CIGNA DENTAL CARE CIGNA DENTAL CARE

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					                                                                                                                                Exclusions And Limitations
CIGNA DENTAL CARE                                                                                   LIMITATIONS ON COVERED SERVICES:                                                                                                                                          CIGNA
                                                                                                                                                                                                                                                                              DENTAL
                                                                                                    Listed below are limitations on services covered by the Dental Plan:
                                                                                                    A. Frequency – The frequency of certain covered services, such as cleanings, is limited. The
See, we weren’t kidding when we said savings:                                                           Patient Charge Schedule lists any limitations on frequency.
                                                                                                    B. Specialty Care – Payment authorization is required for coverage of services by a Network
                                                                                                        Specialist.
                                                                                                    C. Pediatric Dentistry – Coverage for referral to a Pediatric Dentist ends on an enrolled child’s
                                                                                                                                                                                                                                                                              CARE
                                                                                                        7th birthday; however, exceptions for medical reasons may be considered on an individual
                                                                                                        basis. The Network General Dentist shall provide care after the child’s 7th birthday.
                                                               What You’ll Pay                      D. Oral Surgery – The surgical removal of an impacted wisdom tooth is not covered if the tooth
                                                                                                        is not diseased or if the removal is only for orthodontic reasons.                                                                                                    Health coverage
                                                              With                   Without        EXCLUSIONS
                                                             CIGNA                   Dental         Listed below are the services or expenses which are NOT covered under your Dental Plan and
                                                                                                                                                                                                                                                                              for your mouth.
                                                           Dental Care              Coverage        which are your responsibility at the dentist's Usual Fees. There is no coverage for:
                                                                                                    A) Services not listed on the Patient Charge Schedule.
Typical Adult Annual Cost                                                                           B) Services provided by a non-Network Dentist except as described in your plan document or as
                                                                                                        otherwise required by law.
Two periodic exams

Four bitewing x-rays
                                                              $

                                                              $
                                                                      0

                                                                      0
                                                                                      $

                                                                                      $
                                                                                             54

                                                                                             48
                                                                                                    C) Services related to an injury or illness paid under workers' compensation, occupational disease
                                                                                                        or similar laws.
                                                                                                    D) Services provided or paid by or through a federal or state governmental agency or authority,
                                                                                                                                                                                                                                               Significant savings.
                                                                                                                                                                                                                                               No surprises.
                                                                                                        political subdivision or a public program, other than Medicaid.
Two quadrants of periodontal                                                                        E) Services relating to injuries which are intentionally self-inflicted. (Ohio and Texas residents:
  scaling and root planing                                    $      90               $    296          Services relating to injuries which are intentionally self-inflicted are not excluded.)
                                                                                                    F) Services required while serving in the armed forces of any country or international authority
Two routine cleanings                                         $       0               $    116          or relating to a declared or undeclared war or acts of war.
                                                                                                    G) Cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to
One resin/composite 1-surface filling                                                                   improve appearance).                                                                                                                            With CIGNA Dental Care, you’ll know
  (anterior)                                                  $       0               $      91     H) General anesthesia, sedation and nitrous oxide, unless specifically listed on your Patient
                                                                                                        Charge Schedule. When listed on your Patient Charge Schedule, general anesthesia and IV                                                         exactly what you pay — even for specialty
Anterior root canal                                           $      95               $    465          Sedation are covered when medically necessary and provided in conjunction with Covered
                                                                                                        Services performed by an Oral Surgeon or Periodontist. (Maryland residents: General                                                             care with a referral approved for payment.
Porcelain crown                                               $    390                $    777          anesthesia is covered when medically necessary and authorized by your physician.)
                                                                                                    I) Prescription drugs.
Subtotal                                                      $ 575                   $1,847        J) Procedures, appliances or restorations if the main purpose is to: (1) change vertical dimension
                                                                                                        (degree of separation of the jaw when teeth are in contact); (2) diagnose or treat abnormal
                                                                                                        conditions of the temporomandibular joint ("TMJ"), unless TMJ therapy is specifically listed on


