4-Dental Plan.pdf

City of Lewisville

CIGNA DENTAL CHOICE

EFFECTIVE DATE: January 1, 2026

ASO63

3328347

This document printed in February, 2026 takes the place of any documents previously issued to You which described Your benefits.

Printed in U.S.A.

HCDFB-CVR30 06-21

Table of Contents Important Information Important Notices How To File A Claim Eligibility - Effective Date Covered Dental Expenses Missing Tooth Limitation Cigna Dental Choice Insurance

The Schedule

Covered Dental Services General Limitations and Expenses Not Covered Coordination of Benefits Expenses For Which A Third Party May Be Responsible Payment of Benefits Termination of Insurance Dental Benefits Extension Special Plan Provisions

Appointment of Authorized Representative

The Following Will Apply To Residents Of Texas When You Have A Complaint Or An Adverse Determination Appeal Miscellaneous Definitions Federal Requirements

Qualified Medical Child Support Order (QMCSO) Effect of Section 125 Tax Regulations on This Plan Eligibility for Coverage for Adopted Children Group Plan Coverage Instead of Medicaid Requirements of Family and Medical Leave Act of 1993 (as amended) (FMLA) Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) Claim Determination Procedures COBRA Continuation Rights Under Federal Law

HCDFB-TOC28 06-21

Important Information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR

ANY RIDER ATTACHED HERETO ARE SELF-INSURED BY CITY OF LEWISVILLE WHICH IS

RESPONSIBLE FOR THEIR PAYMENT. CIGNA HEALTH AND LIFE INSURANCE COMPANY

(CIGNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT CIGNA DOES NOT

INSURE THE BENEFITS DESCRIBED.

THIS DOCUMENT MAY USE WORDS THAT DESCRIBE A PLAN INSURED BY CIGNA. BECAUSE

THE PLAN IS NOT INSURED BY CIGNA, ALL REFERENCES TO INSURANCE SHALL BE READ TO

INDICATE THAT THE PLAN IS SELF-INSURED. FOR EXAMPLE, REFERENCES TO "CIGNA,"

"INSURANCE COMPANY," AND "POLICYHOLDER" SHALL BE DEEMED TO MEAN YOUR

"EMPLOYER" AND "POLICY" TO MEAN "PLAN" AND "INSURED" TO MEAN "COVERED" AND

"INSURANCE" SHALL BE DEEMED TO MEAN "COVERAGE."

HCDFB-NOT1

Explanation of Terms You will find terms starting with capital letters throughout Your Certificate. To help You understand Your benefits, most of these terms are defined in the Definitions section of Your Certificate.

The Schedule The Schedule is a brief outline of Your maximum benefits which may be payable under Your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents.

HCDFB-NOTICE

myCigna.com6

Important Notices Discrimination is Against the Law Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as

• Qualified interpreters

• Information written in other languages

If you need these services, contact customer service at the toll-free phone number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address:

Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

HC-NOT96 07-17

Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call

1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。

對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。

其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 현재 Cigna

가입자님들께서는 ID 카드 뒷면에 있는 전화번호로

연락해주십시오. 기타 다른 경우에는 1.800.244.6224

(TTY: 다이얼 711)번으로 전화해주십시오.

myCigna.com7

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224

(TTY: 711).

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro

1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para

1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サー

ビスをご利用いただけます。現在のCignaの

お客様は、IDカード裏面の電話番号まで、お電話にてご

連絡ください。その他の方は、1.800.244.6224（TTY:

711）まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione.

In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung.

Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte

an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

HC-NOT97 07-17

How To File A Claim There is no paperwork to submit for Covered Dental Services received from a Contracted Provider. Pay Your share of the cost, if any, Your provider will submit a claim to Us for reimbursement. Claims for services received from a Non- Contracted Provider can be submitted by the provider if the provider is able and willing to file on Your behalf. If Your plan provides coverage when care is received only from a Contracted Provider, You may still have claims for services received from a Non-Contracted Provider. For example, when Emergency Services are received from a Non-Contracted Provider, You should follow the claim submission instructions for those claims. Claims can be submitted by the provider if the provider is able and willing to file on Your behalf. If the provider is not submitting on Your behalf, You must send Your completed claim form and itemized bills to the claims address listed on the claim form.

You may get the required claim forms from the website listed on Your identification card, if You received one, or by calling Customer Services using the toll-free number listed below.

