T E R LL To Enroll u mEr SeRvIcE Customer Service • New and existing COSE members not participating • For questions about how the dental HMO ando no in the CIGNA Dental program may enroll at any dental PPO plans work, for questions about a time. Enrollment applications must be returned PPO claim, to change your HMO dentist, or to Group Services, Inc. by the 15th of the month for more information on dental facilities in in order to be effective the first of the following your area, please call a CIGNA Customer month. Service Representative at (800) 642-5810. Or visit us at www.cigna.com/dental. • If you are already enrolled in a CIGNA Dental Plan and would like to change your plan, you • For patient charge schedules, additional may make changes during the annual enrollment brochures and written plan descriptions, period (July-August). please contact CIGNA at (216) 642-2953 or COSE Customer Service at (888) 304-GROW, • COSE companies may offer any one of the dental ext 2222. plans on a standalone basis, or may offer a combi- nation of plans: Basic Dental HMO, High Dental • For questions about your bill, contact Group HMO, Basic Dental PPO, Medium Dental PPO Services, Inc. at (216) 573-1960 or C StO and High Dental PPO. (800) 586-4504. • Group coverage must remain in force for a mini- mum of one year. If a company elects to cancel the dental coverage for employees before the year of coverage is up, CIGNA Dental reserves the right to require an additional surcharge. • Enrollment applications may be obtained from Group Services, Inc. at (216) 573-1960 or toll-free at (800) 586-4504.
The key to a healthy smile is to take care of your teeth and gums, bn a mO CIGNA Dental HMO features and benefits Choice • Choose a primary dentist from Benefits Basic Dental HMO 1 High Dental HMO 2 DE T L H our nationwide HMO – type Calendar Year Maximum No Dollar Maximum! No Dollar Maximum! network – one of the largest in Annual Deductible No Annual Deductible! No Annual Deductible! the United States. Reimbursement Levels Reduced, fixed preset charges for all Reduced, fixed preset charged for all covered services – cleanings, fillings, den- covered services – cleanings, fillings, • Covered family members can tures, root canals, braces, etc. – when you dentures, root canals, braces, etc. – when choose their own network use your primary dentist. See your W1-04 you use your primary dentist. See your Patient Charge Schedule for specifics. F1-04 Patient Charge Schedule for specifics. dentists – near home, work or school. Monthly Plan Rates Employee only: $11.41 Employee only: $19.56 Employee + Spouse: $20.50 Employee + Spouse: $36.35 Employee + Child: $23.65 Employee + Child: $40.36 Savings Employee + Children: $23.65 Employee + Children: $40.36 • No deductible to meet. No dollar Family: $34.79 Family: $60.80 maximums. No claim forms to Enrollment No minimum employee participation 50% employee participation file. No waiting periods for Requirements coverage. Employer No employer contribution required 50% employer contribution • Savings from dentists’ usual Contribution charges. • Coverage of most preventive services reduces the potential for Basic Dental HMO High Dental HMO more serious problems later on. What You’ll Pay With Cigna With Cigna Without • If you need a more complex Dental Care Dental Care Dental Coverage procedure, you’ll know exactly Two periodic exams $0 $0 $66 what the fees will be up front, Four bitewing x-rays $0 $0 $74 before starting treatment. Two quadrants of periodontal $130 $110 $344 • Specialty care provided at the scaling and root planing same fee as general care with Two routine cleanings $0 $0 $130 referral approved for payment. One resin/composite 1-surface $9 $0 $105 filling (anterior) Service Anterior root canal $215 $0 $529 Porcelain crown $400 $335 $885 • Call our friendly, responsive Single Extraction $30 $0 $106 Member Services representatives Orthodontic evaluation, treatment $190 $190 $293 toll-free at 1-800-642-5810. Our plan and records knowledgeable representatives Banding for Comprehensive $300 $300 $1,155 are dedicated to helping you find Orthodontic Treatment• answers and solutions. 12 months Comprehensive $950 $800 $1,217 • Or e-mail us anytime at Orthodontic Treatment, child• www.cigna.com • Orthodontic treatment is limited to a lifetime maximum benefit of 24 months.Additional charges apply for retention and/or interceptive • Locate convenient network orthodontic treatment. Patient charges listed are not applicable to orthodontics in progress. dentists 24 hours a day, seven days a week by calling Member Services or visiting www.cigna.com. Maps and dri- ving directions are also available. • Visit myCIGNA.com for real time information about your dental benefits. • 95% of customer service issues are resolved in the first call.