Typical Child Annual Cost
                                                                                                        your Patient Charge Schedule; or (3) restore teeth which have been damaged by attrition,
                                                                                                        abrasion, erosion and/or abfraction.                                                                                                            Porcelain Crown
                                                                                                    K) The completion of crown and bridge, dentures or root canal treatment already in progress on
                                                                                                        the effective date of your CIGNA Dental coverage. (Texas residents: Pre-existing conditions,
Two periodic exams                                            $       0               $      54         including the completion of crown and bridge, dentures or root canal treatment already in
                                                                                                                                                                                                                                                        What you may pay without dental coverage   $777
                                                                                                        progress on the effective date of your coverage, are not excluded, if otherwise covered under
Two bitewing x-rays                                           $       0               $      24         your Patient Charge Schedule.)                                                                                                                  What you’ll pay with CIGNA Dental Care     $390
                                                                                                    L) Replacement of fixed and/or removable prosthodontic or orthodontic appliances that have
Two routine cleanings                                         $       0               $      82         been lost, stolen, or damaged due to patient abuse, misuse or neglect.
                                                                                                    M) Services associated with the placement or prosthodontic restoration of a dental implant.                                                         Savings                            $387
Two fluoride treatments                                       $       0               $      44     N) Services considered to be unnecessary or experimental in nature. (Maryland residents: This
                                                                                                        exclusion should read "Services considered to be unnecessary." Pennsylvania residents: This
Single extraction                                             $       0               $      83         exclusion should read "Services considered experimental in nature.")
                                                                                                    O) Procedures or appliances for minor tooth guidance or to control harmful habits.
Orthodontic evaluation, treatment                                                                   P) Hospitalization, including any associated incremental charges for dental services performed in
  plan and records                                            $    190                $    262          a hospital.                                                                                                                                                This fee overview shows
Banding for Comprehensive Orthodontic
                                                                                                    Q) Services to the extent you, or your Dependent, are compensated for them under any group
                                                                                                        medical plan, no-fault auto insurance policy, or insured motorist policy. (Arizona and
                                                                                                                                                                                                                                                                    the highlights of your
  Treatment*                                                  $    300                $    816          Pennsylvania residents: Services compensated under group medical plan, no-fault auto
                                                                                                        insurance policies or insured motorist polices are not excluded. Kentucky and North Carolina
                                                                                                                                                                                                                                                                  CIGNA Dental Care plan.
12 months Comprehensive Orthodontic                                                                     residents: Services compensated under no-fault auto insurance policies or insured motorists
                                                                                                        policies are not excluded. Maryland residents: Services compensated under group medical
                                                                                                                                                                                                                                                                  See more savings inside!
  Treatment, child*                                           $    700                $ 1,532
                                                                                                        plans are not excluded.)
Subtotal                                                      $1,190                  $2,897        R) Crowns and bridges used solely for splinting.
                                                                                                    S) Resin bonded retainers and associated pontics.
Grand Total                                                   $1,765                  $4,744        Additional clinical guidelines may be specified in your plan documents.
                                                                                                    Except as set forth above, pre-existing conditions are not excluded.
      Total Savings with CIGNA Dental Care — $2,979                                                 CIGNA Dental refers to the following operating subsidiaries of CIGNA Corporation: Connecticut General Life Insurance Company and
                                                                                                    CIGNA Dental Health, Inc., and its operating subsidiaries. The CIGNA Dental Care plan is provided by CIGNA Dental Health Plan of
*Orthodontic treatment is limited to a lifetime maximum benefit of 24 months. Additional            Arizona, Inc.; CIGNA Dental Health of California, Inc.; CIGNA Dental Health of Colorado, Inc.; CIGNA Dental Health of Delaware, Inc.;
charges apply for retention and/or interceptive orthodontic treatment. Patient charges listed are
                                                                                                    CIGNA Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; CIGNA
not applicable to orthodontics in progress.