Cigna's Toll-Free Number(s):

1-(800) CIGNA24 (1-800-244-6224)

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CLAIM REMINDERS

• BE SURE TO USE YOUR MEMBER ID AND

ACCOUNT/GROUP NUMBER WHEN YOU FILE

CLAIM FORMS, OR WHEN YOU CALL OUR CLAIM

OFFICE.

YOUR MEMBER ID IS THE ID SHOWN ON YOUR

BENEFIT IDENTIFICATION CARD. YOUR

ACCOUNT/GROUP NUMBER IS SHOWN ON YOUR

BENEFIT IDENTIFICATION CARD.

• BE SURE TO FOLLOW THE INSTRUCTIONS LISTED

ON THE BACK OF THE CLAIM FORM CAREFULLY

WHEN SUBMITTING A CLAIM TO US.

Timely Filing Of Claims We will consider claims for coverage under Your plan when proof of loss (a claim) is submitted to Us within:

• 12 months for both Contracted and Non-Contracted

Provider claims after services are rendered. If services are rendered on consecutive days, the limit will be counted from the last date of service. If claims are not submitted to Us within the timeframe shown above, the claim will not be considered valid and will be denied. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

NOTE: Cigna considers one month to equal 30 days regardless of the number of days within a Calendar month.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person: files an application for insurance or statement of claim containing any materially false information; or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.

HCDFB-CLM37 01-19

Eligibility - Effective Date Eligible Class Each Employee as reported to Us by Your Employer.

Eligibility for Dental Insurance You will become eligible for insurance on the day You complete the Eligibility Waiting Period, if any, and:

• You are an eligible Full-Time Employee;

• You normally work at least 30 hours a week; and

• You pay any required contribution.

Eligibility Waiting Period – New Hire Your Eligibility Waiting Period is:

• Coverage begins for a new employee who is actively at work on the date following his/her thirtieth (30th) consecutive day of employment.

Effective Date of Your Insurance You will become insured on:

• the date that:

You are in Active Service and You elect the insurance by:

• authorizing premium payment,

• approving a payroll deduction, or

• signing an enrollment form, as applicable, but no earlier than the date You become eligible.

You will become insured on Your first day of eligibility, following Your election, if You are in Active Service on that date, or if You are not in Active Service on that date due to Your health status.

Dependent Insurance For Your Dependents to be insured under the Policy, You must elect the Dependent Insurance for Yourself no later than 30 days after You become eligible. For Your Dependents to be insured, You will have to pay the required contribution, if any, toward the cost of Dependent Insurance.

Eligibility for Dependent Insurance Your Dependent will become eligible for Dependent Insurance on the later of:

• the day You meet the eligibility requirements noted above;

or

• the day You acquire Your first Dependent.

Effective Date of Dependent Insurance Insurance for Your Dependents will become effective on the date You elect it, by signing a written agreement with the Employer to make the required contribution, but no earlier than the day You become eligible for Dependent Insurance.

All of Your Dependents as defined will be included.

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Your Dependents will be insured only if You are insured.

Eligibility for Coverage for Adopted Children Any child who is adopted by You, including a child who is placed with You for adoption, will be eligible for Dependent coverage, if otherwise eligible as a Dependent, upon the date of placement with You. A child will also be eligible on the date the child is the subject of a suit for which the insured seeks to adopt the child. A child will be considered placed for adoption when You become legally obligated to support that child, totally or partially prior to that child’s adoption. If a child placed for adoption is not adopted, all dental coverage ceases when the placement ends, and will not be continued.

The provisions in the Exception for Newborns provision that describe requirements for enrollment and Effective Date of insurance will also apply to an adopted child or a child placed with You for adoption.

Exception for Newborns Any Dependent child born while You are insured will become insured on the date of the child’s birth if You elect Dependent Insurance no later than 31 days after birth. If You do not elect to insure Your newborn child within such 31 days, coverage for that child will end on the 31st day. No benefits for expenses incurred beyond the 31st day will be payable.

Dual Eligibility If both You and Your Spouse or Your Domestic Partner are in an Eligible Class of the Employer, You may each enroll individually or as a Dependent of the other, but not as both.

Any eligible Dependent child may also be enrolled by either You or Your Spouse or Your Domestic Partner. If the Spouse or Your Domestic Partner who enrolls for Dependent coverage ceases to be eligible, notify Your plan administrator immediately for coverage to continue under the plan of the other Spouse or Domestic Partner.

HCDFB-ELG58 01-19

V1

Late Entrant Limit Coverage for Late Entrants:

• Class I and Class II services are paid at the amounts set forth in The Schedule.

