network (P0010) 05/12/2021 01:08 PM
Oppty #: OP-5090054 5/12/2021 3:09 PMDISCRIMINATION IS AGAINST THE LAW
Dental coverage
Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.
Cigna:
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats,
other formats)
• Provides free language services to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact customer service at the toll-free number shown on your ID card, and
ask a Customer Service Associate for assistance.
If you believe that Cigna has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email
to ACAGrievance@Cigna.com or by writing to the following address:
Cigna
Nondiscrimination Complaint Coordinator
PO Box 188016
Chattanooga, TN 37422
If you need assistance filing a written grievance, please call the number on the back of your ID card
or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1.800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna
Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company,
Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of
Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are
owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language
assistance services, free of charge are available to you. For current Cigna customers, call the number on the
back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que
no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna,
llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224
(los usuarios de TTY deben llamar al 711).
911105 10/17 © 2017 Cigna.Proficiency of Language Assistance Services
English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna
customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).
Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente
actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame
al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).
Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其
他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。
Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của
Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).
Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna
가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224
(TTY: 다이얼 711)번으로 전화해주십시오.
Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga
kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa
1.800.244.6224 (TTY: I-dial ang 711).
Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже
участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей
идентификационной карточки участника плана. Если вы не являетесь участником одного из наших
планов, позвоните по номеру 1.800.244.6224 (TTY: 711).
. الحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصيةCigna لعمالء. – برجاء االنتباه خدمات الترجمة المجانية متاحة لكمArabic
.)711 اتصل ب:TTY( 1.800.244.6224 او اتصل ب
French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele
nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).
French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un
client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez
appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).
Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para
clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso
contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).
Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy
Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby
prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).
Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaの
お客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）
まで、お電話にてご連絡ください。
Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali,
chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero
1.800.244.6224 (utenti TTY: chiamare il numero 711).
German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung.
Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer
Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).
لطفا ً با شمارهای که در٬Cigna برای مشتریان فعلی. به صورت رایگان به شما ارائه میشود٬ خدمات کمک زبانی: – توجهPersian (Farsi)
را711 شماره: تماس بگیرید (شماره تلفن ویژه ناشنوایان1.800.244.6224 در غیر اینصورت با شماره.پشت کارت شناسایی شماست تماس بگیرید
.)شمارهگیری کنید
911105 10/17K1-09
DENTAL INSURANCE THAT FITS
1
Cigna Dental Care Plan
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY
ONLY. THE EVIDENCE OF COVERAGE AND HEALTH SERVICES AGREEMENT SHOULD BE CONSULTED FOR A
DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
Regular dental care is important for a healthy smile. And a healthy body. With the Cigna Dental Care® plan, you get
comprehensive dental coverage that’s easy to use. At a wallet-friendly price. Now that’s something to smile about.
This overview shows you a sampling of covered services. And what your plan pays. For a full listing of covered
services, please call Customer Service at 800.Cigna24 (800.244.6224).
Get the most value from your plan
With your Cigna Dental Care plan, some preventive services are covered at 100%. (See chart below.) Your plan also
covers many other dental services that help your mouth stay healthy.
Your Cigna Dental Care plan is a copayment plan. Here’s how it works. When you get a dental service, Cigna allows
your network dentist to charge a certain amount. Then you pay a fixed portion of that cost, in addition to any
allowable charge for upgraded materials (such as gold, high noble metal or porcelain used in molar restorations),
CAD/CAM services, complex rehabilitation or characterizations (for dentures). And your plan pays the rest. There
are no annual maximums and no deductibles!
Review your plan materials for more information about how your plan works. If you have questions before enrollment,
call 800.Cigna24 (800.244.6224) and select the “Enrollment Information” prompt.
