2025 Cigna Dental Plan Summary - High Option

Cigna Dental Benefit Summary Mid-America Apartments, L.P. - High Plan Renewal Date: 01/01/2025

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. Your DPPO plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-of-pocket expenses. DPPO Network Options In-Network: Total 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 & IX expenses

$2,500

Calendar Year Deductible Individual Family

$50 $150

Plan Pays

You Pay

Plan Pays

You Pay

Benefit Highlights

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 (Note: This service is administered at the in-network coinsurance level.) Class II: Basic Restorative Restorative: fillings (Includes composite (white/tooth-colored) fillings on molars.)

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

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 Class IV: Orthodontia Coverage for Employee and All Dependents Lifetime Benefits Maximum: $2,500

60% After Deductible

40% After Deductible

60% After Deductible

40% After Deductible

50% No Deductible

Class IX: Implants

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 submitted amounts in the geographic area. The dentist may balance bill up to their usual fees.

Non-Network Reimbursement

Cross Accumulation

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. 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.

Calendar Year Benefits Maximum

Calendar Year Deductible

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)

Diagnostic Casts

Payable only in conjunction with orthodontic workup.

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.

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; • 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.

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

Product availability may vary by location and plan type and is subject to change. All group dental insurance policies and den tal benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative.

A copy of the NH Dental Outline of Coverage is available and can be downloaded at Health Insurance & Medical Forms for Custom ers | Cigna under Dental Forms.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, and Cigna Dental Health, Inc.

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