• All other classes of service are paid at 50% of the amounts set forth in The Schedule.

After a person has been continuously insured for 24 months, this limit no longer applies.

HCDFB-LEL23 06-21

myCigna.com10

Covered Dental Expenses Dental services described in this section are Covered Dental Expenses when such services are:

• Medically Necessary and/or Dentally Necessary (refer to the section entitled Definitions);

• Provided by or under the direction of a Dentist or other appropriate provider as specifically described;

• Covered after Your Deductible, if any, has been met;

• Eligible for reimbursement because the maximum benefit in

The Schedule has not been exceeded;

• The charge does not exceed the amount allowed under the

Alternate Benefit Provision; and

• Not excluded as described in the section entitled General

Limitations and Expenses Not Covered.

Alternate Benefit Provision If more than one Covered Dental Service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, Medically Necessary and/or Dentally Necessary, and appropriate treatment.

If the Covered Person requests or accepts a more costly Covered Dental Service, the Covered Person is responsible for expenses that exceed the amount covered for the least costly service. Therefore, We recommend Predetermination of Benefits before major treatment begins.

Predetermination of Benefits Predetermination of Benefits is a voluntary review of a Dentist’s proposed treatment plan and expected charges. It is not preauthorization of service and is not required. The treatment plan should include supporting pre-operative radiographic images and other diagnostic materials as requested by Our dental consultant. If there is a change in the treatment plan, a revised plan should be submitted. We will determine Covered Dental Expenses for the proposed treatment plan. If there is no Predetermination of Benefits, We will determine Covered Dental Expenses when We receive a claim.

Review of proposed treatment is advised whenever extensive dental work is recommended when charges exceed $200.

Predetermination of Benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.

The following section lists Covered Dental Services. We may agree to cover expenses for a service not listed. To be considered the service should be identified using the American Dental Association Uniform Code of Dental Procedures and Nomenclature, or by description and then submitted to Us.

HCDFB-COV19 06-21

Payment Option If You or any one of Your Dependents, while insured for these benefits, incurs Covered Dental Expenses, We will pay an amount determined as follows:

Dental Choice – Contracted and Non-Contracted Provider Payment Plan payment for a Covered Dental Service delivered by a Contracted Provider is the Contracted Fee for that procedure, times the benefit percentage that applies to the class of service, as specified in The Schedule. The Covered Person is responsible for the balance of the Contracted Fee.

Plan payment for a Covered Dental Service delivered by a Non-Contracted Provider is the Maximum Reimbursable Charge for that procedure times the benefit percentage that applies to the class of service, as specified in The Schedule.

The Covered Person is responsible for the balance of the Non- Contracted Provider’s actual charge.

HCDFB-DEN91 06-21

V1

Missing Tooth Limitation The amount payable for the replacement of teeth that are missing when a person first becomes insured is 50% of the amount payable for the replacement of teeth that are extracted after a person has dental coverage.

This payment limitation no longer applies after 24 months of continuous coverage.

HCDFB-MTL21 06-21

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Cigna Dental Choice Insurance

The Schedule Benefits For You and Your Dependents

The Dental Benefits Plan offered by Your Employer includes Contracted and Non-Contracted Providers. If You select a Contracted Provider, Your cost will be less than if You select a Non-Contracted Provider.

Emergency Services The Benefit Percentage for Emergency Services incurred for charges made by a Non-Contracted Provider is the same Benefit Percentage as for Contracted Provider charges.

Deductibles Deductibles are expenses to be paid by You or Your Dependent. Deductibles are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached You and Your family need not satisfy any further dental deductible for the rest of that year.

Contracted Provider Payment Services are paid based on the Contracted Fee that is agreed to by the provider and Us. Based on the provider’s Contracted Fee, a higher level of plan payment (shown below as “The Percentage of Covered Expenses the Plan Pays”) may be made to a Contracted Provider resulting in a lower payment responsibility for You. To determine how Your Contracted Provider compares refer to Your provider directory.

Provider information may change annually; refer to Your provider directory prior to receiving a service. You have access to a list of all providers who participate in the network by visiting www.mycigna.com..

Non-Contracted Provider Payment Benefit Payment

Services are paid based on the Maximum Reimbursable Charge. For this plan, the Maximum Reimbursable Charge is calculated at the 80th percentile. See definition section for further explanation of Maximum Reimbursable Charge..

