260125_Chapter_1E_-_Dental_COT_PPO_Summary_-_AZ.pdf

Cigna Dental Benefit Summary City of Tucson - AZ Plan Renewal Date: 07/01/2025

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.

Benefit Plan Features DPPO Total Network Non-Network Network Options

Advantage Network Total Network See Non-Network Reimbursement

Reimbursement Levels Fee Schedule Discount on Fees Maximum Reimbursable Charge

Policy Year Benefits Maximum Applies to: Class I, II, III & IX expenses

$2,000 $1,500 $1,500

Policy Year Deductible Individual Family

$25 $75

$50

$150

$50 $150

Benefit Highlights Plan Pays Plan Pays Plan Pays 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.)

100% No Deductible

80%

80%

Class II: Basic Restorative Restorative: fillings 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

90% After Deductible

80% After Deductible

80% After Deductible

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

60% After Deductible

50% After Deductible

50% After Deductible

Class IV: Orthodontia Coverage for Employee and All Dependents Lifetime Benefits Maximum:

In-network: $2,000 Out-of-network: $1,500

60%

Class IX: Implants

After Deductible

50%

50%

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.

Non-Network Reimbursement

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 80th percentile of all provider submitted amounts in the geographic area. The dentist may balance bill up to their usual fees.

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.

Policy Year Benefits Maximum The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable.

Benefit-specific Maximums may also apply.

Policy Year Deductible This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply.

Late Entrant Limitation Provision Payment will be reduced by 50% for Class III, IV and IX services for 24 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period.

This provision does not apply to new hires.

Pretreatment Review Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision 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.

Oral Health Integration Program®

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.

Timely Filing Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations:

Missing Tooth Limitation For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 24 months; thereafter, considered a Class III expense.

Oral Evaluations/Exams 2 per policy year.

X-rays (routine) Bitewings: 2 per policy year.

X-rays (non-routine) Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months.

Diagnostic Casts Payable only in conjunction with orthodontic workup.

Cleanings 2 per policy year, including periodontal maintenance procedures following active therapy.

Fluoride Application 1 per policy year for children under age 19.

Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14.

Space Maintainers Limited to non-orthodontic treatment, no age limit.

Crowns, Bridges, Dentures and Partials 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.

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 1 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.

http://www.mycigna.com/

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 official 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 dental 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 Customers | 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.

© 2025 Cigna / version 10142024

Class IX: Implants