Cigna Dental Preferred Provider Organization - John Carroll University

CIGNA Dental Benefit SummaryJohn Carroll UniversityPPO Core NetworkAll deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network.BenefitsCIGNA Dental PPOIn-NetworkOut-of-NetworkCalendar Year Maximum(Class I, II and III expenses) $1,000 $1,000Annual DeductibleIndividual $50 per person $50 per personFamily $150 per family $150 per familyReimbursement Levels ** Based on Reduced Contracted Fees Based on Maximum Allowable Charge(In-network fee level)Plan Pays You Pay Plan Pays You PayClass I - Preventive & Diagnostic CareOral ExamsRoutine CleaningsFull Mouth X-raysBitewing X-raysPanoramic X-rayPeriapical X-raysFluoride ApplicationSealantsSpace MaintainersEmergency Care to Relieve Pain100% No Charge 90% 10%Class II - Basic Restorative Care80%* 20%* 70%* 30%*FillingsRoot Canal Therapy/EndodonticsOsseous SurgeryPeriodontal Scaling and Root PlaningDenture Adjustments and RepairsOral Surgery – Simple ExtractionsOral Surgery – all except simple extractionsAnestheticsSurgical Extractions of Impacted TeethRepairs to Bridges, Crowns and InlaysNo Waiting PeriodNo Waiting PeriodClass III - Major Restorative Care50%* 50%* 40%* 60%*CrownsDenturesBridgesInlays/OnlaysHistopathologic ExamsH12 Month Waiting Period 12 Month Waiting PeriodClass IV - Orthodontia 50%* 50%* 40%* 60%*Lifetime Maximum $1,000 $1,000Dependent childrento age 19Dependent children toage 1924 Month Waiting Period 24 Month Waiting PeriodMissing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense.Pretreatment review is available on a voluntary basis when extensive dental work in excess of $500 is proposed.* Subject to annual deductible**For services provided by a CIGNA Dental PPO network dentist, CIGNA Dental will reimburse the dentist according to a Contracted Fee Schedule. For servicesprovided by an out-of-network dentist, CIGNA Dental will reimburse according to the Contracted Fee Schedule but the dentist may balance bill up to their usual fees.

• Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusionsandlimitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by ConnecticutGeneral Life Insurance Company.The CIGNA Dental PPO is underwritten or administered by Connecticut General Life Insurance Company with network management services provided by CIGNADental Health, Inc. The CIGNA Dental EPO is underwritten or administered by Connecticut General Life Insurance Company with network management servicesprovided by CIGNA Dental Health, Inc. “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to,prepaid plans, managed care plans, and plans with open access features. The CIGNA Dental PPO is underwritten or administered by Connecticut General LifeInsurance Company with network management services provided by CIGNA Dental Health, Inc., and certain of its operating subsidiaries. For Arizona/Louisianaresidents the dental PPO product is known as the CG Dental PPO. For Texas residents the dental PPO product is known as CIGNA Dental Choice Plan.© 2010 CIGNABSD21283