BENEFIT MAXIMUMS AND

DEDUCTIBLES

CONTRACTED PROVIDER NON-CONTRACTED

PROVIDER

Classes I, II, III, IX Combined Calendar Year Maximum

Refer to the section of this Schedule entitled “Wellness Incentive Plan” for more information

Class IV Lifetime Maximum Class IV applies only to a Dependent Child less than 19

$2,500 $2,500 myCigna.com12

BENEFIT MAXIMUMS AND

DEDUCTIBLES

CONTRACTED PROVIDER NON-CONTRACTED

PROVIDER

Calendar Year Deductible

Individual $50 per person

Not Applicable to Class I

Family Maximum $150 per family

Not Applicable to Class I

Expenses incurred for either Contracted or Non-Contracted Provider charges will be used to satisfy both the Contracted and Non Contracted Provider Deductibles shown in the Schedule.

Benefits Paid for Contracted and Non-Contracted Provider Services will be applied toward both the Contracted and Non-Contracted maximum shown in the Schedule.

BENEFIT HIGHLIGHTS CONTRACTED PROVIDER NON-CONTRACTED

PROVIDER

Class I The Percentage of Covered Expenses the Plan Pays

The Percentage of Covered Expenses the Plan Pays

Preventive Care 100% 100%

Class II The Percentage of Covered Expenses the Plan Pays

The Percentage of Covered Expenses the Plan Pays

Basic Restorative 80% after plan deductible 80% after plan deductible

Class III The Percentage of Covered Expenses the Plan Pays

The Percentage of Covered Expenses the Plan Pays

Major Restorative 50% after plan deductible 50% after plan deductible

Class IV The Percentage of Covered Expenses the Plan Pays

The Percentage of Covered Expenses the Plan Pays

Orthodontia 50% 50%

Class IV Orthodontia applies only to a Dependent Child less than 19 years of age.

Class IX The Percentage of Covered Expenses the Plan Pays

The Percentage of Covered Expenses the Plan Pays

Implants 50% after plan deductible 50% after plan deductible myCigna.com13

Wellness Incentive Plan Your plan is designed to encourage yearly visits to Your Dentist for preventive care.

If a Covered Person obtains Class I services in the prior Calendar Year, the Calendar Year maximum progresses to the next level.

LEVELS Calendar Year MAXIMUM

Level 1 $2,500

Level 2 $3,000 myCigna.com14

Covered Dental Services Teledentistry services are covered only when administered in conjunction with procedures and services which are covered under this plan. Covered Dental Services delivered through teledentistry are covered to the same extent We cover services rendered through in-person contact including the same cost-share, frequency limitations or any applicable benefit maximums or lack thereof.

Class I Services – Diagnostic and Preventive Clinical oral evaluation – limited to 2 per person per Calendar Year. All oral cleaning services cross accumulate for frequency limit.

Palliative treatment of dental pain, per visit - unlimited.

Covered as a separate benefit and administrated at the In- Network coinsurance percentage only if no other services, other than exam and radiographic images, were performed during the visit.

Full mouth or panoramic radiographic images – limited to 1 per person, including panoramic images, in any 36 consecutive months.

Bitewing radiographic images – limited to 2 sets per person per Calendar Year.

Extraoral posterior radiographic images – limited to 1 image in any Calendar Year.

Prophylaxis (Cleaning) – limited to 2 per person per Calendar Year. Oral cleaning services include prophylaxis, periodontal maintenance, or scaling in the presence of gingival inflammation; all oral cleaning services cross accumulate for frequency limit.

Periodontal maintenance procedures (following active therapy) – limited to 2 per person per Calendar Year. Oral cleaning services include prophylaxis, periodontal maintenance, and scaling in the presence of gingival inflammation; all oral cleaning services cross accumulate for frequency limit.

Topical application of fluoride (excluding prophylaxis) Limited to 1 per person per Calendar Year.

Sealant, per tooth, on an unrestored primary and permanent bicuspid or molar tooth only for a person less than 19 years old - limited to 1 treatment per tooth in any 36 consecutive months.

Caries medicament application – limited to 2 per tooth in any 1 Calendar Year.

Space Maintainers - limited to non-Orthodontic Treatment for prematurely removed or missing teeth for a person less than 19 years old.

Removeable appliances to correct harmful habits.

HC-DEN341 06-21

V2 M

Class II Services – Basic Restorations, Periodontics, Endodontics, Oral Surgery, Prosthodontic Maintenance Amalgam restorations – unlimited. Multiple restorations on one surface will be treated as a single restoration. The replacement of any amalgam restoration involving the same surface(s) on the same tooth, by the same Dentist or a different Dentist in the same office, within a 12 consecutive month period is considered as part of the charges for the initial placement.

