Effective Jan. 1, 2017

Cigna Dental PPO Basic 750 Benefit Summary This is a summary of benefits for your dental plan. All deductibles, plan maximums and service specific maximums (dollar and occurrence) cross accumulate between in and out of network. Total Network Benefits Calendar Year Maximum (Class I, II and III Expenses) Calendar Year Deductible Per Individual Per Family Class I Expenses – Preventive and Diagnostic Care Oral Exams Cleanings Routine X-rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-rays Emergency Care to Relieve Pain Class II Expenses – Basic Restorative Care Fillings Oral Surgery – Simple Extractions Oral Surgery – All Except Simple Extraction Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy/Endodontics Brush Biopsy Class III Expenses – Major Restorative Care Relines, Rebases and Adjustments Repairs – Bridges, Crowns and Inlays Repairs – Dentures Crowns/Inlays/Onlays Dentures Bridges Stainless Steel/Resin Crowns Class IV Expenses – Orthodontia

Cigna Dental Basic 750 In Network Out of Network $750 Class I, II Applies

$750 Class I, II Applies

$10 No Limit

$10 No Limit

100% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Not Covered

Not Covered

Not Covered

Not Covered

Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. © 2016 IUHealth 9/16 IUH#22285

H7220_IUHMA17010 CMS Approved 8.31.2016

Total Network Benefits Calendar Year Maximum Missing Tooth Provision

Late Entrant Limit Pretreatment Review Dental Plan Reimbursement Levels Additional Member Responsibility in Excess of Coinsurance

Cigna Dental Basic 750 In Network Out of Network The amount payable is 50% of the amount otherwise payable until insured for a specified time period; thereafter, considered a Class III expense. Not Covered Available on a voluntary basis when extensive work in excess of $200 is proposed. Based on 80th Percentile Contracted Fees None Yes, the difference between billed charges and the plan reimbursement.

Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO-POS. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on Jan. 1 of each year. ATTENTION: Our Customer Solutions Center has free language interpreter services available for non-English speakers. Call 800.455.9776 (TTY: 800.743.3333). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800.455.9776 (TTY: 800.743.3333). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800.455.9776 (TTY: 800.743.3333). IU Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. IU Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. IU Health Plans 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。 © 2016 IUHealth 9/16 IUH#22285

H7220_IUHMA17010 CMS Approved 8.31.2016