2
WHAT YOU'LL PAY
Sampling of covered procedures With Cigna Dental Care Without dental coverage
Adult cleaning (two per calendar year – each at $0) (additional cleanings available at $45.00 each) $0 $68–$155 each
Child cleaning (two per calendar year – each at $0) (additional cleanings available at $30.00 each) $0 $53–$121 each
Periodic oral evaluation $0 $40–$90
Comprehensive oral evaluation $0 $63–$143
Topical fluoride (two per calendar year – each at $0) (additional topic fluoride available at $15.00 each) $0 $28–$63 each
X-rays – (bitewings) 2 films $0 $33–$75
X-rays – panoramic film $0 $83–$189
Sealant – per tooth $12.00 $41–$94
Amalgam filling (silver colored) – 2 surfaces $0 $117–$266
Composite filling (tooth – colored) – 1 surface, Anterior $0 $118–$270
Molar root canal (excluding final restoration) $335.00 $840–$1,914
Comprehensive orthodontic treatment of the adolescent dentition – Banding $515.00 $967–$2,203
Periodontal (gum) scaling & root planning – 1 quadrant $83.00 $182–$414
Periodontal (gum) maintenance $53.00 $107–$243
Removal/extraction of erupted tooth $12.00 $124–$282
Removal/extraction of impacted tooth – completely bony $115.00 $362–$825
Crown – porcelain fused to high noble metal* $450.00 $839–$1,911
Implant supported retainer for porcelain fused to metal fixed partial denture* $750.00 $1,079–$2,458
Occlusal appliance, by report (for treatment of TMJ) $330.00 $730–$1,662
*The co-payments for fixed and removable restorations (crowns, bridges, implant/abutment supported prosthetics, complete and partial dentures) do not include additional charges for material
upgrades (such as gold/high noble metal or porcelain used in molar restorations), CAD/CAM services, complex rehabilitation or characterizations (for dentures). Any additional allowable charge
for these upgrades is the patient’s responsibility as specifically outlined in your Patient Charge Schedule (PCS). For questions regarding these charges you may contact Customer Service at
800.Cigna24 (800.244.6224). Please refer to your PCS for full details.
Offered by: Cigna Health and Life Insurance Company or its affiliates.
DFO.Copay.Template.1 856785d 8/19Smile. You’re covered.
You can save money on a wide range of services, including: Choosing a Dentist
› Preventive care – cleanings, fluoride, sealants, bitewing X-rays, full mouth › You must choose a network general
X-rays and more dentist to manage your overall care.
› Basic care – tooth-colored fillings (called resin or composite) and You won't be covered if you go to
4
silver-colored fillings (called amalgam) a dentist who's not in our network.
› Major services – crowns, bridges, dentures (including those placed over › Each family member can choose
implants), root canals, oral surgery, extractions, treatment for periodontal their own dentist
(gum) disease, and more
› Referrals are required for specialty
› Orthodontic care – braces for children and adults care services, except for pediatric
› General anesthesia – when medically necessary dentists for children under 13 and
orthodontics.*
› Teeth whitening – using take-home bleaching trays and gel
› Temporomandibular joint (TMJ) – diagnosis and treatment, including Finding a network dentist is
cone beam x-ray and appliance easy.
Visit Cigna.com to find a network
› Athletic mouth guard – including creation and adjustments
general dentist.
More about your coverage Call 800.Cigna24 (800.244.6224) to
› No deductibles or waiting periods. You don’t have to reach an speak with a customer service
out-of-pocket cost before your insurance starts. representative. You can ask for a
› No dollar maximums. Your coverage isn't limited by a dollar amount. customized dental directory to be sent
to you via email
› Network dentists file claims for you. No paperwork for you.
› No age limit on sealants. Helps prevent tooth decay.
* Coverage for treatment by a pediatric dentist ends on your child’s
› Cancer detection. Your plan covers procedures such as biopsy and light 13th birthday. Effective on your child’s 13th birthday, dental
detection to help find oral cancer in its early stages. services generally must be obtained from a network general
› 24/7 access to dental information line. Trained professionals can help dentist.
answer your questions about dental treatment and clinical symptoms.
› 3
Cigna Identity Theft Program. Help resolving critical identity theft issues.
› Cigna Dental Oral Health Integration Program®. Enhanced dental coverage
for customers with certain medical conditions who enroll in this program.