Resin-based composite restoration – unlimited. Multiple restorations on one surface will be treated as a single restoration. The replacement of any amalgam restoration involving the same surface(s) on the same tooth, by the same Dentist or a different Dentist in the same office, within a 12 consecutive month period is considered as part of the charges for the initial placement.

Pin Retention - Covered only in conjunction with amalgam or resin-based composite restoration. Payable one time per restoration regardless of the number of pins used.

Hydroxyapatite regeneration -limited to 1 service per tooth per consecutive 36 months.

Root canal therapy - any radiographic images, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and not a separate Covered Dental Service.

Root canal therapy, retreatment - unlimited - covered only if more than 6 consecutive months have passed since the original endodontic therapy and only if necessity is confirmed by professional review.

Gingivectomy or gingivoplasty - unlimited.

Gingival flap procedure - including root planing - unlimited.

Clinical crown lengthening - hard tissue - unlimited.

Osseous surgery - flap entry and closure is part of the allowance for osseous surgery and not a separate Covered Dental Service - unlimited.

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Bone replacement graft - unlimited.

Guided tissue regeneration - per site, per natural tooth – unlimited.

Pedicle soft tissue graft - unlimited.

Mesial/Distal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) - unlimited.

Free soft tissue graft (including recipient and donor surgical sites) - unlimited.

Autogenous connective tissue graft procedure (including donor and recipient surgical site surgery) - unlimited.

Non‐autogenous connective tissue graft (including recipient site and donor material) - unlimited.

Removal of non-resorbable barrier - unlimited. Removal of a non-resorbable barrier is considered inclusive to guided tissue regenerative services, unless performed by a Dentist other than the Dentist who installed it.

Periodontal scaling and root planing - full mouth - unlimited.

Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation. Limited to 2 per Calendar Year. Oral cleaning services include prophylaxis, periodontal maintenance, and scaling in the presence of gingival inflammation; all oral cleaning services cross accumulate for frequency limit.

Full Mouth Debridement - limited to one per lifetime.

Adjustments to complete and partial dentures within 6 months of its installation is part of the allowance for adjustments and is not a separate Covered Dental Service.

Repairs to complete and partial dentures within 6 months of its installation is part of the allowance for repairs and is not a separate Covered Dental Service.

Rebasing dentures - limited to rebasing done more than 6 months after the initial insertion, and then not more than one time in any 36 month period.

Relining dentures - limited to relining done more than 6 months after the initial insertion, and then not more than one time in any 36 month period.

Soft Liner - Complete or Partial Removable Dentures - limited to services done more than 6 months after the initial insertion, and then not more than one time in any 36 month period.

Tissue conditioning - maxillary or mandibular.

Re-cement or re-bond crown, inlays, onlays, veneer or partial coverage restoration, indirectly fabricated or prefabricated post and core. Limited to repairs performed more than 6 consecutive months after the initial insertion.

Crown repair and fixed partial dental repair. Limited to repairs performed more than 6 consecutive months after the initial insertion.

Re-cement fixed partial denture/bridge - limited to repairs done more than 6 months after the initial insertion.

Routine extractions.

Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth.

Removal of impacted tooth, soft tissue, partially bony, completely bony.

Removal of residual tooth roots - 1 per tooth per lifetime.

Coronectomy - 1 per lifetime.

Biopsy of oral tissue.

Brush biopsy.

Alveoloplasty.

Vestibuloplasty.

Excision of benign cysts/lesions.

Removal of exostosis (maxilla or mandible).

Removal of torus services.

Incision and drainage.

Frenectomy/Frenuloplasty.

Excision of hyperplastic tissue - per arch or pericoronal gingiva.

Local anesthetic, analgesic and routine postoperative care for dental procedures are not separately reimbursed but are considered as part of the submitted fee for the global procedure.

General anesthesia - Paid as a separate benefit only when Medically Necessary and/or Dentally Necessary, in accordance with Our clinical guidelines, and only when administered in conjunction with procedures which are covered under this plan.

I. V. Sedation - Paid as a separate benefit only when Medically Necessary and/or Dentally Necessary, in accordance with Our clinical guidelines, and only when administered in conjunction with procedures which are covered under this plan.

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Consultation – diagnostic service provided by Dentist or physician other than the requesting Dentist or physician.

