Dental Insurance: Cigna Dental 1500 Plan Details

  • Calendar Year Deductible
    $50** Individual | $150** Family
  • Calendar Year Benefit Maximum
    $1,500 per person Individual
  • Lifetime Individual Orthodontia Benefit
    $50
  • From
    $30
  • per person, per month

Benefit DPPO Advantage NetworkOut-of-network
Individual Calendar Year Deductible $50 per person (waived for preventive services) $50 per person (waived for preventive services)
Family Calendar Year Deductible $150 per family (waived for preventive services) $150 per family (waived for preventive services)
Calendar Year Benefit Maximum $1,500 per person $1,500 per person
Separate lifetime individual orthodontia deductible $50 $50
Benefit DPPO Advantage NetworkOut-of-network
Preventive/Diagnostic Services Waiting Period Not Applicable Not Applicable
Preventive Diagnostic Services (Oral exams, cleanings, x-rays, fluoride application, sealants, non-orthodontic space maintainers) You pay 0% You pay the difference between the provider's standard fee and 100% of the Maximum Allowable Charge (MAC)*
ProcedureFrequency/Limitation**
Oral Exams 1 per consecutive 6-month period
Routine Cleanings 1 routine prophylaxis or periodontal maintenance procedure per consecutive 6-month period (routine prophylaxis is Class I; periodontal maintenance procedure is Class III).
Routine X-Rays Bitewings: 1 set in any consecutive 12-month period. Limited to a maximum of 4 films per set
Fluoride Treatment 1 per consecutive 12 months for participants less than age 14
Sealants 1 treatment per tooth per lifetime. Payable on unrestored permanent bicuspid or molar teeth for participants less than age 14
Space Maintainers (non-orthodontic) Limited to non-orthodontic treatment for prematurely removed or missing teeth for a person less than 14 years old
*

For North Carolina customers: You pay the difference between the provider's standard fee and 95% of the Maximum Allowable Charge (MAC)

For Massachusetts and Alaska customers: You pay the difference between the provider's standard fee and 100% of the Maximum Reimbursable Charge (MRC)

**
For Maryland customers, please refer to the Summary of Benefits for Frequency/Limitation information.
Benefit DPPO Advantage NetworkOut-of-network
Basic Restorative Services Waiting Period 6-month waiting period * 6-month waiting period *
Basic Restorative Services (Fillings, non-routine x-rays) You pay 20% of the provider's contracted fee (after deductible) You pay the difference between the provider's standard fee and 80% of the Maximum Allowable Charge (MAC) after deductible**
ProcedureFrequency/Limitation***
Fillings 1 per tooth per 12 consecutive months (applies to replacement of identical surface fillings only). No white/tooth colored fillings on bicuspid or molar teeth
Non-routine X-Rays Full mouth or Panorex: 1 per 60 consecutive months
Routine Tooth Extraction Includes an allowance for local anesthesia and routine postoperative care
Emergency Treatment Paid as a separate benefit only if no other service, except x-rays, is rendered during the visit
*
For West Virginia customers, 3-month waiting period applies. For Missouri and Rhode Island customers, waiting period does not apply.
**

For North Carolina customers: You pay the difference between the provider's standard fee and 75% of the Maximum Allowable Charge (MAC) after deductible.

For Massachusetts and Alaska customers: You pay the difference between the provider's standard fee and 80% of the Maximum Reimbursable Charge (MRC) after deductible.

***
For Maryland customers, please refer to the Summary of Benefits for Frequency/Limitation information.
Benefit DPPO Advantage NetworkOut-of-network
Major Restorative Services Waiting Period 12-month waiting period * 12-month waiting period *
Major Restorative Services ** You pay 50% of the provider's contracted fee (after deductible) You pay the difference between the provider's standard fee and 50% of the Maximum Allowable Charge (MAC) after deductible***
ProcedureFrequency/Limitation
Periodontal (Deep Cleaning) 1 per quadrant per consecutive 36 month period
Periodontal Maintenance Payable only if a consecutive 6 month period has passed since the completion of active periodontal surgery. 1 periodontal maintenance or routine prophylaxis procedure per consecutive 6 month period (periodontal maintenance procedure is Class III; routine prophylaxis is Class I)
Crowns 1 per tooth per consecutive 84 month period. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crown or bridges. Replacement must be indicated by major decay. For participants less than 16, benefits limited to resin or stainless steel
Root Canal Therapy 1 per tooth per lifetime
Wisdom Tooth Extraction Includes an allowance for local anesthesia and routine postoperative care
Dentures and Partials 1 per arch per consecutive 84 month period
Bridges 1 per consecutive 84 month period. Benefits will be considered for the initial replacement of a Necessary Functioning Natural Tooth extracted while the person was covered under this plan
*
For West Virginia customers, 3-month waiting period applies. For New Jersey and Vermont customers, 6-month waiting period applies. For Missouri and Rhode Island customers, waiting period does not apply.
**
For AR, MN, NM, NV and VT customers, coverage is provided for Temporomandibular Joint Dysfunction (TMJ) services, non-surgical, at 50% in network and out of network.
***

For North Carolina customers: You pay the difference between the provider's standard fee and 45% of the Maximum Allowable Charge (MAC) after deductible.

