2020 DPPO 2 Tier

Cigna Dental Benefit Summary Mid-America Apartments, L.P. - Low Plan Renewal Date: 01/01/2020

Administered 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. Cigna Dental PPO Network Options In-Network: Total Cigna DPPO Network Non-Network: See Non-Network Reimbursement Reimbursement Levels Based on Contracted Fees Maximum Reimbursable Charge

Calendar Year Benefits Maximum Applies to: Class I, II & III expenses

$1,500

$1,500

Calendar Year Deductible Individual Family

$50 $150

$50 $150

Plan Pays

You Pay No Charge

Plan Pays

You Pay No Charge

Benefit Highlights

100% No Deductible

100% No Deductible

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

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

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 Adjustments Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

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. 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 charges in the geographic area. The dentist may balance bill up to their usual fees. 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. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply.

Non-Network Reimbursement

Cross Accumulation

Calendar Year Benefits Maximum

Calendar Year Deductible

Pretreatment Review

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

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