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



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.

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. Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional 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 discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the annual deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Oral Health Integration Program (OHIP)

Timely Filing

Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations: Oral Evaluations

2 per calendar year

X-rays (routine)

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-routine)


2 per calendar year, including periodontal maintenance procedures following active therapy

Fluoride Application

2 per calendar year for children under age 19

Sealants (per tooth)

Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 16

Space Maintainers

Limited to non-orthodontic treatment for children under age 19

Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Inlays, Crowns, Bridges, Dentures and Partials

Denture and Bridge Repairs

Reviewed if more than once

Denture Relines, Rebases and Adjustments

Covered if more than 6 months after installation

Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Prosthesis Over Implant

Restorative: 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; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: 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; Periodontics: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Implants: implants or implant related services; Orthodontics: orthodontic treatment; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; 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 Reimbursable Charge.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail.

Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home 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.

© 2017 Cigna / version 06192017

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