Calendar Year Deductible
This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed. When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. This provision does not apply to composite (white/tooth-colored) fillings on molars. The Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with certain medical conditions. There is no additional charge to participate in the program. Those who qualify can receive reimbursement of their coinsurance for eligible dental services. Eligible customers can also receive guidance on behavioral issues related to oral health. Reimbursements under this program are not subject to the annual deductible, but will be applied to the plan annual maximum. For more information on how to enroll in this program and a complete list of terms and eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1-800-Cigna24.
Pretreatment Review
Alternate Benefit Provision
Oral Health Integration Program ®
Timely Filing
Out of network claims submitted to Cigna after 365 days from date of service will be denied.
Benefit Limitations: Oral Evaluations/Exams
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)
Cleanings
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.
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
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;
• 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 of dysfunction of the temporomandibular joint (TMJ), stabilize periodontally involved teeth or restore occlusion; • Athletic mouth guards;
• Services performed primarily for cosmetic reasons; • Personalization or decoration of any dental device or dental work;
• 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.
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