Cypress-Fairbanks Independent School District

Cigna DHMO Dental Plan

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Dental Coverage That Fits
Cigna Dental Care DHMO1 Monthly Rates Employee Only $9.04
Employee + Dependent $14.18
Employee + 2 or More Dependents $22.40

Regular dental care is important for a healthy smile. And a healthy body. With Cigna Dental Care® DHMO, you get comprehensive dental coverage that's easy to use. At a wallet-friendly price. Now that's something to smile about.

This overview shows you a sampling of covered services. And your estimated costs with - and without - coverage. For a full listing of covered services, please call Customer Service at 800.Cigna24 (800.244.6224).

Get the most value from your plan

With your Cigna DHMO plan, some preventive services are covered at no extra cost to you. (See below.) Your plan also covers many other dental services that can help your mouth stay healthy.

Your Cigna DHMO plan is a copayment plan. Here's how it works. When you get a dental service, Cigna allows your network dentist to charge a certain amount. Then you pay a fixed portion of that cost. And your plan pays the rest. There are no annual maximums and no deductibles!

Review your plan materials for more information about how your plan works. If you have questions before enrollment, call 800.Cigna24 (800.244.6224) and select the "Enrollment Information" prompt.

WHAT YOU'LL PAY2
Sampling of covered procedures With Cigna Dental Care Without Dental Coverage
Adult Cleaning (two per calender year - each at $0) (additional cleanings available at $45 each) $0 $69 - $139 each
Child Cleaning (two per calender year - each at $0) (additional cleanings available at $30 each) $0 $69 - $139 each
Periodic oral evaluation $0 $40 - $81
Comprehensive oral evaluation $0 $62 - $126
Topical flouride (two per calender year - each at $0) (additional topic flouride available at $15 each) $0 $28 - $57
X-rays - (bitewings) 2 films $0 $32 - $66
X-rays - panoramic film $0 $83 - $168
Sealant - per tooth $17 $41 - $84
Amalgam fillings (silver colored - 2 surfaces) $22 $116 - $237
Composite filling (tooth - colored) - 1 surface, Anterior $22 $119 - $241
Molar root canal (excluding final restoration) $530 $847 - $1,720
Comprehensive orthodontic treatment of the adolescent detention - Banding $515 $987 - $2,004
Periodontal (gum) scaling & root planning - 1 quardrant $115 $181 - $367
Periodontal (gum) maintenance $78 $107 - $217
Removal / extraction of erupted tooth $53 $123 - $250
Removal / extraction of impacted tooth - completely bony $230 $366 - $743
Crown - porcelain fused high noble metal $470 $845 - $1,717
Implant supported retainer for porcelain fused to metal fixed partial denture $770 $1,200 - $2,437
Occlusal appliance, by report (for treatment of TMJ) $455 $632 - $1,284
Cigna Logo

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

Smile. You're Covered

You can save money on a wide range of services, including:

  • Preventive care - cleanings, fluoride, sealants, bitewing X-rays, full mouth X-rays and more
  • Basic care - tooth-colored fillings (called resin or composite) and silver-colored fillings (called amalgam)
  • Major services - crowns, bridges, dentures (including those placed over implants), root canals, oral surgery, extractions, treatment for periodontal (gum) disease and more
  • Orthodontic care - braces for children and adults
  • General anesthesia - when medically necessary
  • Temporomandibular joint (TMJ) - diagnosis and treatment, including cone beam x-ray and appliance
  • Athletic mouth guard - including creation and adjustments

More about your DHMO coverage

  • No deductibles You don't have to reach an out-of-pocket cost before your insurance starts.
  • No dollar maximums Your coverage isn't limited by a dollar amount. No matter the amount of your covered expenses.
  • Easy to understand plan. Dentist fees are clearly listed on your Patient Charge Schedule (PCS).
  • No claim forms to file. And no waiting periods for coverage.
  • No age limit on sealants. Helps prevent tooth decay.
  • Cancer detection. Your plan covers procedures such as biopsy and light detection to help find oral cancer in its early stages.
  • 24/7 access to dental information line. Trained professionals can help answer your questions about dental treatment and clinical symptoms.
  • Cigna's Identity Theft Program.3 Help resolving critical identity theft issues.
  • Cigna Dental Oral health Integration Program. Enhanced dental coverage for enrolled Cigna dental plan participants with certain medical conditions.

