SUMMARY OF BENEFITS PLAN INFORMATION

944122 09/22

SUMMARY OF BENEFITS

PLAN INFORMATION

Cigna Dental 3000/100 Plan

1. Cigna internal data as of July 2022. Subject to change.

2. View Dental Beneﬁt details on page 3 for applicable waiting periods. The previous plan’s termination date must be within 63 days of the start date of this Cigna plan. The prior plan must have

been eﬀective 12 or more consecutive months prior to your new plan start date and must have included coverage for Class III, Major Restorative Services. Any prior dental insurance plan that

did not include Class III services will not count toward waiting period waiver. Waiting periods are waived for Class II and Class III in Maine if under the age of 19.

3. Estimate based on the national average of a standard Cigna Dental 3000/100 Plan; subject to deductible and coinsurance (as applicable), results in speciﬁc states may vary. If you visit an out-

of-network provider, you are responsible for the diﬀerence in the amount that Cigna reimburses (i.e., Contracted Fee) for such services and the amount charged by the dentist.

4. Estimates based on 2021 Cigna Dental internal claims data, projected to 2022. Subject to change.

With Cigna, there is more to smile about.

You get ﬂexible beneﬁts and premium levels to meet your needs and budget, plus:

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Access to one of the nation’s top networks, the Total Cigna DPPO Network, which has 147,000 dentists at more

than 740,000 locations across the U.S.

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No referral needed to see a specialist

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Available for all ages, including those 65 and older

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No application or processing fees

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Waiting periods may be waived for select procedures if you have had prior similar dental coverage

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No need to submit claims when you use a Total Cigna DPPO Network provider

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24/7/365 customer service

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Online access with myCigna.com

. You can view bills and claims online, anytime – and make a payment too

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Mobile access on the go. Find a dentist, check coverage and show your ID card with the myCigna

App

You have freedom.

You are free to choose a provider from our large national network or one from outside the network. Keep in mind,

you’llsave the most if you visit a Total Cigna DPPO Network provider. Find providers in our network at

Cigna.com/ifp-providers.

In the chart below, you can see how your savings may be greater when visiting a Total Cigna DPPO Network provider

with a Cigna Dental 3000/100 Plan compared with your other options.

SAMPLE OUT-OF-POCKET COSTS

PROCEDURE

CLASS

CATEGORY

TOTAL

CIGNA DPPO

NETWORK

OUT-OF-

NETWORK

WITHOUT DENTAL

INSURANCE

Cleaning (Adult Prophy) – D1110 Class I (preventive) $0 $66 $109

Filling (2 Surfaces) – D2392 Class II (basic) $38 $180 $255

Crown (Porcelain & High Noble Metal) – D2750 Class III (major) $309 $982 $1,283

If you have a dierent plan, services may not be covered and discounts may vary. Chart is estimated; beneﬁts may vary by

provider and location. Out-of-network expenses may be lower in Alaska and Massachusetts.

amily PlansIndividual and F

Insured by Cigna Health and Life Insurance Company

Dental Terms

Below you will ﬁnd easy-to-understand deﬁnitions for commonly used words.

Actual Billed Charges: The fee that a provider charges a patient who does not have dental insurance. If a patient

has dental insurance and visits a Total Cigna DPPO Network provider, the provider charges the negotiated rate/

contracted fee.

Balance Billing: When an out-of-network provider bills you for the dierence between the charges for a service and

what Cigna will pay for that service after coinsurance and Contracted Fee (CF), or Maximum Reimbursable Charge

(MRC) in AK and MA, have been applied. For example, an out-of-network provider may charge $100 to ﬁll a cavity.

IfCF is $50 for that service and the coinsurance is 50%, Cigna will pay $25 and you will pay $25. Because you are

visiting an out-of-network provider, the provider may bill you the remaining $50; thus, your total out-of-pocket cost

will be $75. These charges are separate from any applicable deductible and coinsurance.

Calendar-Year Deductible: The dollar amount you must pay each year for eligible dental expenses before the

insurance begins paying for all dental services, if covered by your plan.

Calendar-Year Maximum: The most your plan will pay during a calendar year (12-month period beginning each

January 1). You’ll need to pay 100% out of pocket for any services after you reach your calendar-year maximum. This

typically applies to Class I, II and III.

