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.