856593 q5-00 dhmo 09 pcs v11 - cigna · 24/7 at 1.800.cigna24 or the phone number on your id card....

• The covered procedures are listed by American Dental Association Common Dental Terminology (CDT) code so you’ll always know what services are included in your plan.Remember,ifaprocedureisnotlistedonthePatientChargeSchedule,thenit’snotacoveredbenefitonyourplan.

• The coinsurance is listed as a percentage of the total cost that you owe directly to the dentistandiscalculatedbasedonthenetworkdentist’scontractedfeeschedule,whichistheamountCignaagreestopaydentistsfortheirservices.Thecontractedfeeschedulesvarybynetworkdentist.Yourexactout-of-pocketcostsarecalculatedbymultiplyingthecoinsurancepercentageforagivenprocedurebythedentist’scontractedfeeforthatsameprocedure.Ifyou’dlikemoreinformationaboutyourspecificout-of-pocketcosts,callus24/7at1.800.Cigna24orthephonenumberonyourIDcard.

• The copay is the fixed dollar amount that you owe directly to the dentist.Yourout-of-pocketcostforanycoveredprocedurewithacopayisonlythatexactdollaramount.

• ThisPatientChargeScheduleappliesonlywhencovereddentalservicesareperformedbyyourNetworkDentist,unlessotherwiseauthorizedbyCignaDentalasdescribedinyourplandocuments.

• ThisPatientChargeScheduleappliestoSpecialtyCarewhenanappropriatereferralismadetoaNetworkSpecialtyPeriodontistorOralSurgeon.YoumustverifywiththeNetworkSpecialtyDentistthatyourtreatmentplanhasbeenauthorizedforpaymentbyCignaDental.PriorauthorizationisnotrequiredforspecialtyreferralsforPediatric,Orthodontic,andEndodonticservices.YoumayselectaNetworkPediatricDentistforyourchildundertheageof7bycallingMemberServicesat1.800.Cigna24togetalistofNetworkPediatricDentistsinyourarea.CoveragefortreatmentbyaPediatricDentistendsonyourchild’s7thbirthday;however,exceptionsformedicalreasonsmaybeconsideredonanindividualbasis.YourNetworkGeneralDentistwillprovidecareuponyourchild’s7thbirthday.

Q5-00

cigna dental care® (*dHMO)

patient cHarge scHeduleThisPatientChargeScheduledescribesthebenefitsofyourdentalplanandincludesalistofcoveredprocedures,andcoinsurancepercentageorcopayforeachcoveredprocedure.

Important Highlights

92260 856593 02/13 Q5-00

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cigna dental care® patient charge schedule

• ProceduresnotlistedonthisPatientChargeSchedulearenotcoveredandarethepatient’sresponsibilityatthedentist’susualfees.

• Thecostofgold/highnoblemetalisanadditionalchargeforanyprocedure(i.e.,inlays,crowns,bridgesorpartialdentures)andisthepatient’sresponsibility.

• CignaDentalconsidersinfectioncontroland/orsterilizationtobeincidentaltoandpartofthechargesforservicesprovidedandnotseparatelychargeable.

• TheadministrationofIVsedation,generalanesthesia,and/ornitrousoxideisnotcoveredexceptasspecificallylistedonthisPatientChargeSchedule.Theapplicationoflocalanestheticiscoveredaspartofyourdentaltreatment.

• ThisPatientChargeScheduleissubjecttoannual changeinaccordancewiththetermsofthegroupagreement.

• ProcedureslistedonthePatientChargeSchedulearesubjecttotheplanlimitationsandexclusionsdescribedinyourplanbook/certificateofcoverageand/orgroupcontract.

• AllpatientchargescorrespondtothePatientChargeScheduleineffectonthedatetheprocedure is initiated.

• TheAmericanDentalAssociationmayperiodicallychangeCDTCodesordefinitions.Differentcodesmaybeusedtodescribethesecoveredprocedures.

Code Procedure Description Patient Coinsurance

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).