before problems begin.That’s why COSE has teamed up with CIGNA to bring na o CIGNA Dental PPO features and benefits Summary of Dental Benefits for COSE Members DE T L PP Basic Dental PPO 3 Benefits In-Network Out-of- Network Calendar Year Maximum (Class I, II and III expenses) $750 $500 CalendarYear Deductible Per Individual $50 $75 Per Family $150 $225 Reimbursement Levels Based on Based on reduced reasonable & contracted customary fees allowances Plan Pays Plan Pays Class I - 85%, 70%, Preventive & Diagnostic Care No After Oral Exams (Two per year) Deductible Deductible Routine Cleanings (Two per year) Full Mouth X-rays (One complete set every three years) Bitewing X-rays (Two per year) Choice Service Panoramic X-ray • Visit any dentist in or out of our • Call our friendly, responsive (One every three years) Fluoride Application Preferred Provider network – Member Services representatives (One per year for one of the nation’s largest. toll-free at 1-800-642-5810. Our persons under 19) knowledgeable representatives are Sealants (Limited to posterior tooth The choice is yours! for a person less than 14; • No referral required to see a dedicated to helping you find one treatment per tooth specialist. answers and solutions. every three years) Space Maintainers (Limited to • Or e-mail us anytime at non-orthodontic treatment) Savings www.cigna.com Emergency Care to relieve pain • Visit a network dentist for maxi- • We process your claims quickly and accurately. Call us toll-free Class II - 50%, 35%, mum savings.Your out-of-pocket Basic Restorative Care for claims status update. After After expenses will generally be higher Fillings Deductible Deductible if you visit a dentist out of the • Locate convenient network Root Canal Therapy Osseous Surgery dentists 24 hours a day, seven Periodontal Scaling and Root Planing network. Denture Adjustments and Repairs • In network or not, you’ll be days a week by calling Member Extractions Services or visiting Oral Surgery reimbursed for all or part of your costs for covered procedures, up www.cigna.com. Maps and dri- Not covered Class III - Not covered to your annual dollar maximum, ving directions are also available. Major Restorative Care • Visit myCIGNA.com for real Crowns, Dentures, Bridges after meeting your deductible or satisfying any waiting periods. time information about your Class IV - Orthodontia Not covered Not covered dental benefits. Lifetime Orthodontia Maximum • 95% of customer service issues Monthly Plan Rates are resolved in the first call. Employee only: $14.39 Employee + Spouse: $29.50 Employee + Child: $32.37 Employee + Children: $32.37 Family: $ 47.48 Enrollment Requirements No minimum employee participation Employer Contribution No employer contribution required
g you 5 quality dental plans. Summary of Dental Benefits for COSE Members Medium Dental PPO 4 High Dental PPO 5 In-Network Out-of- Out-of- Benefits Network Benefits In-Network Network Calendar Year Maximum Calendar Year Maximum (Class I, II and III expenses) $1,000 $750 (Class I, II and III expenses) $1,500 $1,250 CalendarYear Deductible CalendarYear Deductible Per Individual $50 $75 Per Individual $25 $50 Per Family $150 $225 Per Family $75 $150 Reimbursement Levels Based on Based on Reimbursement Levels Based on Based on reduced reasonable & reduced reasonable & contracted customary contracted customary fees allowances fees allowances Plan Pays Plan Pays Plan Pays Plan Pays Class I - 100%, 85%, Class I - 100%, 85%, Preventive & Diagnostic Care No No Preventive & Diagnostic Care No No Oral Exams (Two per year) Deductible Deductible Oral Exams (Two per year) Deductible Deductible “Dental HMO*” is used to Routine Cleanings (Two per year) Routine Cleanings (Two per year) refer to product designs that may differ by state of resi- Full Mouth X-rays Full Mouth X-rays dence of enrollee, including (One complete set every (One complete set every but not limited to, prepaid three years) three years) plans, managed care plans, and Bitewing X-rays (Two per year) Bitewing X-rays (Two per year) plans with open access fea- tures. Panoramic X-ray Panoramic X-ray (One every three years) (One every three years) CIGNA Dental refers to the Fluoride Application Fluoride Application following operating sub- (One per year for (One per year for sidiaries of CIGNA Corporation: Connecticut persons under 19) persons under 19) General Life Insurance Sealants (Limited to posterior tooth Sealants (Limited to posterior tooth Company, and CIGNA Dental for a person less than 14; for a person less than 14; Health, Inc., and its operating one treatment per tooth one treatment per tooth subsidiaries and affiliates.The CIGNA Dental Care plan is every three years) every three years) provided by CIGNA Dental Space Maintainers (Limited to Space Maintainers (Limited to Health Plan of Arizona, Inc., non-orthodontic treatment) non-orthodontic treatment) CIGNA Dental Health of Emergency Care to relieve pain Emergency Care to relieve pain California, Inc., CIGNA Dental Health of Colorado, Inc., CIGNA Dental Health of Class II - Basic Restorative Care 70%, 55%, Class II - Basic Restorative Care 85%, 70%, Delaware, Inc., CIGNA Dental Fillings After