Not Covered. Cigna Dental PPO Basic 750 Benefit Summary. Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract.
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
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.
