|Dental Coverage That Fits
Cigna Dental Care DHMO1
|Monthly Rates|| Employee Only $9.48
Employee + 1 Dependent $14.88
Employee + 2 or More Dependents $23.50
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.
|WHAT YOU'LL PAY2|
|Sampling of covered procedures||With Cigna Dental Care||Without Dental Coverage|
|Adult Cleaning (two per calender year - each at $0) (additional cleanings available at $45 each)||$0||$68 - $155 each|
|Child Cleaning (two per calender year - each at $0) (additional cleanings available at $30 each)||$0||$53 - $121 each|
|Periodic oral evaluation||$0||$40 - $90|
|Comprehensive oral evaluation||$0||$63- $143|
|Topical flouride (two per calender year - each at $0) (additional topic flouride available at $15 each)||$0||$28 - $63 each|
|X-rays - (bitewings) 2 films||$0||$33 - $75|
|X-rays - panoramic film||$0||$83 - $189|
|Sealant - per tooth||$17||$41 - $94|
|Amalgam fillings (silver colored - 2 surfaces)||$22||$117 - $266|
|Composite filling (tooth - colored) - 1 surface, Anterior||$22||$118 - $270|
|Molar root canal (excluding final restoration)||$530||$840 - $1,914|
|Comprehensive orthodontic treatment of the adolescent detention - Banding||$515||$967 - $2,203|
|Periodontal (gum) scaling & root planning - 1 quardrant||$115||$182 - $414|
|Periodontal (gum) maintenance||$78||$107 - $243|
|Removal / extraction of erupted tooth||$53||$124 - $282|
|Removal / extraction of impacted tooth - completely bony||$230||$362 - $825|
|Crown - porcelain fused high noble metal *||$470||$839 - $1,911|
|Implant supported retainer for porcelain fused to metal fixed partial denture *||$770||$1,079 - $2,458|
|Occlusal appliance, by report (for treatment of TMJ)||$455||$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.
You can save money on a wide range of services, including:
Visit Cigna.com to find a network general dentist.
Call 800.Cigna24 (800.244.6224) to speak with a customer service representative. You can ask for a customized dental directory to be sent to you via email.
* Coverage for treatment by a pediatric dentist ends on your child's 13th birthday. Effective on your child's 13th birthday, dental services generally must be obtained from a network general dentist.
|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 planning and scaling||Limit 4 quadrants per consecutive 12 months|
|Periodontal maintenence||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 intallation|
|Prosthesis over implant||Replacement 1 every 5 years if unserviceable and cannot be repaired|
|Temporomandibular Joint (TMJ) treatment||One occlusal orthotic device per 24 months|
|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.|
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.
856781d 8/19 © 2019 Cigna. Some content provided under license.