Table of Contents
Important Information..................................................................................................................4
Important Notices ..........................................................................................................................6
How To File Your Claim ...............................................................................................................7
Eligibility - Effective Date .............................................................................................................7 Employee Insurance ...............................................................................................................................................7 Waiting Period........................................................................................................................................................8 Dependent Insurance ..............................................................................................................................................8 Cigna Dental Preferred Provider Insurance ...............................................................................9 The Schedule ..........................................................................................................................................................9 Covered Dental Expense ......................................................................................................................................11 Dental PPO – Participating and Non-Participating Providers ..............................................................................11 Expenses Not Covered .........................................................................................................................................13
General Limitations .....................................................................................................................13
Dental Benefits .....................................................................................................................................................13
Coordination of Benefits..............................................................................................................14
Expenses For Which A Third Party May Be Responsible .......................................................16
Payment of Benefits .....................................................................................................................17
Termination of Insurance............................................................................................................18 Employees ............................................................................................................................................................18 Dependents ...........................................................................................................................................................18
Dental Benefits Extension............................................................................................................18
Federal Requirements .................................................................................................................18 Notice of Provider Directory/Networks................................................................................................................18 Qualified Medical Child Support Order (QMCSO) .............................................................................................19 Effect of Section 125 Tax Regulations on This Plan ............................................................................................19 Eligibility for Coverage for Adopted Children.....................................................................................................20 Group Plan Coverage Instead of Medicaid...........................................................................................................20 Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) ...............................................20 Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) ....................................20 Claim Determination Procedures under ERISA ...................................................................................................21 Dental - When You Have a Complaint or an Appeal ...........................................................................................22 COBRA Continuation Rights Under Federal Law ...............................................................................................22 ERISA Required Information ...............................................................................................................................26
Definitions.....................................................................................................................................27
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