For Massachusetts and Alaska customers: You pay the difference between the provider's standard fee and 50% of the Maximum Reimbursable Charge (MRC) after deductible.

For Maryland customers, please refer to the Summary of Benefits for Frequency/Limitation information.
Benefit DPPO Advantage NetworkOut-of-network
Orthodontia Waiting Period 12-month waiting period * 12-month waiting period *
Orthodontia You pay 50% of the provider's contracted fee (after separate lifetime deductible) You pay the difference between the provider's standard fee and 50% of the Maximum Allowable Charge (MAC) after separate lifetime deductible **
Orthodontia Individual Lifetime Maximum $1,000 per person $1,000 per person
ProcedureFrequency/Limitation***
Orthodontia The total amount payable for all expenses incurred for orthodontics during a person’s lifetime will not be more than the orthodontia maximum
*
For West Virginia customers, 3-month waiting period applies. For New Jersey and Vermont customers, 6-month waiting period applies. For Missouri and Rhode Island customers, waiting period does not apply.
**

For North Carolina customers: You pay the difference between the provider’s standard fee and 45% of the Maximum Allowable Charge (MAC) after separate lifetime deductible.

For Massachusetts and Alaska customers: You pay the difference between the provider’s standard fee and 50% of the Maximum Reimbursable Charge (MRC) after separate lifetime deductible.

***
For Maryland customers, please refer to the Summary of Benefits for Frequency/Limitation information.

You may pay more for out-of-network charges if the dentist’s charges exceed the amount Cigna reimburses for billed services.

You may be eligible to waive the waiting period with prior qualified coverage, not applicable to orthodontia.

This summary contains highlights only and is subject to change.

This website is not intended for New Mexico residents.

When you know you need dental care…

You’ve heard it from the dentist. You or a family member needs orthodontia care. With this plan, you get a $1,000 orthodontia benefit that applies to anyone covered under the plan, with budget friendly one-time deductible. Your restorative services—including crowns, bridges and fillings—are covered up to $1,500, a real savings for your family.

  • 100% coverage for all annual exams, routine x-rays and cleanings when you visit a Cigna DPPO Advantage provider, with no waiting period, once your plan is effective.1
  • $50 individual/$150 family calendar year deductible is waived for preventive and diagnostic services.
  • After the deductible, Cigna covers a portion of restorative procedures up to $1,500— including crowns, bridges, fillings, root canals and dentures—which also helps your wallet.
  • A $1,000 lifetime orthodontia benefit applies to people of all ages, with a one-time $50 deductible—a benefit to fit your specific need.
  • If you have records of dental insurance before you joined Cigna, we will waive the waiting period (not applicable to orthodontia), so you can start accessing your services right away rather than having to wait six months for basic restorative services or a year for major restorative services.2

Cigna promotes a holistic approach to well-being. Cigna Dental plans may provide additional dental services through the Cigna Oral Health Integration Program®* if you have any of the following qualifying medical conditions: heart disease, diabetes, maternity, head and neck cancer, stroke, chronic kidney disease and organ transplants.

* The Oral Health Integration Program (OHIP) may not be available in all areas. Reimbursement under OHIP is subject to dental plan terms and conditions, including applicable annual benefit maximums and other exclusions and limitations. For costs and details of coverage, see your plan documents or contact your Cigna representative.

 

In every myCigna plan...
to help keep you smiling…

It's easier to manage your dental care with:

  • Convenient billing and payments. Get your medical and dental insurance statements on one bill.
  • No claims submissions. Cigna network dentists submit claims automatically.
  • No need to choose a primary dentist. And no referrals needed for specialist care.
  • Freedom to choose a dentist from our large national network or you have the option to select a dentist outside the network. Keep in mind, you’ll save the most if you stay in-network.
  • 24/7 live customer service for dental benefits and claims information. Call 1.800.244.6224 anytime.
  • Online access with myCigna.com. View bills and claims online, anytime—and pay your bills online.
  • Mobile access on the go. Find a dentist, check coverage and show your ID card with the myCigna Mobile app.3
1
Not all preventive services are covered, including athletic mouth guards. Refer to the policy for a complete list of covered and non-covered preventive services. Frequency limitations apply.
2
For West Virginia customers, 3-month waiting period applies to basic and major restorative services, and orthodontia. For New Jersey and Vermont customers, 6-month waiting period applies to major restorative services, and orthodontia. For Missouri and Rhode Island customers, waiting periods do not apply. Waiting period may be waived with 12 months of continuous prior coverage under a qualified dental plan.
3
The downloading and use of the myCigna.com mobile app is subject to the terms and conditions of the app and the online store from which it is downloaded. Standard mobile phone carrier and data usage charges apply.
*Preventive services only.
**Waived for preventive services
Monthly rate is based on a single person and represents Cigna's national average rate for each plan using an average age. Valid through December 31, 2015.