Limitations
PROCEDURE LIMIT
Oral evaluations Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month
period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal
evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145)
X-rays (non-routine) Full mouth: 1 every 3 calendar years Panorex: 1 every 3 calendar years
Periodontal root planing and scaling Limit 4 quadrants per consecutive 12 months
Periodontal maintenance Limited to 4 per year and (Only covered after active periodontal therapy)
Crowns and inlays Replacement 1 every 5 years
Bridges Replacement 1 every 5 years
Dentures and partials Replacement 1 every 5 years
Orthodontic treatment Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24
months require an additional payment by the patient
Relines, rebases One every 36 months
Denture adjustments Four within the first 6 months after installation
Prosthesis over implant Replacement 1 every 5 years if unserviceable and cannot be repaired
TMJ treatment One occlusal orthotic device per 24 monthsLimitations
PROCEDURE LIMIT
Athletic mouth guard One athletic mouth guard per 12 months
General anesthesia/IV sedation General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures
listed on the PCS. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary
for covered procedures listed on the PCS. Plan limitation for this benefit is 1 hour per appointment.
Listed below are the services or expenses which are NOT covered under your Dental plan.
You will be responsible for these services at the dentist’s usual fees. There’s no coverage for:
› Services for or in connection with an injury arising › General anesthesia, sedation and nitrous oxide, unless
out of, or in the course of, any employment for specifically listed on your PCS
wage or profit › General anesthesia or IV sedation when used for the
› Charges which would not have been made in any purpose of anxiety control or patient management
facility, other than a hospital or a correctional › Prescription medications
institution owned or operated by the United States
government or by a state or municipal government › Procedures, appliances or restorations if the main
if the person had no insurance purpose is to: a. change vertical dimension (degree
of separation of the jaw when teeth are in contact);
› Services received to the extent that payment is b. restore teeth which have been damaged by
unlawful where the person resides when the attrition, abrasion, erosion and/or abfraction
expenses are incurred or the services are received
› Replacement of fixed and/or removable appliances
› Services for the charges which the person is not (including fixed and removable orthodontic
legally required to pay appliances) that have been lost, stolen, or damaged
› Charges which would not have been made if the due to patient abuse, misuse or neglect
person had no insurance › Any services related to surgical implants, including
› Services received due to injuries which are placement, repair, maintenance, removal, and implant
intentionally self-inflicted abutment(s) unless specifically listed on your PCS
› Services not listed on the PCS › Services considered unnecessary or experimental in
› Services provided by a non-network dentist without nature or do not meet commonly accepted dental
Cigna Dental’s prior approval (except emergencies, standards
as described in your plan documents)
4
› Procedures or appliances for minor tooth guidance
› Services related to an injury or illness paid under or to control harmful habits
workers’ compensation, occupational disease or › Services and supplies received from a hospital
similar laws › Services to the extent you or your enrolled dependent
› Services provided or paid by or through a federal are compensated under any group medical plan,
or state governmental agency or authority, political no-fault auto insurance policy, or uninsured motorist
6
subdivision or a public program, other than policy.
Medicaid › The completion of crowns, bridges, dentures, or root
› Services required while serving in the armed forces canal treatment already in progress on the effective
7
of any country or international authority or relating date of your Cigna Dental coverage
5
to a declared or undeclared war or acts of war › The completion of implant supported prosthesis
› Services performed primarily for cosmetic reasons (including crowns, bridges and dentures) already in
unless specifically listed on your PCS progress on the effective date of your Cigna Dental
7
› Consultations and/or evaluations associated with coverage, unless specifically listed on your PCS
services that are not covered › Infection control and/or sterilization
› Endodontic treatment and/or periodontal (gum › The recementation of any inlay, onlay, crown, post
tissue and supporting bone) surgery of teeth and core or fixed bridge within 180 days of initial
exhibiting a poor or hopeless periodontal prognosis placement
› Bone grafting and/or guided tissue regeneration › The recementation of any implant supported
when performed at the site of a tooth extraction prosthesis (including crowns, bridges and dentures)
unless specifically listed on your PCS within 180 days of initial placement› Bone grafting and/or guided tissue regeneration › Services to correct congenital malformations,
when performed in conjunction with an including the replacement of congenitally missing
apicoectomy or periradicular surgery teeth
› Intentional root canal treatment in the absence of › The replacement of an occlusal guard (night guard)
injury or disease to solely facilitate a restorative beyond one per any 24 consecutive month period,
procedure when this limitation is noted on the PCS
› Services performed by a prosthodontist › Crowns, bridges and/or implant supported prosthesis
› Localized delivery of antimicrobial agents when used solely for splinting
performed alone or in the absence of traditional › Resin bonded retainers and associated pontics
periodontal therapy › As to orthodontic treatment: incremental costs
› Any localized delivery of antimicrobial agent associated with optional/elective materials;
procedures when more than eight of these orthognathic surgery appliances to guide minor tooth
procedures are reported on the same date of movement or correct harmful habits; and any services
service which are not typically included in orthodontic
treatment.
