Oral Health IntegrationProgram (OHIP)
Cigna Dental Oral Health Integrat ion Program offers enhanced dental coverage for customers with the following medical condit ions: diabetes, heart disease, st roke, maternity, head and neck cancer radiat ion, organ t ransplant s and chronic kidney disease. There’s no addit ional 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 discount s on prescript ion and non-prescript ion dental product s. Reimbursement s under this program are not subject to the annual deduct ible, but will be applied to and are subject to the plan annual maximum. Discount s on certain prescript ion and non-prescription dental product s are available through Cigna Home Delivery Pharmacy only, and you are required to pay the ent ire discounted charge. For more informat ion including how to enroll in this program and a complete list of program terms and eligible medical condit ions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.
Timely Filing
Out of network claims submit ted to Cigna after 365 days from date of service will be denied.
Benefit Limitations: Oral Evaluat ions
2 per calendar year
X-rays (rout ine)
Bitewings: 2 per calendar year
Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months
X-rays (non-rout ine)
Cleanings
2 per calendar year, including periodontal maintenance procedures following act ive therapy
Fluoride Applicat ion
2 per calendar year for children under age 19
Sealant s (per tooth)
Limited to posterior tooth. 1 t reatment per tooth every 36 months for children under age 16
Space Maintainers
Limited to non-orthodontic t reatment for children under age 19
Replacement every 60 months if unserviceable and cannot be repaired. Benefit s are based on the amount payable for non-precious metals. No porcelain or white/tooth-coloredmaterial on molar crowns or bridges.
Inlays, Crowns, Bridges, Dentures and Part ials
Denture and Bridge Repairs
Reviewed if more than once
Denture Relines, Rebases and Adjustment s
Covered if more than 6 months after installation
Replacement every 60 months if unserviceable and cannot be repaired. Benefit s are based on the amount payable for non-precious metals. No porcelain or white/tooth-coloredmaterial on molar crowns or bridges.
Prosthesis Over Implant
Restorat ive: fillings
Includes composite fillings on molars
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;
Diagnost ic: cone beam imaging; Prevent ive Services: inst ruct ion for plaque cont rol, oral hygiene and diet ; Restorat ive: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pont ics on or replacing the upper and or lower first , second and/or thirdmolars; Periodont ics: bite regist rat ions; splint ing; Prosthodontic: precision or semi-precision at tachments; init ial placement of a complete or partial denture per plan guidelines; Implant s: implant s or implant related services; Orthodont ics: orthodontic t reatment; Procedures, appliances or restorat ions, except full dentures, whose main purpose is to: change vert ical dimension; diagnose o r t reat condit ions or dysfunct ion of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athlet ic mouth guards; services performed primarily for cosmet ic reasons; personalizat ion; replacement of an appliance per be nefit 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 cont ract . If there are any differences between this summary and the official plan document s, the terms of the official plan document s will prevail.
Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connect icut Gen eral Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of it s subsidiaries. In T exas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the nat ional Cigna DPPO netwo rk. All Cigna product s and services are provided exclusively by or through operat ing subsidiaries of Cigna Corporat ion “Cigna Hom e 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.
© 2020 Cigna / version 04242020
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