Cigna Dental Benefit Summary
Montgomery County Government
Administered by: Cigna Health and Life Insurance Company
Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your
overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health
issues. That’s why this dental plan includes Cigna Dental WellnessPlus
SM
features. When you or your family members receive any preventive care
service in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the
plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified
below. Please refer to your plan materials for additional information on this plan feature.
Cigna Dental PPO
Network Options
In-Network:
Total Cigna DPPO Network
Out-of-Network:
Non-Network Reimbursement
Reimbursement Levels
Based on Contracted Fees
Maximum Reimbursable Charge
Progressive Maximum Benefit:
Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1.
Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 and 2.
Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 1, 2 and 3.
Calendar Year Benefits Maximum
Applies to: Class I, II, III & IX expenses
Year 1: $2,000
Year 2: $2,100
Year 3: $2,200
Year 4: $2,300
Year 1: $2,000
Year 2: $2,100
Year 3: $2,200
Year 4: $2,300
Calendar Year Deductible
Individual
Family
$50
$150
$50
$150
Benefit Highlights
Plan Pays
You Pay
Plan Pays
You Pay
Class I: Diagnostic & Preventive
Oral Evaluations
Prophylaxis: routine cleanings
Periodontal Maintenance
X-rays: routine
X-rays: non-routine
Fluoride Application
Sealants: per tooth
Space Maintainers: non-orthodontic
Emergency Care to Relieve Pain
100%
No Deductible
No Charge
100%
No Deductible
No Charge
Class II: Basic Restorative
Restorative: fillings
Endodontics: minor and major
Periodontics: minor and major
Oral Surgery: minor and major
Anesthesia: general and IV sedation
Repairs: Bridges, Crowns and Inlays
Repairs: Dentures
Denture Relines, Rebases and Adjustments
80%
After Deductible
20%
After Deductible
80%
After Deductible
20%
After Deductible
Class III: Major Restorative
Inlays and Onlays
Prosthesis Over Implant
Crowns: prefabricated stainless steel / resin
Crowns: permanent cast and porcelain
Bridges and Dentures
60%
After Deductible
40%
After Deductible
60%
After Deductible
40%
After Deductible
Class IV: Orthodontia
Coverage for Employee and All Dependents
Lifetime Benefits Maximum: $1,000
60%
No Deductible
40%
No Deductible
60%
No Deductible
40%
No Deductible
Class IX: Implants
60%
After Deductible
40%
After Deductible
60%
After Deductible
40%
After Deductible
Benefit Plan Provisions:
In-Network Reimbursement
For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the
dentist according to a Fee Schedule or Discount Schedule.
Non-Network Reimbursement
For services provided by a non-network dentist, Cigna Dental will reimburse according to the
Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider
charges in the geographic area. The dentist may balance bill up to their usual fees.
Cross Accumulation
All deductibles, plan maximums, and service specific maximums cross accumulate between in
and out of network. Benefit frequency limitations are based on the date of service and cross
accumulate between in and out of network.
Calendar Year Benefits Maximum
The plan will only pay for covered charges up to the yearly Benefits Maximum, when
applicable. Benefit-specific Maximums may also apply.
Calendar Year Deductible
This is the amount you must pay before the plan begins to pay for covered charges, when
applicable. Benefit-specific deductibles may also apply.
Pretreatment Review
Pretreatment review is available on a voluntary basis when dental work in excess of $200 is
proposed.
Oral Health Integration Program (OHIP)
Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers
with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck
cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for
the program, those who qualify get reimbursed 100% of coinsurance for certain related dental
procedures. Eligible customers can also receive guidance on behavioral issues related to oral
health and discounts on prescription and non-prescription dental products. Reimbursements
under this program are not subject to the annual deductible, but will be applied to and are
subject to the plan annual maximum. Discounts on certain prescription and non-prescription
dental products are available through Cigna Home Delivery Pharmacy only, and you are
required to pay the entire discounted charge. For more information including how to enroll in
this program and a complete list of program terms and eligible medical conditions, go to
www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.
Timely Filing
Out of network claims submitted to Cigna after 365 days from date of service will be denied.
Benefit Limitations:
Oral Evaluations
2 per calendar year
X-rays (routine)
Bitewings: 2 per calendar year
X-rays (non-routine)
Complete series of radiographic images and panoramic radiographic images: Limited to a
combined total of 1 per 36 months
Diagnostic Casts
Payable only in conjunction with orthodontic workup
Cleanings
2 per calendar year, along with 2 periodontal maintenance procedures following active therapy,
not to cross accumulate
Fluoride Application
1 per calendar year with no age limit
Sealants (per tooth)
Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14
Space Maintainers
Limited to non-orthodontic treatment for children under age 19
Inlays, Crowns, Bridges, Dentures and Partials
Replacement every 60 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.
Denture and Bridge Repairs
Reviewed if more than once
Denture Relines, Rebases and Adjustments
Covered if more than 6 months after installation
Prosthesis Over Implant
1 every 60 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.
Benefit Exclusions:
Covered Expenses will not include, and no payment will be made for the following:
Procedures and services not included in the list of covered dental expenses;
Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet;
Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or
third molars; Periodontics: bite registrations; splinting;
Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines;
Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or
dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion;
Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines;
Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs
Charges in excess of the Maximum Reimbursable Charge.
This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the
terms of the official plan documents will prevail.
Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life
Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the
insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network.
The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery
Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC),
GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are
owned by Cigna Intellectual Property, Inc.
© 2017 Cigna / version 06192017
