Cypress-Fairbanks Independent School District

Cigna PPO Dental Plan

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Dental Coverage That Fits
Cigna Dental Choice PPO
Plan Effective Date: 9/1/2017
Monthly Rates Employee Only $34.22
Employee + Dependent $72.68
Employee + 2 or More Dependents $102.76
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.
Cigna Dental Choice Plan
Network Options In-Network:
Total Cigna DPPO Network
Out-of-Network:
See Non-Network Reimbursement
Reimbursement Levels Based on Contracted Fees Maximum Reimbursable Charge
Policy Year Benefits Maximum
Applies to: Class I, II & III expenses
$2,000 $2,000
Policy Year Deductible
Individual
Family
$50
$150
$50
$150
Benefit Highlights Plan Pays You Pay Plan Pays You Pay
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
100%
No Deductible
No Charge 100%
No Deductible
No Charge
Class II: Basic Restorative
Restorative: fillings
Oral Surgery: Simple Extractions
80%
After Deductible
20%
After Deductible
80%
After Deductible
20%
After Deductible
Class III: Major Restorative
Endodontics: minor and major
Periodontics: minor and major
Oral Surgery: All Except Simple Extractions
Extractions of Impacted Teeth
Anesthesia: general and IV sedation
Repairs: Bridges, Crowns and Inlays
Repairs: Dentures
Denture Relines, Rebases and Adjustments
Inlays and Onlays
Prosthesis Over Implant
Crowns: prefabricated stainless steel / resin
Crowns: permanent cast and porcelain
Bridges and Dentures
Brush Biopsy
50%
After Deductible
50%
After Deductible
50%
After Deductible
50%
After Deductible
Class IV Benefit Waiting Period applies for 12 months. Waived for all CFISD employees employed as of August 1, 2017.
Class IV: Orthodontia
Coverage for Employee and All Dependents
Lifetime Benefits Maximum: $1,200
50%
No Deductible
50%
No Deductible
50%
No Deductible
50%
No Deductible
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 90th percentile of all provider charges 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
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 HealthCare 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 (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There's no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and nonprescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and nonprescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical 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:
Oral Evaluations 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 16
Space Maintainers Limited to non-orthodontic treatment for children under age 19
Inlays, 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 Adjustments, Rebases and Relines 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.
Benefit Exclusions:
Covered Expenses will not include, and no payment will be made for the following:
Procedures and services not listed under Benefit Highlights;
Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet;
Restorative: Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and/or third molars;
Periodontic: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments;
Implants: implants or implant related services;
Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion;
Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization;
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.
Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees

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.


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.