                                                                                                    Dental Health of Kansas, Inc. (Kansas and Nebraska); CIGNA Dental Health of Kentucky, Inc.; CIGNA Dental Health of Maryland, Inc.;
                                                                                                                                                                                                                                               1.800.367.1037
                                                                                                    CIGNA Dental Health of New Jersey, Inc.; CIGNA Dental Health of New Mexico, Inc., (available only in Albuquerque and Santa Fe); CIGNA
                                                                                                    Dental Health of North Carolina, Inc.; CIGNA Dental Health of Ohio, Inc.; CIGNA Dental Health of Pennsylvania, Inc.; CIGNA Dental Health   www.cigna.com
1.800.367.1037                                                                                      of Texas, Inc., and CIGNA Dental Health of Virginia, Inc. In certain states, CIGNA Dental Care is provided through the specific state
                                                                                                    subsidiary of CIGNA Dental Health, Inc., as indicated above. In other states, the CIGNA Dental Care plan is underwritten by Connecticut
www.cigna.com                                                                                       General Life Insurance Company and administered by CIGNA Dental Health, Inc.
                                                                                                                                                                                                                                               K1-04
                                                                                                                                                                                                                                               584291    7/2001
                                                                           What You’ll Pay                                                                                                           What You’ll Pay                                                                                                          What You’ll Pay
                                                                            With        Without                                                                                                       With        Without                                                                                                      With        Without
                                                                         CIGNA           Dental                                                                                                    CIGNA           Dental                                                                                                   CIGNA           Dental
                                                                     Dental Care        Coverage                                                                                               Dental Care        Coverage                                                                                              Dental Care        Coverage
Diagnostic/Preventive                                                                                  Endodontics (Root Canal Treatment, Excluding                                                                                      Orthodontics (Tooth Movement)
Periodic Oral Evaluation                              $                        0         $      27     Final Restorations)                                                                                                               This benefit is available for treatment started after your CIGNA Dental Care plan is effective.
Limited Oral Evaluation – Problem Focused                                      0                45     Pulp Cap – Direct (Excluding Final Restoration)                                           $          0            $        51
Comprehensive Oral Evaluation                                                  0                43     Pulp Cap – Indirect (Excluding Final Restoration)                                                    0                     42     Orthodontic Evaluation                                                         $      40          $       68
Re-evaluation – Limited, Problem Focused (Established                                                  Therapeutic Pulpotomy (Excluding Final Restoration)                                                 50                    105     Orthodontic Treatment Plan and Records                                               150                 194
  Patient; Not Post- Operative Visit)                                          0                45     Anterior Root Canal (Permanent Tooth) (Excluding                                                                                  Removable and/or Fixed Appliance(s) Insertion for
X-Rays Intraoral – Complete Series                                                                       Final Restoration)                                                                                95                    465       Interceptive Treatment                                                             275                 475
  (Including Bitewings)#                                                       0                85     Bicuspid Root Canal (Permanent Tooth) (Excluding                                                                                  Fixed Appliance Insertion (Banding) for
X-Rays Intraoral – Periapical First Film                                       0                16       Final Restoration)                                                                              165                     547       Comprehensive Treatment                                                            300                 816
X-Rays Intraoral – Periapical Each Additional Film                             0                12     Molar Root Canal (Permanent Tooth) (Excluding                                                                                     Orthodontic treatment (maximum lifetime benefit of 24 months of interceptive and/or comprehensive
X-Rays (Bitewing) – Single Film                                                0                16       Final Restoration)                                                                              235                     704     treatment) can include:
X-Rays (Bitewing) – Two Films                                                  0                24                                                                                                                                       Interceptive Orthodontic Treatment
X-Rays (Bitewing) – Four Films                                                 0                38
                                                                                                       Periodontics (Treatment of Supporting Tissues [Gum & Bone]
                                                                                                                                                                                                                                         Class I, II, III Malocclusion – Comprehensive Treatment
X-Rays (Panoramic) #                                                           0                68