HC-DEN342 06-21

V3

Class III Services - Major Restorations, Dentures and Bridgework Crowns - Initial placement of a crown is covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture.

Replacement of a crown within 5 Calendar Years after the date it was originally installed is not covered.

Stainless Steel Crowns, Resin Crowns - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration.

Inlays - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture.

Onlays - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture.

Core buildup, including any pins.

Post/post and core - covered only for endodontically treated teeth when there is insufficient tooth structure to retain the final restoration.

Complete dentures - limited to 1 complete denture per arch within 5 Calendar Years. ` Partial Dentures - limited to 1 partial denture per arch within 5 Calendar Years.

Overdentures - complete and partial - limited to 1 denture per arch per 5 Calendar Years.

Fixed partial dentures/bridges, inlays and onlays (pontics and retainer crowns) - replacement is limited to 1 service per tooth per 5 Calendar Years if the previous fixed partial denture/bridges is not serviceable and cannot be repaired.

Temporary clear appliance – limited to 1 service per arch per 12 consecutive months.

Prosthesis Over Implant - A prosthetic device, supported by an implant or implant abutment is a Covered Dental Expense.

Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least 5 Calendar Years old, is not serviceable and cannot be repaired.

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Class IV Services - Orthodontics The total amount payable for all expenses incurred for orthodontics during a Dependent child's lifetime will not be more than the orthodontia maximum shown in The Schedule.

Benefits are payable under this plan only for active Orthodontic Treatment and for the orthodontic services listed below for Dependent children on the date the Orthodontic Treatment is started.

No benefits are payable for retention in the absence of full active Orthodontic Treatment.

Charges will be considered, subject to other plan conditions, as follows:

• 25% of the total case fee will be considered as being incurred on the date the initial active appliance is placed;

and

• the remainder of the total case fee will be divided by the number of months for the total treatment plan and the resulting portion will be considered to be incurred on a monthly basis until the plan maximum is paid, treatment is completed or eligibility ends. Payments will be made quarterly.

Covered Orthodontic Treatment includes:

• Pre-Orthodontic Treatment examination to monitor growth and development;

• Orthodontic work-up including:

• intraoral comprehensive series of radiographic images or panoramic radiographic images taken in conjunction with an Orthodontic Treatment plan (if needed);

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• cephalometric radiographic image (if needed);

• radiographs (if needed);

• diagnostic casts (i.e., study models) for orthodontic evaluation (if needed);

• treatment plan (if needed);

• Fixed or removable orthodontic appliances for limited tooth movement and/or limited tooth guidance;

• Comprehensive Orthodontic Treatment child;

• Periodic Orthodontic Treatment visit;

• Placement of device to facilitate eruption of impacted tooth;

• Transseptal fiberotomy/supra crestal fiberotomy, by report;

• Harmful habits treatment.

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Class IX Services – Implants Covered Dental Expenses include: the surgical placement of the dental implant body; the surgical implant index or surgical template guide used for implant surgery; implant abutment(s) and/or connecting bar(s); periodontal/peri-implant and/or maintenance services specifically related to a dental implant;

and/or removal of an existing implant(s). Implant removal is covered only if the implant is not serviceable and cannot be repaired.

Implant coverage may have a separate deductible amount, yearly maximum and/or lifetime maximum as shown in The Schedule.

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General Limitations and Expenses Not Covered General Limitations For limitations on specific Covered Dental Services, please see the Covered Dental Services.

• any treatment received outside of the United States is not covered unless the treatment is a Covered Dental Service under the plan. Any benefits for services received outside of the United States will be subject to the limitations, if any, stated under the Covered Dental Services and paid based on the Out-of-Network reimbursement shown in The Schedule;

• replacement of a partial denture, complete denture, fixed bridge, any prosthesis over implant, or the addition of teeth to a partial denture is not covered, unless the replacement is needed due to a Medically Necessary and/or Dentally Necessary extraction of an additional Functioning Natural Tooth while the person is covered under this plan;

• replacement of a crown, bridge, onlay, post/post and core, or other laboratory prepared or CAD/CAM prepared restoration, partial denture, or complete denture within the frequency limitation stated under the Covered Dental Services is not covered unless:

• the replacement is made necessary by the placement of an original opposing complete denture or the Medically Necessary and/or Dentally Necessary extraction of a Functioning Natural Tooth; or

• the crown, bridge, onlay, post/post and core, other laboratory prepared or CAD/CAM prepared restoration, partial denture, or complete denture while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits;

• replacement of any amalgam or resin-based composite restoration involving the same surface(s) on the same tooth by the same Dentist or a different Dentist in the same office within the frequency limitation stated under the Covered Dental Services is not covered;

• a combination of radiographic images (such as ten or more periapical radiographic images; or a panoramic radiographic image with bite-wing radiographic images) completed on the same date of service will not be covered when the allowance meets or exceeds the allowance for an intraoral comprehensive series of radiographic images. Plan reimbursement will be based on an intraoral comprehensive series;

• Cone Beam CT;

• localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth.