Total Cigna DPPO Network: Dentists who have contracted with Cigna and agreed to accept a predetermined

contracted fee for the services provided to Cigna customers. Visiting a provider in this network means you’ll save the

most money because the fee is discounted.

Coinsurance: Your share of the cost of a covered dental service (a percentage amount). You pay coinsurance plus

any deductible amount not met yet for that calendar year. For example, if you go to the dentist and your visit costs

$200, the dentist sends a claim to Cigna. If you have already met your annual deductible amount, Cigna may pay

50% ($100) and you will pay a coinsurance of 50% ($100).

Contracted Fee (CF): The most Cigna will pay a dentist for a covered service or procedure for out-of-network dental

care that is based on a basic Total Cigna DPPO fee schedule within a speciﬁed area. See example provided under

Balance Billing.

Maximum Reimbursable Charge (MRC) – applies in AK and MA only: Also referred to as U&C, R&C and UCR. The

most Cigna will pay a dentist for a covered service or procedure for out-of-network dental care. Normally applies as

a percentile, based on the published prevailing HealthCare charges designated by zip code data. See example

provided under Balance Billing.

Non-participating Providers (Out-of-Network): Providers who have not contracted with Cigna to oer you savings.

They charge their own fees. Covered expenses for Non-participating Providers are based on the Contracted Fee,

which may be less than Actual Billed Charges. Non-participating Providers can bill you for amounts exceeding

covered expenses.

Waiting Period: The amount of time that you must be enrolled in the plan before certain beneﬁts are payable.

Waiting periods may vary by state. You may be eligible to waive the waiting period for Classes II & III if you have a

continuous 12 months of prior coverage from a valid dental insurance plan which included coverage for Class III,

Major Restorative Services, and not more than 63 days have lapsed between the prior coverage and this plan. Any

prior dental insurance plan that did not include Class III services will not count toward waiting period waiver. Waiting

periods are waived for Class II and Class III in Maine if under the age of 19.

amily PlansIndividual and F

Insured by Cigna Health and Life Insurance Company

Cigna Dental 3000/100 Plan

DENTAL BENEFIT TOTAL CIGNA DPPO NETWORK

OUT-OF-NETWORK

Your out-of-pocket expenses will be higher; these providers

have not agreed to oﬀer Cigna customers our contracted or

discounted fees. Example provided on page 1.

Individual Calendar-Year Deductible $100 per person

Calendar-Year Maximum

(For Class I, II and III services)

$3,000 per person

Payment Levels Based on provider’s contracted fees

Based on provider’s actual billed charges

and the contracted fee

CLASS I: PREVENTIVE/DIAGNOSTIC SERVICES

Preventive/Diagnostic Services Waiting Period None

Preventive/Diagnostic Services

Oral Exams, Routine Cleanings, Routine X-rays,

Nonroutine X-rays, Fluoride Application,

Sealants, Space Maintainers (Non-orthodontic),

Emergency Care to Relieve Pain

You pay $0

(after deductible)

You pay the diﬀerence between the provider’s

actual billed charges and 100% of the

contracted fee

(after deductible)

CLASS II: BASIC RESTORATIVE SERVICES

Basic Restorative Services Waiting Period 6-month waiting period

Basic Restorative Services

Fillings, Root Canal Therapy/Endodontics,

Minor Periodontics, Major Periodontics, Oral

Surgery, Simple Extractions, Oral Surgery, All

Except Simple Extractions, Surgical Extraction

of Impacted Teeth, Relines, Rebases, and

Adjustments, Repairs - Bridges, Crowns, and

Inlays, Repairs - Dentures, Anesthetics

You pay 50% of the provider’s contracted fee

(after deductible)

You pay the diﬀerence between the provider’s

actual billed charges and 50%, of the

contracted fee

(after deductible)

CLASS III: MAJOR RESTORATIVE SERVICES

Major Restorative Services Waiting Period 12-month waiting period

Major Restorative Services

Crowns/Inlays/Onlays, Prosthesis Over Implant,

Dentures, Bridges

You pay 50% of the provider’s contracted fee

(after deductible)

You pay the diﬀerence between the provider’s

actual billed charges and 50%, of the

contracted fee

(after deductible)

This summary contains highlights only. For additional plan information, including out-of-network beneﬁts, please refer to the Policy for details.