If any law requires coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) does not apply.
This document outlines the highlights of your plan. For a complete list of both covered and non-covered services, including benefits required
by your state, see your official plan documents (the Group Contract and Plan Booklet/Combined Evidence of Coverage and Disclosure Form/
Certificate of Coverage). If there are any differences between the information contained here and the plan documents, the information in
the plan documents takes precedence.
1. “Cigna Dental Care” is the brand name used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care (including Dental HMO) plans, and plans with
open access features. Cigna Dental Care plans are not available in the following states: AK, HI, ME, MT, NH, NM, ND, PR, RI, SD, VI, VT, WV, and WY.
2. Costs listed for the Cigna Dental Care plan do not vary. Estimated costs without dental coverage may vary based on location and dentists’ actual charges. These estimated costs are based on
charges submitted to Cigna in 2015/2016 and are intended to reflect national average charges as of July 2018 assuming an annual cost increase of three percent. Estimates have been adjusted
to reflect the 2016 Cigna Dental Care geographical membership distribution. Office visit fee may also apply.
3. This is NOT insurance and does not provide for reimbursement of financial losses. The Cigna Identity Theft Program is provided under a contract with Generali Global Assistance. Full terms,conditions and
exclusions are contained in the client program description.
4. Minnesota residents: You must visit your selected network dentist in order for the charges on the PCS to apply. You may also visit other dentists that participate in our network or you may visit dentists outside the Cigna
Dental Care network. If you do, the fees listed on the PCS will not apply. You will be responsible for the dentist’s usual fee. We will pay 50% of the value of your network benefit for those services. Of course, you’ll pay less if you
visit your selected Cigna Dental Care network dentist. Call Customer Services for more information.
Oklahoma residents: Cigna Dental Care is an Employer Group Pre-Paid Dental Plan. You may also visit dentists outside the Cigna Dental Care network. If you do, the fees listed on the PCS will not apply. You will be responsible
for the dentist’s usual fee. We pay non-network dentists the same amount we’d pay network dentists for covered services. Of course, you’ll pay less if you visit a network dentist in the Cigna Dental Care network. Call Customer
Services for more information.
5. Oklahoma residents: This exclusion is replaced by the following: War or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war
whether voluntarily or as required by an employer.
6. Arizona and Pennsylvania residents: This exclusion does not apply. Kentucky and North Carolina residents: Services compensated under no-fault auto insurance policies or uninsured motorist policies are not
excluded. Maryland residents: Services compensated under group medical plans are not excluded.
7. California and Texas residents: Treatment for conditions already in progress on the effective date of your coverage are not excluded if otherwise covered under your PCS.
Dentists who participate in Cigna’s network are independent contractors solely responsible for the treatment provided to their patients. They are not agents of Cigna.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. Cigna Dental Care plans are insured by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California,
Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes,
Cigna Dental Health of Kansas, Inc. (KS & NE), Cigna Dental Health of Kentucky, Inc. (KY & IL), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health
of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are insured by
Cigna Health and Life Insurance Company or Cigna HealthCare of Connecticut, Inc., and administered by Cigna Dental Health, Inc. Policy forms: OK - HP-POL115; TN - HP-POL134/HC-CER17V1 et al. The Cigna name, logo, and
other Cigna marks are owned by Cigna Intellectual Property, Inc.
856785d 8/19 © 2019 Cigna. Some content provided under license.You can also read
