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:
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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