5. If you choose to visit a dentist out-of-network, you will pay the out-of-network beneﬁt and the diﬀerence between the amount that Cigna reimburses for such services (CF, or MRC in AK and

MA) and the amount charged by the dentist, except for emergency services as deﬁned in the policy. This is known as balance billing. See the deﬁnitions for Contracted Fee (CF), Maximum

Reimbursable Charge (MRC; applies in AK and MA only) and Balance Billing on the previous page. Refer to the policy for more details.

6. Waiting periods may vary by state. Refer to the policy for more details. You may be eligible to waive the waiting period for Classes II & III if you had 12 continuous months of prior coverage

from a dental coverage which included coverage for Class III, Major Restorative Services, and not more than 63 days have lapsed between the prior coverage and this plan. Any prior dental

insurance plan that did not include Class III services will not count toward waiting period waiver. Waiting periods are waived for Class II and Class III in Maine if under the age of 19.

amily PlansIndividual and F

Insured by Cigna Health and Life Insurance Company

Cigna Dental 3000/100 Plan

PROCEDURE

FREQUENCY/LIMITATION

Oral Exams 2 per person per calendar year

Routine Cleanings 2 routine prophylaxis or periodontal maintenance procedure per person per calendar year

Routine X-rays Bitewings: 2 sets per person per calendar year

Sealants 1 treatment per tooth in any 3 consecutive years, on a posterior tooth for a person less than 14 years old

Fluoride Treatment Limited to persons less than 19 years old. Only 1 per person per calendar year

Space Maintainers (Non-orthodontic)

Limited to non-orthodontic treatment for prematurely removed or missing teeth for participants less than

age 19

Nonroutine X-rays Only 1 per person, including panoramic ﬁlm, in any 36 consecutive months

Crowns

1 per tooth per consecutive 60-month period. Crown restorations are Dental Services only when the tooth, as

a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or

plastic restoration.

Root Canal Therapy

Re-treatment of a previous root canal is covered if 180 days have passed since the original

root canal.

Dentures and Partials

Limited to 1 complete/partial denture per arch per 60 consecutive months unless there is a necessary

extraction of an additional functioning natural tooth

Bridges 1 per consecutive 60-month period if not serviceable and cannot be repaired

This summary contains highlights only. Please refer to the Covered Expenses section of the Policy for details.

amily PlansIndividual and F

Insured by Cigna Health and Life Insurance Company

What is not covered by this plan

Excluded services

Covered expenses do not include expenses incurred for:

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Services performed solely for cosmetic reasons;

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Replacement of a lost or stolen appliance;

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Replacement of a bridge, crown or denture within

5 years after the date it was originally installed

unless: (a) the replacement is made necessary by

the placement of an original opposing full denture

or the necessary extraction of natural teeth; or (b)

the bridge, crown or denture, while in the mouth,

has been damaged beyond repair as a result of an

injury received while a person is insured for these

benefits;

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Any replacement of a bridge, crown or denture

which is or can be made usable according to

common dental standards;

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Procedures, appliances or restorations

(except full dentures) whose main purpose

is to: (a) change vertical dimension; (b)

diagnose or treat conditions or dysfunction

of the temporomandibular joint; (c) stabilize

periodontally involved teeth; or (d) restore

occlusion;

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Porcelain or acrylic veneers of crowns or pontics

on, or replacing, the upper and lower first, second

and third molars;

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Bite registrations, precision or semiprecision

attachments, or splinting;

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Instruction for plaque control, oral hygiene and

diet;

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Dental services that do not meet common dental

standards;

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Services that are deemed to be medical services;

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Services and supplies received from a hospital;

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Orthodontic treatment;

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The surgical placement of an implant body or

framework of any type; surgical procedures in

anticipation of implant placement; any device,

index or surgical template guide used for implant

surgery; treatment or repair of an existing implant;

prefabricated or custom implant abutments;

removal of an existing implant;

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Services for which benefits are not payable

according to the “General Limitations” section.

General Limitations

No payment will be made for expenses incurred for

you or any one of your dependents:

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For services not specifically listed as covered

services in the policy.

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For services or supplies that are not

dentally necessary.

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For services received before the start date

of coverage.

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For services received after coverage under this

policy ends.

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For services for which you have no legal

obligation to pay or for which no charge

would be made if you did not have dental

insurance coverage.