D9310 Consultation(diagnosticserviceprovidedbydentistorphysicianotherthanrequestingdentistorphysician)

0%

D9430 Officevisitforobservation–Nootherservicesperformed 0%

D9450 Casepresentation–Detailedandextensivetreatmentplanning

0%

D0120 Periodicoralevaluation–Establishedpatient 0%

D0140 Limitedoralevaluation–Problemfocused 0%

D0145 Oralevaluationforapatientunder3yearsofageandcounselingwithprimarycaregiver

0%

Important Highlights (continued)

(Q5-00)

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D0150 Comprehensiveoralevaluation–Neworestablishedpatient 0%

D0160 Detailedandextensiveoralevaluation–problemfocused,byreport(limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

0%

D0170 Reevaluation–Limited,problemfocused(notpostoperativevisit)

0%

D0180 Comprehensiveperiodontalevaluation–Neworestablishedpatient

0%

D0210 X-raysintraoral–Completeseriesofradiographicimages(limit 1 every 3 years)

0%

D0220 X-raysintraoral–Periapical–Firstradiographicimage 0%

D0230 X-raysintraoral–Periapical–Eachadditionalradiographicimage

0%

D0240 X-raysintraoral–Occlusalradiographicimage 0%

D0250 X-raysextraoral–Firstradiographicimage 0%

D0260 X-raysextraoral–Eachadditionalradiographicimage 0%

D0270 X-rays(bitewing)–Singleradiographicimage 0%

D0272 X-rays(bitewings)–2radiographicimages 0%



D0277 X-rays(bitewings,vertical)–7to8radiographicimages 0%

D0330 X-rays(panoramicradiographicimage)–(limit 1 every 3 years)

0%

D0368 ConebeamCTcaptureandinterpretationforTMJseriesincludingtwoormoreexposures(limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

50%

D0350 Oral/facialphotographicimages 50%

D0415 Collectionofmicroorganismsforcultureandsensitivity 0%

D0425 Cariessusceptibilitytests 0%

D0431 Oralcancerscreeningusingaspeciallightsource 0%

(Q5-00)

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D0460 Pulpvitalitytests 0%

D0470 Diagnosticcasts 50%

D0472 Pathologyreport–Grossexaminationoflesion(onlywhentoothrelated)

0%

D0473 Pathologyreport–Microscopicexaminationoflesion(onlywhentoothrelated)

0%

D0474 Pathologyreport–Microscopicexaminationoflesionandarea(onlywhentoothrelated)

0%

D0486 Laboratoryaccessionofbrushbiopsysample,microscopicexamination,preparationandtransmissionofwrittenreport

0%

D1110 Prophylaxis(cleaning)–Adult(limit 2 per calendar year) 0%

Additionalprophylaxis(cleaning)–Inadditiontothe2prophylaxes(cleanings)allowedpercalendaryear

$40.00

D1120 Prophylaxis(cleaning)–Child(limit 2 per calendar year) 0%

Additionalprophylaxis(cleaning)–Inadditiontothe2prophylaxes(cleanings)allowedpercalendaryear

$30.00

D1206 Topicalapplicationoffluoridevarnish(limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year.

0%

Additionaltopicalapplicationoffluoridevarnish–Inadditiontoanycombinationoftwo(2)D1206s(topicalapplicationoffluoridevarnish)and/orD1208s(topicalapplicationoffluoride)percalendaryear.

$15.00

D1208 Topicalapplicationoffluoride(limit 2 per calendar year).There is a combined limit of a total of 2 D1208s and/or D1206s per calendar year.

0%

Additionaltopicalapplicationoffluoride–Inadditiontoanycombinationoftwo(2)D1206s(topicalapplicationsoffluoridevarnish)and/orD1208s(topicalapplicationoffluoride)percalendaryear.

$15.00

D1310 Nutritionalcounselingforcontrolofdentaldisease 0%

D1320 Tobaccocounselingforthecontrolandpreventionoforaldisease

0%

(Q5-00)

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D1330 Oralhygieneinstructions 0%

D1351 Sealant–Pertooth 0%

D1352 Preventiveresinrestorationinamoderatetohighcariesriskpatient–Permanenttooth

0%

D1510 Spacemaintainer–Fixed–Unilateral 0%

D1515 Spacemaintainer–Fixed–Bilateral 0%

D1520 Spacemaintainer–Removable–Unilateral 0%

D1525 Spacemaintainer–Removable–Bilateral 0%

D1550 Recementationofspacemaintainer 0%

D1555 Removaloffixedspacemaintainer 0%

Restorative (fillings, including polishing)