How the plan works

  • You must choose a network general dentist to manage your overall care. You won't be covered if you go to a dentist who's not in our network.
  • Each family member can choose their own dentist.
  • Referrals are required for specialty care services. Exceptions are pediatric dentists for children under 7, orthodontics and endodontics.*

Finding a network dentist is easy.

Visit Cigna.com to find a network general dentist.

Call 800.Cigna24 (800.244.6224) to speak with a customer service representative. You can ask for a customized dental directory to be sent to you via email.

* Coverage for treatment by a pediatric dentist ends on your child's 7th birthday. Effective on your child's 7th birthday, dental services generally must be obtained from a network general dentist.


Limitations

Procedure Limit
Oral evaluations Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluation (D0120), comprehensive oral evaluations(D0150), compreghensive periodonal evaluations (D0180) ,and oral evaluations for patients under 3 years of age (D0145)
X-rays (routine) Bitewings: 2 per calender year
X-rays (non-routine) Full mouth: 1 every 3 calender years
Panorex: 1 every 3 calender years
Periodontal root planning and scaling Limit 4 quadrants per consecutive 12 months
Periodontal maintenence Limited to 4 per year and (only covered after active periodontal therapy)
Crowns and inlays Replacement 1 every 5 years
Bridges Replacement 1 every 5 years
Dentures and partials Replacement 1 every 5 years
Orthodontic treatment Maximum benefit of 24 months of interceptive and / or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient
Relines, rebases One every 36 months
Denture adjustments Four within the first 6 months after intallation
Prosthesis over implant Replacement 1 every 5 years if unserviceable and cannot be repaired
Temporomandibular Joint (TMJ) treatment One occlusal orthotic device per 24 months
Athletic mouth guard One athletic mouth guard per 12 months
General anesthesia / IV sedation General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the PCS. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the PCS. Plan limitation for this benefit is 1 hour per appointment

Specialty treatment plans require payment authorization for services to be covered. Before treatment starts, you should verify with your network specialty dentist that your treatment plan has been authorized for payment by Cigna

Listed below are the services or expenses which are NOT covered under your dental plan. You will be responsible for these services at the dentist's usual fees. There's no coverage for:

  • Services for or in connection with an injury arising out of, or in the course of, any employment for wage or profit.
  • 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 received to the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received
  • Services for the charges which the person is not legally required to pay
  • Charges which would not have been made if the person had no insurance Services received due to injuries which are intentionally self-inflicted
  • Services not listed on the PCS
  • Services provided by a non-network dentist without Cigna Dental's prior approval (except emergencies, as described in your plan documents)4
  • Services related to an injury or illness paid under workers' compensation, occupational disease or similar laws
  • Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid
  • Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war
  • Services performed primarily for cosmetic reasons unless specifically listed on your PCS
  • Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis
  • Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS
  • Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure
  • Services performed by a prosthodontist
  • Localized delivery of antimicrobial agents when performed alone or in the absence of traditional periodontal therapy
  • Any localized delivery of antimicrobial agent procedures when more than eight of these procedures are reported on the same date of service
  • Infection control and/or sterilization
  • The recementation of any inlay, onlay, crown, post and core or fixed bridge within 180 days of initial placement
  • General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS
  • General anesthesia or IV sedation when used for the purpose of anxiety control or patient management
  • Prescription medications
  • Procedures, appliances or restorations if the main purpose is to: a. change vertical dimension (degree of separation of the jaw when teeth are in contact); b. restore teeth which have been damaged by attrition, abrasion, erosion and/or abfraction
  • Replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect
  • Surgical implant of any type unless specifically listed on your PCS
  • Services considered unnecessary or experimental in nature or do not meet commonly accepted dental standards
  • Procedures or appliances for minor tooth guidance or to control harmful habits
  • Services and supplies received from a hospital
  • The completion of crowns, bridges, dentures, or root canal treatment already in progress on the effective date of your Cigna Dental coverage5
  • The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS6
  • Consultations and/or evaluations associated with services that are not covered
  • The recementation of any implant supported prosthesis (including crowns, bridges and dentures) within 180 days of initial placement
  • Services to correct congenital malformations, including the replacement of congenitally missing teeth
  • The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS
  • Crowns, bridges and/or implant supported prosthesis used solely for splinting
  • Resin bonded retainers and associated pontics
  • As to orthodontic treatment: incremental costs associated with optional/elective materials; orthognathic surgery appliances to guide minor tooth movement or correct harmful habits; and any services which are not typically included in orthodontic treatment.
  • If any law requires coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) does not apply.