After Fillings After After Health of Florida, Inc., a Root Canal Therapy Deductible Deductible Root Canal Therapy Deductible Deductible Prepaid Limited Health Services Organization licensed Osseous Surgery Osseous Surgery under Chapter 636, Florida Periodontal Scaling and Root Planing Periodontal Scaling and Root Planing Statutes, CIGNA Dental Denture Adjustments and Repairs Denture Adjustments and Repairs Health of Kansas, Inc. (Kansas Extractions and Nebraska), CIGNA Dental Extractions Health of Kentucky, Inc., Oral Surgery Oral Surgery CIGNA Dental Health of Maryland, Inc., CIGNA Class III - 55%, 45%, Class III - 55%, 45%, Dental Health of Missouri, Major Restorative Care After After After After Inc., CIGNA Dental Health of Deductible Major Restorative Care Deductible Deductible Deductible New Jersey, Inc., CIGNA Crowns, Dentures, Bridges Crowns, Dentures, Bridges Dental Health of North Carolina, Inc., CIGNA Dental Class IV Expenses – Orthodontia 50%, After Not Class IV - Orthodontia 50%, After 50%, After Health of Ohio, Inc., CIGNA Separate $50 Covered Deductible Deductible Dental Health of Pennsylvania, Deductible Inc., CIGNA Dental Health of Texas, Inc., and CIGNA Lifetime Orthodontia Maximum $1,000 Lifetime Orthodontia Maximum $2,000 $1,000 Dental Health of Virginia, Inc. In other states, the CIGNA Monthly Plan Rates Employee only: $21.80 Employee only: $25.46 Dental Care plan is underwrit- Monthly Plan Rates ten by Connecticut General Employee + Spouse: $44.68 Employee + Spouse: $52.20 Life Insurance Company or Employee + Child: $49.04 Employee + Child: $57.29 CIGNA HealthCare of Connecticut, Inc. and adminis- Employee + Children: $49.04 Employee + Children: $57.29 tered by CIGNA Dental Family: $71.92 Family: $84.03 Health, Inc. The CIGNA Dental PPO is underwritten or administered by Enrollment Requirements No minimum employee Enrollment Requirements 50% employee participation Connecticut General Life participation Insurance Company with Employer Contribution 50% employer contribution network management services Employer Contribution No employer contribution required provided by CIGNA Dental required Health, Inc., and certain of its operating subsidiaries. Pretreatment review is suggested when dental work in excess of $200 is proposed. All plan deductibles and maximums (dollar and occurrence) cross-accumulate between In-Network and Out-of Network unless otherwise noted.
Limitations on Covered Services – Exclusions – CIGNA Dental PPO General Limitations –CIGNA Dental HMO (plans 1 & 2) (plans 3, 4, 5) CIGNA Dental PPO (plans 3, 4, 5)Listed below are limitations on services covered by the Dental Plan: Covered expenses will not include, and no payment will be made No payment will be made for expenses incurred for you or anyFrequency – The frequency of certain covered services, such as for, expenses incurred for: one of your Dependents:cleanings, is limited. The Patient Charge Schedule lists any limita- • Services performed solely for cosmetic reasons; • For or in connection with an injury arising out of, or in thetions on frequency. • Replacement of a lost or stolen appliance; course of, any employment for wage or profit;Specialty Care – Payment authorization is required for coverage of • Replacement of a bridge, crown or denture within five years • For or in connection with a sickness which is covered underservices by a Network Specialist. after the date it was originally installed unless: (a) such any workers’ compensation or similar law;Pediatric Dentistry – Coverage for referral to a Pediatric Dentist replacement is made necessary by the placement of an origi- • For charges made by a Hospital owned or operated by orends on an enrolled childs 7th birthday; however, exceptions nal opposing full denture or the necessary extraction of nat- which provides care or performs services for the Unitedfor medical reasons may be considered on an individual basis. ural teeth; or (b) the bridge, crown or denture, while in the States Government, if such charges are directly related to aThe Network General Dentist shall provide care after the childs mouth, has been damaged beyond repair as a result of an military service connected condition;7th birthday. injury received while a person is insured for these benefits; • To the extent that payment is unlawful where the personOral Surgery – The surgical removal of an impacted wisdom tooth • Any replacement of a bridge, crown or denture which is or resides when the expenses are incurred;is not covered if the tooth is not diseased or if the removal is only can be made useable according to common dental standards; • For charges which the person is not legally required to pay;for orthodontic reasons. • Procedures, appliances or restorations (except full dentures) • To the extent that they are more than either the applicable whose main purpose is to (a) change vertical dimension; (b) Contracted Fee, applicable Reasonable or Customary Charges diagnose or treat conditions or dysfunction of the temporo- or the applicable Schedule Amount;Exclusions – CIGNA Dental HMO mandibular joint; (c) stabilize periodontally involved teeth; • For charges for unnecessary care, treatment or surgery;(plans 1 & 