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2017 Benefits Enrollment

For more information
and to see the
complete list of eligible Total Cigna DPPO
conditions, go to Cigna Beneits In-Network Out-of-Network
www.mycigna.com Exams Two per calendar year
or call customer Prophylaxis (cleanings) Two per calendar year
service 24/7 at Fluoride One per calendar year for people age
800.Cigna24. 18 and under
X-rays (routine) Bitewings: two per calendar year
X-rays (non-routine) Full mouth: one every 60 months
Panorex: one every 60 months
Minor perio (non-surgical) Various limitations depending on the
service
Perio surgery Various limitations depending on the
service
Crowns and inlays Replacement every 84 months
Prosthesis over implants One per every ive years if
unserviceable and cannot be repaired;
beneits are based on the amount
payable for non-precious metals;
no porcelain or white/tooth colored
material on molar crowns or bridges
Bridges Replacement every 84 months
Dentures and partials Replacement every 84 months
Relines, rebases Covered if more than six months after
installation
Adjustments Covered if more than six months after
installation
Repairs—bridges Reviewed if more than once
Repairs—dentures Reviewed if more than once
Sealants Limited to posterior tooth; one
treatment per tooth every three years
up to age 14
Space maintainers Limited to non-orthodontic treatment
up to age 14
Alternate beneit 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 which will be included as
covered expenses
Exclusions Some exclusions do apply; please
consult the full plan document for
review of these

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