2022 Cigna Dental Plan Summary - High Option

2022 Cigna Dental Plan Summary - High Option

Cigna Dental Benefit Summary Mid-America Apartments, L.P. – High Plan Renewal Date: 01/01/2022

Admini stered by: Cigna Health andLife Insurance Company

This material is for informat ional purposes only and is designed to highlight some of the benef it s available 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 denti st may minimize your out-of-pocket expenses. Cigna Dental PPO Network Options In-Network: Total Cigna DPPO Network Non-Network: See Non-Network Reimbursement

Reimbursement Levels

Maximum Reimbursable Charge

Based on Cont racted Fees

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

$2,500

$2,500

Calendar Year Deductible Individual Family

$50 $150

$50 $150

Plan Pays 100% No Deduct ible

You Pay No Charge

Plan Pays 100% No Deduct ible

You Pay No Charge

Benefit Highlights

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 Class IV:Orthodontia Coverage for Employee and All Dependent s

60% After Deduct ible

40% After Deduct ible

60% After Deduct ible

40% After Deduct ible

50% No Deduct ible

50% No Deduct ible

50% No Deduct ible

50% No Deduct ible

Lifet ime Benefit sMaximum: $2,500

Class IX: Implants

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.

Non-NetworkReimbursement

Cross Accumulation

Calendar Year BenefitsMaximum

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. Pret reatment reviewis available on a voluntary basis when dental work in excess of $200 is proposed. When more than one coveredDental Service could provide suitable t reatment based on common dental standards, Cigna 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. The Cigna Dental Oral Health Integrat ion Program offers enhanced dental coverage for customers with certain medical condit ions. There is no addit ional charge to part icipate in the program. Those who qualify can receive reimbursement of their coinsurance for eligible dental services. Eligible customers can also receive guidance on behavioral issues related to oral health. Reimbursement s under this program are not subject to the annual deduct ible, but will be applied to the plan annual maximum. For more informat ion on howto enroll in this program and a complete list of terms and eligible condit ions, go to www.mycigna.com or call customer service 24/7 at 1-800-Cigna24.

Calendar Year Deductible

PretreatmentReview

Alternate Benefit Provision

Oral Health IntegrationProgram ®

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/Exams

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)

Diagnost ic Cast s

Payable only in conjunct ion with orthodontic workup.

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;  Procedures, appliances or restorat ions, except full dentures, whose main purpose is to change vert ical dimension , diagnose or t reat condit ions of 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 or decorat ion of any dental device or dental work ;

 Replacement of an appliance per benefit 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 offici al plan document s, the terms of the official plan document s will prevail.

Product availability may vary by locat ion and plan type and is subject to change. All group dental insurance policies and dental benefit plans contain exclusions and limitat ions. For cost s and details of coverage, review your plan document s or contact a Cigna representat ive .

All Cigna product s and services are provided exclusively by or through operat ing subsidiaries of Cigna Corporat ion, includingCigna Health and Life Insurance Company (CHLIC), Connect icut General Life Insurance Company, andCigna Dental Health, Inc.

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