Page 18 - 2018 Carlstar Benefit Guide
P. 18
18 BENEFITS ENROLLMENT • 2018
Summary of Benefits—Dental (continued)
Cigna Beneits Total Cigna DPPO Out-of-Network
In-Network
Exams Two per calendar year
Prophylaxis (cleanings) Two per calendar year
Fluoride One per calendar year for children under age 19
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
For more information and to see the complete list of eligible conditions, go to
www.mycigna.com or call customer service 24/7 at 800.Cigna24.
Summary of Benefits—Dental (continued)
Cigna Beneits Total Cigna DPPO Out-of-Network
In-Network
Exams Two per calendar year
Prophylaxis (cleanings) Two per calendar year
Fluoride One per calendar year for children under age 19
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
For more information and to see the complete list of eligible conditions, go to
www.mycigna.com or call customer service 24/7 at 800.Cigna24.