    This document outlines the highlights of your plan. For a complete list of both covered and non-covered services, including benefits required by your state, see your insurance certificate or plan description. If there are any differences between the information contained here and the plan documents, the information in the plan documents takes precedence.


    1. The term "DHMO" is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. The Cigna DHMO is not available in the following states: AK, HI, ME, MT, NH, NM, ND, PR, RI, SD, VT, WV, and WY.
    2. Costs listed for the Cigna Dental Care plan do not vary. Estimated costs without dental coverage may vary based on location and dentists' actual charges. These estimated costs are based on charges submitted to Cigna in 2014/2015 and are intended to reflect national average charges as of July 2016 assuming an annual cost increase of three percent. Estimates have been adjusted to reflect the 2015 Cigna DHMO geographical membership distribution. Office visit fee may also apply.
    3. This is NOT insurance and does not provide for reimbursement of financial losses. Cigna's Identity Theft services are provided under a contract with Europ Assistance USA. Full terms are contained in Cigna's Identity Theft Program service agreement.
    4. Minnesota residents: You must visit your selected network dentist in order for the charges on the Patient Charge Schedule to apply. You may also visit other dentists that participate in our network or you may visit dentists outside the Cigna Dental Care network. If you do, the fees listed on the Patient Charge Schedule will not apply. You will be responsible for the dentist's usual fee. We will pay 50% of the value of your network benefit for those services. Of course, you'll pay less if you visit your selected Cigna Dental Care network dentist. Call Customer Services for more information. Oklahoma residents: DHMO for Oklahoma is an Employer Group Pre-Paid Dental Plan. You may also visit dentists outside the Cigna Dental Care network. If you do, the fees listed on the Patient Charge Schedule will not apply. You will be responsible for the dentist's usual fee. We pay non-network dentists the same amount we'd pay network dentists for covered services. Of course, you'll pay less if you visit a network dentist in the Cigna Dental Care network. Call Customer Services for more information.
    5. California and Texas residents: Treatment for conditions already in progress on the effective date of your coverage are not excluded if otherwise covered under you PCS. Dentists who participate in Cigna's network are independent contractors solely responsible for the treatment provided and are not agents of Cigna.


    HEALTHY REWARDS®
    Vision Network Savings Program1 powered by Cigna Vision
    Plan #: 9234030
    ROUTINE VISION CARE SERVICES CUSTOMER COST3
    Routine vision examination:
    Including but not limited to eye health examination, dilation, refraction and prescription for glasses

    $5 off routine exam
    Standard clear plastic or glass lenses:
    Single vision
    Bifocal
    Trifocal

    Up to $50
    Up to $75
    Up to $105
    Lens Options:
    Standard UV coating
    Standard scratch-resistance
    Standard polycarbonate
    Standard anti-reflective coating
    Progressives
    Other add-ons and services

    Up to $15
    Up to $15
    Up to $40
    Up to $45
    20% savings
    20% savings
    Frames:
    Most locations:
    Retailers such as:
    JC Penney Optical, Sears Optical, Target Optical, Pearle Vision and Visionworks

    25% off retail prices on frames
    40% off retail prices on most frames3
    Contact lenses and professional services:
    Contact lens professional services (fitting and evaluation)
    Contact lenses

    $10 off contact lens exam
    Check with your Cigna Vision network eye care professional for any available offers on contact lenses.
    Non-Prescription Sunglasses2 20% savings
    Frequency:
    Exam and Materials

    Unlimited

    The Cigna Vision network offers over 25,000 locations nationwide, including these national retail opticals:

    Cigna Vision Network

    These discounts are only available through a Cigna Vision network eye care professional. Stated discounts cannot be used in conjunction with other discounts, promotions or prior orders. Network eye care professionals are independent contractors solely responsible for your routine vision examinations and products.

    1. The Cigna Vision Network Savings program offered through Healthy Rewards is a discount program. Some programs are not available in all states and programs may be discontinued at any time. If your Cigna plan includes coverage for any of these services, this program is in addition to, not instead of, your plan coverage. Discount programs are separate from plan benefits. A discount program is NOT insurance, and you must pay the entire discounted charge directly to the participating eye care provider.
    2. Provider participation is 100% voluntary. Please check with your eye care professional for any discount offer.
    3. Select frames may not be available for savings.
    4. Regional pricing and availability may vary depending on your location. Check with your Cigna Vision network eye care professional for details.

    All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

    830501 c 05/15 © 2015 Cigna. Some content provided under license.