                                                                                                       of the Teeth)
                                                                                                                                                                                                                                           – Combination of Primary and Permanent Teeth
Prophylaxis – Adult ##                                                         0                       Periodontal Evaluation and Treatment Plan                                                 $         30            $         68
                                                                                                58                                                                                                                                       Class I, II, III Malocclusion – Comprehensive Treatment
Prophylaxis – Adult (In addition to the 1 Prophylaxis                                                  Periodontal Scaling and Root Planing I (Limit                                                                                       – Permanent Teeth
  Allowed Every 6 months)                                                     50                58       4 Quadrants Per Consecutive 12 Months)                                                            45                    148           Children (Up to 19th Birthday)                                               1,400              3,065
Prophylaxis – Child ##                                                         0                41     Periodontal Scaling and Root Planing I (1 tooth)                                                                                        Adults                                                                       1,900              3,616
                                                                                                         (Limit 4 Quadrants Per Consecutive 12 Months)                                                     20                      59
Prophylaxis – Child (In addition to the 1 Prophylaxis                                                                                                                                                                                    Atypical cases or cases beyond 24 months require an additional payment by the patient.
  Allowed every 6 months)                                                     35                41     Periodontal Scaling and Root Planing I (2-4 teeth)
                                                                                                         (Limit 4 Quadrants Per Consecutive 12 Months)                                                     25                      88    Retention – Post Treatment Stabilization (Includes
Topical Application of Fluoride – (Prophylaxis Not                                                                                                                                                                                         Appliance(s) and Treatment)                                                        300                 639
  Included) – Child N##                                                        0                22     Full Mouth Debridement to Enable Comprehensive
                                                                                                         Periodontal Evaluation and Diagnosis ❂                                                            45                    135
Oral Hygiene Instructions                                                      0                36                                                                                                                                       General Anesthesia/IV Sedation
                                                                                                       Periodontal Maintenance Procedure
Sealant I I ✤                                                                 10                34       (Following Active Therapy)(Limit 2 Within
                                                                                                         12 Months)                                                                                        35                      91    Covered when performed by a periodontist or oral surgeon when medically necessary for covered
Restorative (Fillings)                                                                                                                                                                                                                   procedures listed on the Patient Charge Schedule.
Amalgam – One Surface, Primary                                        $        0         $      64     Prosthetics
Amalgam – Two Surfaces, Primary                                                0                81                                                                                                                                       General Anesthesia – First 30 Minutes                                          $     115          $      230
                                                                                                       Removable tooth replacement – dentures. Includes up to 4 adjustments within first 6 months after                                  General Anesthesia – Each Additional 15 Minutes                                       60                 123
Amalgam – One Surface, Permanent                                               0                71     insertion – replacement limit 1 every 5 years.
                                                                                                                                                                                                                                         Intravenous Sedation/Analgesia – First 30 Minutes                                    115                 230
Amalgam – Two Surfaces, Permanent                                              0                90
Amalgam – Three Surfaces, Permanent                                            0               110     Complete Denture – Maxillary                          $                                           440             $       805     Intravenous Sedation/Analgesia – Each Additional
                                                                                                       Complete Denture – Mandibular                                                                     440                     775       15 Minutes                                                                          60                 123
Amalgam – Four or More Surfaces, Permanent                                     0               131
Resin-Based Composite – One Surface, Anterior                                  0                91     Maxillary Partial Denture – Cast Metal Framework with
                                                                                                        Resin Denture Bases (Including Any Conventional                                                                                  Emergency Services
Resin-Based Composite – Two Surfaces, Anterior                                 0               112                                                                                                       440                     970     Emergency Exam and Visit – Pain Relief Treatment
                                                                                                        Clasps, Rests and Teeth)
