Cigna DHMO Dental Plan

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Offered by: Cigna Health and Life Insurance Company or its affiliates.

Smile. You're Covered

You can save money on a wide range of services, including:

• Preventive care - cleanings, fluoride, sealants, bitewing X-rays, full mouth X-rays and more
• Basic care - tooth-colored fillings (called resin or composite) and silver-colored fillings (called amalgam)
• Major services - crowns, bridges, dentures (including those placed over implants), root canals, oral surgery, extractions, treatment for periodontal (gum) disease and more
• Orthodontic care - braces for children and adults
• General anesthesia - when medically necessary
• Teeth whitening - using take-home bleaching trays and gel
• Temporomandibular joint (TMJ) - diagnosis and treatment, including cone beam x-ray and appliance
• Athletic mouth guard - including creation and adjustments

More about your coverage

• No deductibles or waiting periods. You don't have to reach an out-of-pocket cost before your insurance starts.
• No dollar maximums. Your coverage isn't limited by a dollar amount.
• Network dentists file claims for you. No paperwork for you.
• No age limit on sealants. Helps prevent tooth decay.
• Cancer detection. Your plan covers procedures such as biopsy and light detection to help find oral cancer in its early stages.
• 24/7 access to dental information line. Trained professionals can help answer your questions about dental treatment and clinical symptoms.
• Cigna's Identity Theft Program.³ 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.

Choosing a Dentist

• You must choose a network general dentist to manage your overall care. You won't be covered if you go to a dentist who's not in our network.⁴
• Each family member can choose their own dentist.
• Referrals are required for specialty care services, except for pediatric dentists for children under 13 and orthodontics.*

Finding a network dentist is easy.

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.

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Limitations

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 out of, or in the course of, any employment for wage or profit.

Charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States government or by a state or municipal government if the person had no insurance

Services received to the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received

Services for the charges which the person is not legally required to pay

Charges which would not have been made if the person had no insurance

Services received due to injuries which are intentionally self-inflicted

Services not listed on the PCS

Services provided by a non-network dentist without Cigna Dental's prior approval (except emergencies, as described in your plan documents)⁴

Services related to an injury or illness paid under workers' compensation, occupational disease or similar laws

Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid

Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war ⁵

Services performed primarily for cosmetic reasons unless specifically listed on your PCS

Consultations and/or evaluations associated with services that are not covered

Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis

Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS

Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery

Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure

Services performed by a prosthodontist

Localized delivery of antimicrobial agents when performed alone or in the absence of traditional periodontal therapy

Any localized delivery of antimicrobial agent procedures when more than eight of these procedures are reported on the same date of service

General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS

General anesthesia or IV sedation when used for the purpose of anxiety control or patient management

Prescription medications

Procedures, appliances or restorations if the main purpose is to: a. change vertical dimension (degree of separation of the jaw when teeth are in contact); b. restore teeth which have been damaged by attrition, abrasion, erosion and/or abfraction

Replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect

Any services related to surgical implants, including placement, repair, maintenance, removal, and implant abutment(s) unless specifically listed on your PCS

Services considered unnecessary or experimental in nature or do not meet commonly accepted dental standards

Procedures or appliances for minor tooth guidance or to control harmful habits

Services and supplies received from a hospital

Services to the extent you or your enrolled dependent are compensated under any group medical plan, no-fault auto insurance policy, or uninsured motorist policy.⁶

The completion of crowns, bridges, dentures, or root canal treatment already in progress on the effective date of your Cigna Dental coverage⁷

The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS⁷

Infection control and/or sterilization

The recementation of any inlay, onlay, crown, post and core or fixed bridge within 180 days of initial placement

The recementation of any implant supported prosthesis (including crowns, bridges and dentures) within 180 days of initial placement

Services to correct congenital malformations, including the replacement of congenitally missing teeth

The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS

Crowns, bridges and/or implant supported prosthesis used solely for splinting

Resin bonded retainers and associated pontics

As to orthodontic treatment: incremental costs associated with optional/elective materials; orthognathic surgery appliances to guide minor tooth movement or correct harmful habits; and any services 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.

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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.