CHOOSE CIGNA DENTAL (DHMO) FOR COST AND

DHMO LimitationsPROCEDURELIMITOral evaluationsOral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive monthperiod: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontalevaluations (D0180), and oral evaluations for patients under 3 years of age (D0145)Bitewings: 2 per calendar yearFull mouth: 1 every 3 calendar years.Panorex: 1 every 3 calendar yearsLimit 4 quadrants per consecutive 12 monthsX-rays (routine)X-rays (non-routine)Periodontal root planningand scalingPeriodontal maintenanceCrowns and inlaysBridgesDentures and partialsOrthodontic treatmentRelines, rebasesDenture adjustmentsProsthesis over implantTemporomandibular Joint(TMJ) treatmentAthletic mouth guardGeneral anesthesia/IV sedationLimited to 4 per year and (only covered after active periodontal therapy)Replacement 1 every 5 yearsReplacement 1 every 5 yearsReplacement 1 every 5 yearsMaximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or casesbeyond 24 months require an additional payment by the patientOne every 36 monthsFour within the first 6 months after installationReplacement 1 every 5 years if unserviceable and cannot be repairedOne occlusal orthotic device per 24 monthsOne athletic mouth guard per 12 monthsGeneral anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedureslisted on the PCS. IV sedation is covered when performed by a periodontist or oral surgeon when medicallynecessary for covered procedures listed on the PCS. Plan limitation for this benefit is 1 hour per appointment.Specialty treatment plans require payment authorization for services to be covered. Before treatmentstarts, you should verify with your network specialty dentist that your treatment plan has been authorizedfor payment by Cigna.Alternate BenefitsIf more than one professionally accepted and appropriate method of treatment can be used to treat adental condition, coverage will be limited to the less costly covered service. If you choose the more costlyservice, the copay listed on the PCS will not apply. Discuss your options and increased financial obligationswith your dentist.DHMO Exclusions:›››››Services for or in connection with an injury arisingout of, or in the course of, any employment for wageor profitCharges which would not have been made in anyfacility, other than a hospital or a correctionalinstitution owned or operated by the United Statesgovernment or by a state or municipal governmentif the person had no insuranceServices received to the extent that payment isunlawful where the person resides when theexpenses are incurred or the services are receivedServices for the charges which the person is notlegally required to payCharges which would not have been made if theperson had no insurance››››››Services received due to injuries which areintentionally self-inflictedServices not listed on the PCSServices provided by a non-network dentist withoutCigna Dental’s prior approval (except emergencies,as described in your plan documents)Services related to an injury or illness paid underworkers’ compensation, occupational disease orsimilar lawsServices provided or paid by or through a federal orstate governmental agency or authority, politicalsubdivision or a public program, other than MedicaidServices required while serving in the armed forcesof any country or international authority or relatingto a declared or undeclared war or acts of war

DHMO Exclusions �››Services performed primarily for cosmetic reasonsunless specifically listed on your PCSGeneral anesthesia, sedation and nitrous oxide,unless specifically listed on your PCSGeneral anesthesia or IV sedation when used for thepurpose of anxiety control or patient managementPrescription medicationsProcedures, appliances or restorations if the mainpurpose is to: a. change vertical dimension (degreeof separation of the jaw when teeth are in contact);b. restore teeth which have been damaged byattrition, abrasion, erosion and/or abfractionReplacement of fixed and/or removable appliances(including fixed and removable orthodonticappliances) that have been lost, stolen, or damageddue to patient abuse, misuse or neglectSurgical implant of any type unless specifically listedon your PCSServices considered unnecessary or experimental innature or do not meet commonly accepted dentalstandardsProcedures or appliances for minor tooth guidanceor to control harmful habitsServices and supplies received from a hospitalServices to the extent you or your enrolleddependent are compensated under any groupmedical plan, no-fault auto insurance policy, oruninsured motorist policyThe completion of crowns, bridges, dentures, or rootcanal treatment already in progress on the effectivedate of your Cigna Dental coverageThe completion of implant supported prosthesis(including crowns, bridges and dentures) already inprogress on the effective date of your Cigna Dentalcoverage, unless specifically listed on your PCSConsultations and/or evaluations associated withservices that are not coveredEndodontic treatment and/or periodontal (gumtissue and supporting bone) surgery of teethexhibiting a poor or hopeless periodontal �›Bone grafting and/or guided tissue regenerationwhen performed at the site of a tooth extractionunless specifically listed on your PCSIntentional root canal treatment in the absence ofinjury or disease to solely facilitate a restorativeprocedureServices performed by a prosthodontistLocalized delivery of antimicrobial agents whenperformed alone or in the absence of traditionalperiodontal therapyAny localized delivery of antimicrobial agentprocedures when more than eight of theseprocedures are reported on the same date of serviceInfection control and/or sterilizationThe recementation of any inlay, onlay, crown, postand core or fixed bridge within 180 days of initialplacementInfection control and/or sterilizationThe recementation of any inlay, onlay, crown, postand core or fixed bridge within 180 days of initialplacementThe recementation of any implant supportedprosthesis (including crowns, bridges and dentures)within 180 days of initial placementServices to correct congenital malformations,including the replacement of congenitallymissing teethThe replacement of an occlusal guard (night guard)beyond one per any 24 consecutive month period,when this limitation is noted on the PCSCrowns, bridges and/or implant supportedprosthesis used solely for splintingResin bonded retainers and associated ponticsAs to orthodontic treatment: incremental costsassociated with optional/elective materials;orthognathic surgery appliances to guide minortooth movement or correct harmful habits; andany services which are not typically included inorthodontic treatmentThis guide provides highlights of coverage only. It is not a contract. For complete details of coverage, see your plan documents. If there are any differences between the information in thisdocument and the official plan documents, the terms of the plan documents will control.1. The term DHMO (“Dental HMO”) is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and planswith open access features. The Cigna Dental Care Plan is not available in all states.2. This program is NOT insurance and does not provide reimbursement of financial losses. Services are provided under a contract with Generali Global Assistance. Full terms, conditionsand exclusions are contained in Cigna’s Identity Theft program service agreement.3. You must enroll in the program prior to receiving treatment to be eligible for reimbursement. For DPPO plans, deductible does not apply, but reimbursements under this program are applied toand subject to the calendar year maximum. For a complete list of covered services and program terms, contact Cigna.The dentists that participate in the Cigna network are independent contractors solely responsible for the treatment provided to their patients. They are not agents of Cigna.All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. Dental PPO plans are insured and/or administered by Cigna Health and LifeInsurance Company (CHLIC) with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Georgia, Cigna Dental Care (DHMO) plans are insured byCHLIC and administered by Cigna Dental Health, Inc. TN policy form (DHMO): HP-POL134/HC-CER17V1 et al. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property,Inc. All pictures are used for illustrative purposes only.917118 09/18 2018 Cigna. Some content provided under license.

Cigna Dental Care (DHMO) Cigna Dental PPO-Mid Cigna Dental PPO-High EE Only 161.28 397.92 617.76 EE Spouse 322.44 795.24 1,235.40 EE Child(ren) 403.08 994.08 1,544.16 EE Family 483.60 1,191.84 1,849.68 Costs are subject to change. Plan Details* Cigna Dental Care (DHMO) (Patient Charge Schedule)