2) or (d) restore occlusion; • To the extent that you or any of your Dependents is in any • Porcelain or acrylic veneers of crowns or pontics on or replac- way paid or entitled to payment for those expenses by orListed below are the services or expenses which are NOT covered ing the upper and lower first, second or third molars; through a public program, other than Medicaid;under the Dental Plan and which are the Covered Persons respon- • Bite registrations; precision or semi-precision attachments; or • For or in connection with experimental procedures or treat-sibility at the dentists Usual Fees. There is no coverage for: splinting; ment methods not approved by the American Dental• Services not listed on the Patient Charge Schedule. • A surgical implant of any type including any prosthetic device Association or the appropriate dental specialty society.• Services provided by a non-Network Dentist without CIGNA Dental Healths prior approval (except emergencies as attached to it; • Instruction for plaque control, oral hygiene and diet; No payment will be made for expenses incurred by you or any one described in Plan Documents). • Dental services that do not meet common dental standards; of your Dependents to the extent that benefits are paid or payable• Services related to an injury or illness covered under work- • Services that are deemed to be medical services; for those expenses under the mandatory part of any auto insur- ers compensation, occupational disease or similar laws. • Services and supplies received from a hospital; ance policy written to comply with a "no-fault" insurance law or an (FL residents – This exclusion relates to such services paid • Services for which benefits are not payable according to the uninsured motorist insurance law. Connecticut General Life under Workers’ Compensation, occupational disease or "General Limitations" section. Insurance Company will take into account any adjustment option similar laws.) chosen under such part by you or any one of your Dependents.• Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a In addition, these benefits will be reduced so that the total pay- ment will not be more than 100% of the charge made for the Missing Teeth and Late Entrant Limit public program other than Medicaid. Dental Service if benefits are provided for that service under this Many indemnity and PPO dental benefit plans limit the replace-• Services relating to injuries which are intentionally self-inflict- plan and any medical expense plan or prepaid treatment program ment of missing teeth and Class III and IV dental services or have ed. (TX and OH residents – Services related to self-inflicted sponsored or made available by your Employer. a waiting period for these services. Check with your plan adminis- injuries are not excluded.) trator for details.• Services required while serving in the armed forces of any country or international authority or relating to a declared or Most dental indemnity and PPO plans contain an Alternate Benefit undeclared war or acts of war. provision. If more than one professionally accepted procedure can• Cosmetic dentistry or cosmetic dental surgery (dentistry or be performed to treat a dental condition, the plan will provide cov- dental surgery performed solely to improve appearance). erage for the least costly procedure.• General anesthesia, sedation and nitrous oxide. (MD resi- dents – General anesthesia is covered when medically nec- (07/2004) essary and authorized by Covered Persons Physician.)• Prescription drugs.• Procedures, appliances or restorations if the main purpose is to: (1) change vertical dimension (degree of separation of the jaw when teeth are in contact) or (2) diagnose or treat abnormal conditions of the temporomandibular joint, except as specifically listed on the Patient Charge Schedule.• The completion of crown and bridge, dentures or root canal treatment already in progress on the date Covered Person becomes covered by the Dental Plan. (TX residents – This exclusion does not apply to Texas residents.)• Replacement of fixed and/or removable prosthodontic appli- ances that have been lost; stolen; or damaged due to patient abuse, misuse or neglect.• Services associated with the placement or prosthodontic restoration of a dental implant.• Services considered to be unnecessary or experimental in nature. (PA Residents – Delete "unnecessary or" and MD residents – delete "or experimental in nature.)• Procedures or appliances for minor tooth guidance or to con- trol harmful habits.• Hospitalization, including any associated incremental charges for dental services performed in a hospital.• Services to the extent the Covered Person is compensated for them under any group medical plan, no-fault auto insur- ance policy, or insured motorist policy. (AZ residents – This exclusion does not apply to Arizona Residents. KY and NC Residents – Services compensated under no-fault auto or insured motorist policies not excluded. MD Residents – Services compensated under group medical plans not Designed by excluded.) Custom Publishing Group (CPG)Except as set forth above, pre-existing conditions are not excluded.(TX residents delete "except as set forth above.")