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Dental
Care Benefits
Options
A – D, HDHP and HMO
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| Options
A-D & HDHP |
|
Contact
CIGNA toll-free: 800-CIGNA2 (244-6224) |
Your
personalized dental benefit and claim information can be
found at myCIGNA.com
(registration required). |
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| Annual
Deductible |
$100
individual/
$300 family unit**** |
| Preventive
Dental Care** |
100%,
no deductible*** |
| Basic
Dental Care |
80%,
after deductible*** |
| Oral
Surgery |
80%,
after deductible*** |
| Dentures
(initial installation, and replacement if more than
5 years since installation |
80%,
after deductible*** |
| Orthodontic |
50%,
after deductible*** |
| Combined
annual maximum benefit per person for preventive dental
care, basic dental care, and dentures |
$1,500 |
| Individual
lifetime maximum benefit for orthodontic care |
$1,500 |
| "Alternate
Benefit" limitation: When there is a choice of
treatment options for dental care, reimbursement shall
normally be limited to the least expensive, commonly
accepted dental standard for adequate and appropriate
care for that dental condition. |
|
*
Members receive discounted prices for dental work when a
CIGNA network dentist is used. |
| ** Two
exams and/or cleanings, two sets of bitewing x-rays per year,
one set of full mouth or panoramic x-rays every three years,
one fluoride application per year for persons under 19, sealants
(posterior tooth, only for persons under 16, one treatment
per tooth every three years), space maintainers (non-orthodontic
treatment), emergency care to relieve pain, and palliative
(emergency) treatment. |
| ***
Customary charge limits apply. A customary charge is the most
common charge for a medical or dental service or item in a
geographic area. |
| ****
"Family unit" shall mean a member and that member's
enrolled dependents. |
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| Options
HMO |
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Contact
CIGNA toll-free: 800-CIGNA24 (244-6224) |
| Note:
The dental benefit information listed below applies only for
Option HMO in Southern California. To find out if an HMO option
is available in your area, please contact Concordia Plan Services
toll-free: 888-927-7526 |
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In-Network
Member Pays: |
Out-of-Network
Member Pays: |
| CLASS
I: Preventive and Diagnostic Care
Oral exams (two per calendar year), cleanings (two
per calendar year), two sets of bitewing x-rays per
year, one set of full mouth or panoramic x-rays every
three years, fluoride application (two per calendar)
for persons under 19, sealants (limited to posterior
tooth, only for persons under 16, one treatment per
tooth every three years), space maintainers (non-orthodontic
treatment), emergency care to relieve pain. |
$0 |
10%
no deductible |
| CLASS
II: Basic Restorative Services
Fillings, root canal therapy, osseous surgery, periodontal
scaling and root planing, denture adjustments or repairs,
oral surgery (including tooth extractions), anesthesia,
repairs to bridges, crowns, inlays, and dental x-rays
required for the diagnosis or treatment of a dental
defect, injury, or disease. |
20%
after deductible |
30%
after deductible |
| CLASS
III: Major Restorative Services
Crowns, inlays, onlays, bridges, full and partial
dentures, and implants. |
50%
after deductible |
50%
after deductible |
| CLASS
IV: Orthodontia
Treatment and installation of orthodontic appliances
for correction of irregularities in tooth position
and jaw relationship (for adults and dependent children). |
50% |
50% |
| CLASS
V: TMJ Treatment
Temporomandibular joint (TMJ) disorder will be covered
under dental benefits only if deemed by CIGNA Dental
to be a dental expense instead of medical expense. |
20%
after deductible |
30%
after deductible |
| Denture
replacement will be covered only if it has been more
than five years since the installation of the denture
being replaced, whether or not the replaced denture
was installed or furnished while the person was a member
or enrolled dependent. |
| All
services and supplies must be provided by a network
provider. Eligible charges are based on reasonable and
customary allowances. |
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