2021 Cigna Dental Benefit Summary - Low Plan

2021 Cigna Dental Benefit Summary - Low Plan

Cigna Dental Benefit Summary Mid-America Apartments, L.P. – Low Plan Renewal Date: 01/01/2021

Admini stered by: Cigna Health andLife Insurance Company

This material is for informat ional purposes only and is designed to highlight some of the benefit s ava ilable under this plan. Consult the plan document s to determine specific terms of coverage relat ing to your plan. Terms include covered procedures, applicable wait ing periods, exclusions and limitat ions. Your DPPO plan al lows you to see any l icensed dentist, but using an in-network dentist mayminimize your out-of-pocket expenses. Cigna Dental PPO Network Options In-Network: Total Cigna DPPO Network Non-Network: See Non-Network Reimbursement Reimbursement Levels Based on Cont racted Fees Maximum Reimbursable Charge

Calendar Year BenefitsMaximum Applies to: Class I, II & III expenses

$1,500

$1,500

Calendar Year Deductible Individual Family

$50 $150

$50 $150

Benefit Highlights

Plan Pays 100% No Deduct ible

You Pay No Charge

Plan Pays 100% No Deduct ible

You Pay No Charge

Class I:Diagnostic &Preventive Oral Evaluat ions Prophylaxis: rout ine cleanings X-rays: rout ine X-rays: non-rout ine Fluoride Applicat ion Sealant s: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain

Class II: Basic Restorative Restorat ive: fillings Endodont ics: minor and major Periodont ics: minor andmajor Oral Surgery: minor and major

80% After Deduct ible

20% After Deduct ible

80% After Deduct ible

20% After Deduct ible

Anesthesia: general and IV sedat ion Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustment s Class III:Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

50% After Deduct ible

50% After Deduct ible

50% After Deduct ible

50% After Deduct ible

Benefit PlanProvisions: In-Network Reimbursement

For services provided by a Cigna Dental PPO network dent ist , Cigna Dental will reimburse the dent ist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dent ist , Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider submit ted amount s in the geographic area. The dent ist may balance bill up to their usual fees. All deduct ibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitat ions are based on the date of service and cross accumulate between in and out of network. The plan will only pay for covered charges up to the yearly Benefit sMaximum, when applicable. Benefit -specific Maximums may also apply. This is the amount youmust pay before the plan begins to pay for covered charges, when applicable. Benefit -specific deduct ibles may also apply.

Non-NetworkReimbursement

Cross Accumulation

Calendar Year BenefitsMaximum

Calendar Year Deductible

PretreatmentReview

Pret reatment reviewis available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision

When more than one coveredDental Service could provide suitable t reatment based on common dental standards, Cigna HealthCare will determine the coveredDental Service on which payment will be based and the expenses that will be included as Covered Expenses. Does not apply to fillings.

Oral Health IntegrationProgram (OHIP)

Cigna Dental Oral Health Integrat ion Program offers enhanced dental coverage for customers with the following medical condit ions: diabetes, heart disease, st roke, maternity, head and neck cancer radiat ion, organ t ransplant s and chronic kidney disease. There’s no addit ional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discount s on prescript ion and non-prescript ion dental product s. Reimbursement s under this program are not subject to the annual deduct ible, but will be applied to and are subject to the plan annual maximum. Discount s on certain prescript ion and non-prescription dental product s are available through Cigna Home Delivery Pharmacy only, and you are required to pay the ent ire discounted charge. For more informat ion including how to enroll in this program and a complete list of program terms and eligible medical condit ions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Timely Filing

Out of network claims submit ted to Cigna after 365 days from date of service will be denied.

Benefit Limitations: Oral Evaluat ions

2 per calendar year

X-rays (rout ine)

Bitewings: 2 per calendar year

Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months

X-rays (non-rout ine)

Cleanings

2 per calendar year, including periodontal maintenance procedures following act ive therapy

Fluoride Applicat ion

2 per calendar year for children under age 19

Sealant s (per tooth)

Limited to posterior tooth. 1 t reatment per tooth every 36 months for children under age 16

Space Maintainers

Limited to non-orthodontic t reatment for children under age 19

Replacement every 60 months if unserviceable and cannot be repaired. Benefit s are based on the amount payable for non-precious metals. No porcelain or white/tooth-coloredmaterial on molar crowns or bridges.

Inlays, Crowns, Bridges, Dentures and Part ials

Denture and Bridge Repairs

Reviewed if more than once

Denture Relines, Rebases and Adjustment s

Covered if more than 6 months after installation

Replacement every 60 months if unserviceable and cannot be repaired. Benefit s are based on the amount payable for non-precious metals. No porcelain or white/tooth-coloredmaterial on molar crowns or bridges.

Prosthesis Over Implant

Restorat ive: fillings

Includes composite fillings on molars

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following:

Procedures and services not included in the list of covered dental expenses;

Diagnost ic: cone beam imaging; Prevent ive Services: inst ruct ion for plaque cont rol, oral hygiene and diet ; Restorat ive: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pont ics on or replacing the upper and or lower first , second and/or thirdmolars; Periodont ics: bite regist rat ions; splint ing; Prosthodontic: precision or semi-precision at tachments; init ial placement of a complete or partial denture per plan guidelines; Implant s: implant s or implant related services; Orthodont ics: orthodontic t reatment; Procedures, appliances or restorat ions, except full dentures, whose main purpose is to: change vert ical dimension; diagnose o r t reat condit ions or dysfunct ion of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athlet ic mouth guards; services performed primarily for cosmet ic reasons; personalizat ion; replacement of an appliance per be nefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescript ion drugs Charges in excess of the Maximum Reimbursable Charge.

This document provides a summary only. It is not a cont ract . If there are any differences between this summary and the official plan document s, the terms of the official plan document s will prevail.

Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connect icut Gen eral Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of it s subsidiaries. In T exas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the nat ional Cigna DPPO netwo rk. All Cigna product s and services are provided exclusively by or through operat ing subsidiaries of Cigna Corporat ion “Cigna Hom e Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

© 2020 Cigna / version 04242020