Cigna Dental Benefit Summary
Workday, Inc.
Plan Effective Date: 01/01/2024
Administered By: Cigna Health and Life Insurance Company
Your DPPO plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-of-pocket
expenses.
Plan Option Name: DPPO Plan
Network Options
Total Cigna DPPO
Non-Network
Annual Deductible
Individual/Family
Includes: Implants
$50/$150
$50/$150
Annual Maximum
Individual
Includes: Implants
$2500
$2500
Lifetime Maximum
Orthodontics
$2500
$2500
Reimbursement Level
Based on Contracted Fees
Maximum Allowable Charge
Summary of Benefits
For a complete listing of your benefits, please see your Certificate or Plan Document
Diagnostic services - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Oral Evaluations: Limited to 2 per Year
100%
No Deductible
No Maximum
100%
No Deductible
No Maximum
Radiographs (X-Rays): Limited to 2 per Year
100%
No Deductible
No Maximum
100%
No Deductible
No Maximum
Non-Standard Radiographs (X-Rays): Limited to 1
per 36 Consecutive Months
100%
No Deductible
No Maximum
100%
No Deductible
No Maximum
Preventive - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Prophylaxis (Cleaning): Limited to 2 per Year
100%
No Deductible
No Maximum
100%
No Deductible
No Maximum
Fluoride: Limited to 2 per Year, age 0 - 18
100%
No Deductible
No Maximum
100%
No Deductible
No Maximum
Sealants: Limited to 1 per 36 Consecutive Months,
80%
80%
Space Maintainers: Age 0 - 18
100%
No Deductible
No Maximum
100%
No Deductible
No Maximum
Basic Restoration - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Amalgam/Silver Restoration (Filling): Limited to 1
per 12 Consecutive Months
80%
80%
Composite/White Restoration (Filling): Limited to 1
per 12 Consecutive Months
80%
80%
Crown Repair
80%
80%
Bridge Repair
80%
80%
Denture Adjustment: Limited to 1 per 12
Consecutive Months
80%
80%
Denture Repair: Limited to 1 per 12 Consecutive
Months
80%
80%
Denture Reline: Limited to 1 per 12 Consecutive
Months
80%
80%
Major Restoration - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Inlay/Onlay: Limited to 1 per 60 Consecutive
Months
50%
50%
Crown: Limited to 1 per 60 Consecutive Months
50%
50%
Bridge/Pontic: Limited to 1 per 60 Consecutive
Months
50%
50%
Removable and Fixed Prosthetic: Limited to 1 per
60 Consecutive Months
50%
50%
Prosthetic Over Implant: Limited to 1 per 60
Consecutive Months
50%
50%
Endodontics - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Root Canal: Limited to 1 per tooth per Lifetime
80%
80%
Periodontics - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Periodontal Scaling and Root Planing: Limited to 1
per 24 Consecutive Months
80%
80%
Major/Surgical Periodontics: Limited to 1 per 36
Consecutive Months
80%
80%
Oral Surgery - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Simple/Non-Surgical Extraction
80%
Surgical Extraction
80%
Other Oral Surgery
80%
Adjunctive - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Anesthesia
80%
Emergency Care
100%
No Deductible
No Maximum
Implants - Annual Deductible Applies Unless Noted. Annual Maximum Applies Unless Noted
Implants: Limited to 1 per 60 Consecutive Months
50%
Orthodontics - No Deductible Applies. Lifetime Maximum Applies Unless Noted
Orthodontics: Employee and All Dependents
50%
No Deductible
Benefit Plan Provisions
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.
Benefits Maximum
The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit specific
maximums may also apply.
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.
Alternate Benefit Provision
When more than one covered Dental Service could provide suitable treatment based on common dental standards,
Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that
will be included as Covered Expenses.
Oral Health Integration Program
The Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with certain
medical conditions. There is no additional charge to participate for 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 and a complete list of terms and eligible conditions, go to www.mycigna.com or call customer
service 4/7 at 1-800-Cigna24.
Reimbursement Level
For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse according to a Fee
Schedule or Discount Schedule. The term Maximum Allowable Charge (MAC) means the fee for that procedure as
listed in The Primary Schedule aligned to the zip code for the geographical area where the service is performed,
times the benefit percentage that applies to the class of service, as specified in The Schedule.
For Cigna DPPO MAC, the Primary Schedule is usually the fee schedule with the average Contracted Fees available
for acceptance by Participating Providers in the relevant 3-digit zip code.
Timely Filing
Claims submitted to Cigna after a specified number of months from date of service could be denied. Please see your
Certificate or Plan Document for detail.
Pretreatment Review
Pretreatment review is available on a voluntary basis when dental work in excess of $300 is proposed by the provider.
Exclusions
What's Not Covered (not all-inclusive):
Your plan provides for most dentally necessary services. The complete list of exclusions is provided in your Certificate or Plan Document. To the extent there
may be differences, the terms of the Certificate or Plan Document will prevail. Examples of things your plan does not cover, unless required by law, include
but are not limited to:
Procedures and services not included in the list of covered dental expenses;
Diagnostic: cone beam imaging;
Preventive Services: instructions for plaque control, oral hygiene and/or nutritional counseling;
Restorative: tooth-colored materials such as 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 (back or posterior teeth);
Periodontics: bite registrations; splinting;
Prosthodontic: precision or semi-precision attachments;
Procedures, appliances, or restorations whose sole purpose is to change or preserve occlusion (teeth contact or bite) except for orthodontic services as
covered by the plan; or to stabilize teeth affected by periodontal (gum) disease;
Procedures, appliances, or restorations, except full dentures, whose main purpose is to diagnose or treat conditions or dysfunction of the temporomandibular
joint (TMJ);
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 Allowable Charge;
Important things to consider:
This document is an overview provided for your convenience and contains a general description of your dental benefit plan. This document is meant for you
to use as a reference guide. A complete description of your dental benefit plan including plan exclusions and limitations is located in the group contract
between your plan sponsor and Cigna Dental as well as your Certificate or Plan Document. Covered Expenses will not include, and no payment will be
made for procedures and services not listed in the group contract. Benefits will be reduced so that the total payment will not be more than 100% of the
charge made for the Dental Service if benefits are provided for that service under this plan, any medical expense plan or prepaid treatment program
sponsored or made available by your Employer.
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.
Cigna Dental PPO plans are underwritten or administered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company
with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO
plan offered by CGLIC is known as the "CG Dental PPO". In Texas, the insured dental product is referred to as Cigna Dental Choice and this plan uses the
national Cigna DPPO network.
"Cigna," the "Tree of Life" logo and "Cigna Dental Care" are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation.
Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna
HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc., and its subsidiaries.
For questions regarding benefit coverage, plan limitations, plan exclusions, claims or any other information need, please visit our website at
www.mycigna.com or call Cigna Customer Service 24/7 at 1.800.CIGNA24.
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