Allowable only on teeth with both periodontal pocket depths of 5 mm or greater and a prior history of periodontal therapy. Not allowable when more than eight (8) of these procedures are reported on the same date of service;

• tissue preparation such as gingivectomy/gingivoplasty or crown lengthening as a separate allowance on the same date as a restoration on the same tooth;

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• when covered by Your plan, any prosthesis over an implant is subject to the same exclusions, limitations, frequency limitations as standard traditional restorative, fixed and removable prosthetics;

• Covered Dental Services to the extent that billed charges exceed the rate of reimbursement as described in The Schedule;

• any replacement of a crown, bridge, partial denture, or complete denture which is or can be made usable according to commonly accepted dental standards;

• crowns, inlays, cast restorations, or other laboratory prepared or CAD/CAM prepared restorations on teeth unless the tooth cannot be restored with an amalgam or resin-based composite restoration due to major decay or fracture;

The benefits provided under this plan will be reduced so that the total payment will not be more than 100% of the charge made for the dental service if benefits are provided for that service under this plan and any expense plan or prepaid treatment program sponsored or made available by Your Employer.

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Expenses Not Covered Covered Dental Expenses will not include, and no payment will be made for:

• any services not stated under Covered Dental Services and

The Schedule;

• procedures that are deemed to be medical services or are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on an insured basis;

• any charges, including ancillary charges, for services and supplies received from a hospital, outpatient facility, ambulatory surgical center or similar facility;

• charges incurred due to injuries which are intentionally self-inflicted;

• charges for or in connection with an injury or illness arising out of, or in the course of any employment for wage or profit;

• charges for or in connection with an injury or illness which is covered under any workers’ compensation or similar law;

• charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition;

• services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;

• consultations and/or evaluations associated with services that are not covered;

• cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance) which may include but is not limited to the following:

bleaching (tooth whitening), in office and/or at home, enamel microabrasion, odontoplasty, facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth will always be considered cosmetic.

However, for newborn children, benefits will include coverage of an injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities;

• replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances, if orthodontics is covered) that have been lost, stolen, or damaged due to patient abuse, misuse, or neglect;

• procedures, services, supplies, restorations, or appliances (except complete dentures), whose sole or primary purpose is to change or maintain vertical dimension;

• procedures, services, supplies, restorations or appliances whose main purpose is to diagnose or treat jaw joint problems, including dysfunction of the temporomandibular joint and craniomandibular disorders, or other conditions of the joints linking the jawbone and skull, including the complex muscles, nerves and other tissues related to that joint;

• the restoration of teeth which have been damaged by erosion, attrition, abfraction or abrasion;

• bite registration or bite analysis;

• precision or semi-precision attachments;

• any procedure, service, supply or appliance used primarily for the purpose of splinting;

• porcelain, ceramic, resin, or acrylic materials on crowns or pontics on, or replacing the upper or lower first, second and/or third molars;

• procedures, restorations, appliances or services to stabilize periodontally involved teeth;

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• myofunctional therapy;

• replacement of a partial denture or complete denture which can be made serviceable;

• prescription drugs;

• treatment of jaw fractures and/or orthognathic surgery;

• the treatment of cleft lip and cleft palate;

• charges for sterilization of equipment, infection control processes and procedures, disposal of medical waste or other requirements mandated or recommended by the Centers for Disease Control and Prevention (CDC), OSHA or other regulatory agencies; We consider these to be incidental to and part of the charges for services provided and not separately chargeable;

• charges for travel time; transportation costs;

• personal supplies, including but not limited to toothbrushes, rotary toothbrushes, floss holders, and water irrigation devices;

• oral hygiene instructions, tobacco counseling, substance use counseling, and nutritional counseling;

• charges for broken appointments; completion of claim forms; duplication of radiographic images and/or exams required by a third party;

• charges for treatment or surgery that does not meet plan guidelines;