D2140 Amalgam–1surface,primaryorpermanent 0%

D2150 Amalgam–2surfaces,primaryorpermanent 0%

D2160 Amalgam–3surfaces,primaryorpermanent 0%

D2161 Amalgam–4ormoresurfaces,primaryorpermanent 0%

D2330 Resin-basedcomposite–1surface,anterior 0%

D2331 Resin-basedcomposite–2surfaces,anterior 0%

D2332 Resin-basedcomposite–3surfaces,anterior 0%

D2335 Resin-basedcomposite–4ormoresurfacesorinvolvingincisalangle,anterior

0%

D2390 Resin-basedcompositecrown,anterior 50%

D2391 Resin-basedcomposite–1surface,posterior 0%

D2392 Resin-basedcomposite–2surfaces,posterior 0%

D2393 Resin-basedcomposite–3surfaces,posterior 0%

D2394 Resin-basedcomposite–4ormoresurfaces,posterior 0%

(Q5-00)

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Crown and bridge – All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years.

Nomorethan$150pertoothchargeforcrowns,inlays,onlays,postandcores,andveneersifyourdentistusessamedayin-officeCAD/CAM(ceramic)services.Samedayin-officeCAD/CAM(ceramic)servicesrefertodentalrestorationsthatarecreatedinthedentalofficebytheuseofadigitalimpressionandanin-officeCAD/CAMmillingmachine

Complexrehabilitation–Anadditional$125chargeperunitformultiplecrownunits/complexrehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

D2510 Inlay–Metallic–1surface 50%

D2520 Inlay–Metallic–2surfaces 50%

D2530 Inlay–Metallic–3ormoresurfaces 50%

D2542 Onlay–Metallic–2surfaces 50%

D2543 Onlay–Metallic–3surfaces 50%

D2544 Onlay–Metallic–4ormoresurfaces 50%

D2740 Crown–Porcelain/ceramicsubstrate 50%

D2750 Crown–Porcelainfusedtohighnoblemetal 50%

D2751 Crown–Porcelainfusedtopredominantlybasemetal 50%

D2752 Crown–Porcelainfusedtonoblemetal 50%

D2780 Crown–3/4casthighnoblemetal 50%

D2781 Crown–3/4castpredominantlybasemetal 50%

D2782 Crown–3/4castnoblemetal 50%

D2783 Crown–3/4porcelain/ceramic 50%

D2790 Crown–Fullcasthighnoblemetal 50%

D2791 Crown–Fullcastpredominantlybasemetal 50%

D2792 Crown–Fullcastnoblemetal 50%

(Q5-00)

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D2794 Crown–Titanium 50%

D2799 Provisionalcrown 50%

D2610 Inlay–Porcelain/ceramic,1surface 50%

D2620 Inlay–Porcelain/ceramic,2surfaces 50%

D2630 Inlay–Porcelain/ceramic,3ormoresurfaces 50%

D2642 Onlay–Porcelain/ceramic,2surfaces 50%


D2644 Onlay–Porcelain/ceramic,4ormoresurfaces 50%

D2650 Inlay–Resin-basedcomposite,1surface 50%

D2651 Inlay–Resin-basedcomposite,2surfaces 50%

D2652 Inlay–Resin-basedcomposite,3ormoresurfaces 50%

D2662 Onlay–Resin-basedcomposite,2surfaces 50%

D2663 Onlay–Resin-basedcomposite,3surfaces 50%

D2664 Onlay–Resin-basedcomposite,4ormoresurfaces 50%

D2710 Crown–Resin-basedcomposite,indirect 50%

D2712 Crown–3/4resin-basedcomposite,indirect 50%

D2720 Crown–Resinwithhighnoblemetal 50%

D2721 Crown–Resinwithpredominantlybasemetal 50%

D2722 Crown–Resinwithnoblemetal 50%

D2910 Recementinlay–Onlayorpartialcoveragerestoration 0%

D2915 Recementcastorprefabricatedpostandcore 0%

D2920 Recementcrown 0%

D2929 Prefabricatedporcelain/ceramiccrown-Primarytooth 50%

D2930 Prefabricatedstainlesssteelcrown–Primarytooth 50%

D2931 Prefabricatedstainlesssteelcrown–Permanenttooth 50%

D2932 Prefabricatedresincrown 50%

D2933 Prefabricatedstainlesssteelcrownwithresinwindow 50%

(Q5-00)

