DPPO 2 Tier Progressive Max

Cigna Dental Benefit Summary

Indiana University – Employees

Plan Renewal Date: 01/01/2023

Admin istered by: Cigna Health and Life Insurance Company

This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan

documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions

and limitations.

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

healt h issues. That’s why this dental plan includes Cign a De ntal W ellnessPlus

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. Your plan allows you to see

any l ice nsed dentist, but u sing an i n-network de ntist may mi nimize your out-of-pocket e xpenses.

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

WellnessPlus

Progressive Maximum Benefit:

When you or your family members receive any preventive care service during one plan year, the annual dollar maximum will increase in the

following plan year; until it reaches the highest level specified below. Please refer to your plan materials for additional information on this plan

feature.

Calendar Year Benefits Maximum

Applies to: Class I, II & III expenses

Year 1: $1,200

Year 2: $1,300

Year 3: $1,400

Year 4 & Beyond: $1,500

Year 1: $1,200

Year 2: $1,300

Year 3: $1,400

Year 4 & Beyond: $1,500

Calendar Year Deductible

Individual

Family

$25

Benefit Highlights

Plan Pays

You Pay

Plan Pays

You Pay

Class I: Diagnostic & Preventive

Oral Evaluations

Prophylaxis: routine cleanings

X-rays: routine

X-rays: non-routine

Fluoride Application

Sealants: per tooth

Space Maintainers: non-orthodontic

Emergency Care to Relieve Pain

100%

No Deduct ible

No Charge

100%

No Deduct ible

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 Adjust ment s

50%

Aft er Deduct ible

50%

Aft er Deduct ible

50%

Aft er Deduct ible

50%

Aft er Deduct ible

Class III: Major Restorative

Inlays and Onlays

Prosthesis Over Implant

Crowns: prefabricated stainless steel / resin

Crowns: permanent cast and porcelain

Bridges and Dent ures

Dental Surgical Implants

50%

Aft er Deduct ible

50%

Aft er Deduct ible

50%

Aft er Deduct ible

50%

Aft er Deduct ible

Class IV: Orthodontia

Coverage for Dependent Children to age 19

Lifetime Benefits Maximum: $1,000

50%

Aft er Deduct ible

50%

Aft er Deduct ible

50%

Aft er Deduct ible

50%

Aft er Deduct ible

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

submit t ed amount s in the geographic area. T he 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

T his is t he amount you must pay before the plan begins to pay for covered charges, wh en

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

The Cigna Dental Oral Health Integration Program offers enhanced dental coverage for

customers with certain medical conditions. T here is no additional charge to participate in the

program. Those who qualify can receive reimbursement of their coinsurance for eligible dental

services. Eligible customers can also receive guidance on behavioral issues related to oral health.

Reimbursements under this program are not subject to the annual deductible, but will be applied

to the plan annual maximum.

For more information on how to enroll in this program and a complete list of terms and eligible

conditions, go to www. m y c ign a. co m

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/Exams

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 wit h orthodontic workup.

Cleanings

2 per calendar year for Prophylaxis; 2 per calendar year for Periodontal Maintenance procedures

following active therapy.

Fluoride Application

2 per calendar year for children under age 19.

Sealants (per tooth)

Limited to posterior tooth. 1 treatment per tooth every 36 months no age restriction.

Space Maintainers

Limited to non-orthodontic treatment for children under age 19.

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.

Prost hesis 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.

Restorative

Includes Resin-based composite crown, anterior

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;

• Prosthodontic: precision or semi-precision attachments;

• Procedures, appliances or restorations, except full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of

dysfunction of the temporomandibular joint (TMJ), stabilize periodontally involved teeth or restore occlusion;

• At hlet ic mout h guards;

• Services performed primarily for cosmetic reasons;

• Personalization or decoration of any dental device or dental work;

• Replacement of an appliance per benefit guidelines;

• Services that are deemed to be medical in nature;

• Services and supplies received from a hospital;

• Drugs: prescript ion 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.

Product availability may vary by location and plan type and is subject to change. All group dental insurance policies and dental benefit plans contain

exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative.

A copy of the NH Dental Outline of Coverage is available and can be downloaded at Health Insurance & Medical Forms for Customers | Cigna under

Dental Forms.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life

Insurance Company (CHLIC), Connecticut General Life Insurance Company, and Cigna Dental Health, Inc.