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For professional services or supplies received or

purchased directly or on your behalf by anyone,

including a dentist, from any of the following.

–

Yourself or your employer.

–

A person who lives in the insured person’s

home or that person’s employer.

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A person who is related to the insured person

by blood, marriage or adoption or that

person’s employer.

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For or in connection with an injury arising out of,

or in the course of, any employment for wage

or profit.

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For or in connection with a sickness which is

covered under any workers’ compensation or

similar law.

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For charges made by a hospital owned or

operated by or which provides care or performs

services for the United States government, if such

charges are directly related to a military-service-

connected condition.

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For services or supplies received as a result of

dental disease, defect or injury due to an act of

war, declared or undeclared.

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To the extent that payment is unlawful where the

person resides when the expenses are incurred.

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For charges which the person is not legally

required to pay.

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For charges which would not have been made if

the person had no insurance.

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To the extent that billed charges exceed the rate of

reimbursement as described in the schedule.

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For charges for unnecessary care, treatment

or surgery.

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To the extent that you or any of your dependents

are in any way paid or entitled to payment for

those expenses by or through a public program,

other than Medicaid.

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For or in connection with experimental procedures

or treatment methods not approved by the

American Dental Association or the appropriate

dental specialty society.

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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 will take into account any

adjustment option chosen under such part by you

or any one of your dependents.

PLAN EXCLUSIONS AND LIMITATIONS

amily PlansIndividual and F

Insured by Cigna Health and Life Insurance Company

Cigna Dental insurance coverage shall be only for the classes of service referred to in the Schedule of a purchased plan.

Dental plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age,

family size, geographic location (residential zip code) and plan design.

Rates are subject to change upon 30 days’ prior notice in AK, AL, AR, CO, CT, DC, DE, HI, IA, ID, IL, KS, KY, MA, ND, NE, NJ, OK, PA, SD, TN, UT, VT, WI and WY; 45 days’ prior notice

in FL; 75 days’ prior notice in MS; and 60 days’ prior notice in NV, TX, and WV. In NC, dental rates are guaranteed for a 12-month period. Dental plans apply waiting periods to

covered basic (6 months) and major (12 months) dental care services. In ME, waiting periods are waived for Class II and Class III if under the age of 19. Waiting periods may

vary by state. Refer to the policy or outline of coverage for details. Some covered services are determined by age: topical application of fluoride or sealant, space maintainers, and

materials for crowns and bridges.

Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

Dental preferred provider insurance policies (AL, CO, CT, DE, HI, IA, IL, ND, PA, WV and WY: HC-NOT11 et al., AK: HC-NOT53, et al., AR: HC-NOT36 et al., DC: HC-NOT42, et al.,

FL: HC-NOT15 et al., ID: HC-NOT51 et al., KS: HC-NOT49 et al., KY: HC-NOT44, et al., MA: HC-NOT11 et al., MS: HC-NOT48 et al., NC: HC-NOT18, et al., NE HC-NOT47 et al.,

NJ: HC-NOT46, et al., NV: HC-NOT39 et al., OK: HC-NOT26 et al., SD HC-NOT59 et al., TN: HC-NOT20 et al., TX: HC-NOT21 et al., UT: HC-NOT50 et al., VT HC-NOT56 et al., WI

HC-NOT54 et al.) have exclusions, limitations, reduction of benefits and terms under which a policy may be continued in force or discontinued.

The policy may be cancelled by Cigna due to failure to pay premium, fraud, ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies

of this type or any individual dental plans in this state, in accordance with applicable law. You may cancel the policy on the first of the month following our receipt of your

written notice. We reserve the right to modify this policy, including policy provisions, benefits and coverages, consistent with state or federal law. This individual plan is

renewable monthly or quarterly.

For costs and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 866.GET.Cigna

(866.438.2446).

Please contact your insurance carrier, agent/producer or the Health Insurance Marketplace if you wish to purchase PPACA-compliant pediatric dental coverage.

PLAN IMPORTANT DISCLOSURES

amily PlansIndividual and F

Insured by Cigna Health and Life Insurance Company

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, and Cigna Dental Health, Inc.

In Texas, the dental plan is known as Cigna Dental Choice, and this plan uses the national Total Cigna DPPO network. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual

Property, Inc.