• general anesthesia or intravenous sedation when used for the purposes of anxiety control or patient management;

• indirect pulp capping on the same date of service as a permanent restoration, We consider this to be incidental to and part of the charges for services provided and not separately chargeable;

• additional/incremental costs associated with optional/elective orthodontic materials including but not limited to: ceramic, clear, or lingual brackets, or other cosmetic appliances including clear aligners; orthognathic surgery and associated incremental costs; appliances to guide minor tooth movement; and services which are not typically included in Orthodontic Treatment. These services will be identified on a case-by-case basis. This exclusion applies when orthodontics is covered under Your plan;

• endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis;

• intentional root canal treatment in the absence of injury or disease solely to facilitate a restorative procedure;

• services to the extent You or Your enrolled Dependent(s) are compensated under any group medical plan;

• house/extended care facility calls; hospital calls; office visits for observation (during regularly scheduled hours) when no other services are performed; office visits after regularly scheduled hours; and case presentations;

• procedures performed by a Dentist who is a member of the Covered Person’s family except in the case of a dental emergency when no other Dentist is available. (Covered Person’s family is limited to a Spouse, siblings, parents, children, grandparents, and the Spouse’s siblings and parents);

• dental services that do not meet commonly accepted dental standards;

• replacement of teeth beyond the normal adult dentition of thirty-two (32) teeth;

• services not included in The Schedule, unless We agree to accept such expense as a Covered Dental Expense, in which case payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result;

• to the extent that You or any of Your Dependents are in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;

• charges in excess of the Maximum Reimbursable Charge allowances;

• procedures for which a charge would not have been made if the person had no insurance or for which the person is not legally required to pay. For example, if We determine that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of the Copayment, Deductible, and/or Coinsurance amount(s) You are required to pay for a Covered Dental Service (as shown on The Schedule) without Our express consent, We shall have the right to deny the payment of benefits in connection with the Covered Dental Service, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that You remain responsible for any amounts that Your plan does not cover. We shall have the right to require You to provide proof sufficient to Us that You have made Your required cost share payment(s) prior to the payment of any benefits by Us. This exclusion includes, but is not limited to, charges of a Non-Contracted Provider who has agreed to charge You or charged You at an In-Network benefits level or myCigna.com20 some other benefits level not otherwise applicable to the services received;

• charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law;

• Covered Dental Services to the extent that payment is unlawful where the Covered Person resides when the expenses are incurred;

• charges for or in connection with experimental procedures or treatment methods not recognized and approved by the American Dental Association or the appropriate dental specialty organization;

• charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States Government or by a state or municipal government if the person had no insurance;

• services for which benefits are not payable according to the "General Limitations" section;

• charges for care, treatment or surgery that is not Medically Necessary and/or Dentally Necessary;

• athletic mouth guards.

Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.

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Coordination of Benefits This section applies if You or any one of Your Dependents are covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Any other health coverage plans for You or any of Your covered Dependents are taken into account when benefits are paid.

Coverage under this Plan plus another Plan will not guarantee 100% reimbursement.

Definitions For the purposes of this section, the following terms have the meanings set forth below:

A. Plan. A Plan is any of the following that provides benefits or services for medical or dental care or treatment. Plan includes group and non-group insurance contracts, health maintenance organization (HMO) contracts, Closed Panel Plans or other forms of group or non-group type coverage (whether insured or uninsured); and medical or dental benefits under group or individual automobile contracts;

Medicare, Medicaid or any other federal governmental plan, as permitted by law.

Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan.

B. Closed Panel Plan. A Plan that provides medical or dental benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel.

C. Primary Plan. The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. A Plan that does not contain a coordination of benefits provision that is consistent with this section is always primary.

D. Secondary Plan. A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to You.

E. Allowable Expenses. The amount of charges considered for payment under the Plan for a Covered Dental Service prior to any reductions due to Coinsurance or Deductible amounts. If We contract with an entity to arrange for the provision of Covered Dental Services through that entity’s contracted network of health care providers, the amount that We have agreed to pay that entity is the allowable amount used to determine Your Coinsurance or Deductible payments. If the Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.

Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:

• An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.

• If You are covered by two or more Plans that provide services or supplies on the basis of Reasonable and Customary fees, any amount in excess of the highest Reasonable and Customary fee is not an Allowable Expense.

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• If You are covered by one Plan that provides services or supplies on the basis of Reasonable and Customary fees and one Plan that provides services and supplies on the basis of negotiated fees, the Primary Plan's fee…