Resin-Based Composite – Three Surfaces, Anterior                               0               139                                                                                                                                         During Regularly Scheduled Office Hours                                      $       0          $       65
                                                                                                       Mandibular Partial Denture – Cast Metal Framework
Resin-Based Composite – Four or More Surfaces or                                                        with Resin Denture Bases (Including Any                                                                                          Office Visit – After Regularly Scheduled Hours                                        45                  83
  Involving Incisal Angle (Anterior)                                          75               165      Conventional Clasps, Rests and Teeth)                                                            440                     960
Resin-Based Composite – One Surface, Posterior                                                                                                                                                                                           Broken Appointment
  – Primary                                                                   30                84     Repairs To Prosthetics                                                                                                            The following Broken Appointment Section does not apply for Texas residents.
Resin-Based Composite – Two Surfaces, Posterior                                                        Add Tooth to Existing Partial Denture                                                     $         65            $       102
  – Permanent                                                                 40               134                                                                                                                                       This fee will not be charged if patient is unable to provide 24-hours’ notice through no fault of his or
Resin-Based Composite – Three Surfaces, Posterior                                                      Oral Surgery (Includes Routine Post-Operative Treatment)                                                                          her own.
  – Permanent                                                                 55               168
                                                                                                       Extraction (Single Tooth)                                                                 $          0            $        83
                                                                                                                                                                                                                                         Broken Appointment – Less Than 24-hours’ Notice
Crown & Bridge (Including Temporaries)                                                                 Extraction (Each Additional Tooth)                                                                   0                     77
                                                                                                                                                                                                                                           (Per 15-Minute Appointment)                                                  $      10                N/A
                                                                                                       Surgical Extraction Erupted Tooth                                                                   35                    159
All charges for crown and bridge are per unit (each replacement or supporting tooth equals one unit)                                                                                                                                     Maximum Fee For Broken Appointment:
– replacement limit 1 every 5 years.                                                                   Surgical removal of impacted tooth – (not covered unless pathology [disease] exists). Surgical removal of                                 Sealant                                                                       10
                                                                                                       wisdom tooth/3rd molar for orthodontic reasons only is not covered.                                                                       Prophylaxis                                                                   20
Crown – Porcelain/Ceramic Substrate                 $                       390          $     777                                                                                                                                               Any Other Appointment                                                         40
Crown – Porcelain Fused to High Noble Metal                                 380                741
Crown – Porcelain Fused to Predominantly Base Metal                         310                637
Crown – Porcelain Fused to Noble Metal                                      370                687                                                                                                                                       Exclusions and limitations may apply. Consult your group agreement for details. This Fee Overview
Crown – Full Cast Noble Metal                                               370                642                                                                                                                                       reflects the patient charges on your Patient Charge Schedule. In case of any discrepancy between
                                                                                                       Call Member Services for information on procedures not listed.                                                                    this Dental Fee Overview and your Patient Charge Schedule sent to you after your enrollment, the
Recement Crown                                                               20                 59     This Sample is an overview of your costs at your CIGNA Dental Care network office. The complete Patient Charge Schedule will be   Patient Charge Schedule will prevail.
Sedative Filling                                                              0                 63     sent to you after you enroll. Estimated costs without dental coverage are based on Connecticut General Life Insurance Company
Core Buildup, Including Any Pins                                            120                156     national claims analysis, prepared March, 2001. Actual charges without dental coverage may differ from your area charges or
Prefabricated Post and Core In Addition to Crown                            120                210     local dentist’s fees.

 # Limit 1 every 3 years.  N Up to 19th birthday.            I Per quadrant.       ❂ 1 per lifetime.
                                                                                                                                                                                                                                                                                                                             K1-04 / cat #584291 (7/01)
## Limit 1 every 6 months. ✤ Up to 14th birthday.          I I Per tooth.

				
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