-8-



D2934 Prefabricatedestheticcoatedstainlesssteelcrown–Primarytooth

50%

D2940 ProtectiveRestoration 0%

D2950 Corebuildup–Includinganypins 50%

D2951 Pinretention–Pertooth–Inadditiontorestoration 0%

D2952 Postandcore–Inadditiontocrown,indirectlyfabricated 50%

D2953 Eachadditionalindirectlyprefabricatedpost–Sametooth 50%

D2954 Prefabricatedpostandcore–Inadditiontocrown 50%

D2957 Eachadditionalprefabricatedpost–Sametooth 50%

D2960 Labialveneer(resinlaminate)–Chairside 50%

D2970 Temporarycrown(fracturedtooth) 50%

D2971 Additionalprocedurestoconstructnewcrownunderexistingpartialdentureframework

50%

D2980 Crownrepair,necessitatedbyrestorativematerialfailure 0%

D6210 Pontic–Casthighnoblemetal 50%

D6211 Pontic–Castpredominantlybasemetal 50%

D6212 Pontic–Castnoblemetal 50%

D6214 Pontic–Titanium 50%

D6240 Pontic–Porcelainfusedtohighnoblemetal 50%

D6241 Pontic–Porcelainfusedtopredominantlybasemetal 50%

D6242 Pontic–Porcelainfusedtonoblemetal 50%

D6245 Pontic–Porcelain/ceramic 50%

D6250 Pontic–Resinwithhighnoblemetal 50%

D6251 Pontic–Resinwithpredominantlybasemetal 50%

D6252 Pontic–Resinwithnoblemetal 50%

D6253 Provisionalpontic 50%

D6545 Retainer–Castmetalforresinbondedfixedprosthesis 50%

D6600 Inlay–Porcelain/ceramic,2surfaces 50%

(Q5-00)

-9-



D6601 Inlay–Porcelain/ceramic,3ormoresurfaces 50%

D6602 Inlay–Casthighnoblemetal,2surfaces 50%

D6603 Inlay–Casthighnoblemetal,3ormoresurfaces 50%

D6604 Inlay–Castpredominantlybasemetal,2surfaces 50%

D6605 Inlay–Castpredominantlybasemetal,3ormoresurfaces 50%

D6606 Inlay–Castnoblemetal,2surfaces 50%

D6607 Inlay–Castnoblemetal,3ormoresurfaces 50%


D6609 Onlay–Porcelain/ceramic,3ormoresurfaces 50%

D6610 Onlay–Casthighnoblemetal,2surfaces 50%

D6611 Onlay–Casthighnoblemetal,3ormoresurfaces 50%

D6612 Onlay–Castpredominantlybasemetal,2surfaces 50%

D6613 Onlay–Castpredominantlybasemetal,3ormoresurfaces 50%

D6614 Onlay–Castnoblemetal,2surfaces 50%

D6615 Onlay–Castnoblemetal,3ormoresurfaces 50%

D6624 Inlay–Titanium 50%

D6634 Onlay–Titanium 50%

D6710 Crown–Indirectresinbasedcomposite 50%

D6720 Crown–Resinwithhighnoblemetal 50%

D6721 Crown–Resinwithpredominantlybasemetal 50%

D6722 Crown–Resinwithnoblemetal 50%

D6740 Crown–Porcelain/ceramic 50%

D6750 Crown–Porcelainfusedtohighnoblemetal 50%

D6751 Crown–Porcelainfusedtopredominantlybasemetal 50%

D6752 Crown–Porcelainfusedtonoblemetal 50%

D6780 Crown–3/4casthighnoblemetal 50%

D6781 Crown–3/4castpredominantlybasemetal 50%

(Q5-00)

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D6782 Crown–3/4castnoblemetal 50%

D6783 Crown–3/4porcelain/ceramic 50%

D6790 Crown–Fullcasthighnoblemetal 50%

D6791 Crown–Fullcastpredominantlybasemetal 50%

D6792 Crown–Fullcastnoblemetal 50%

D6794 Crown–Titanium 50%

D6930 Recementfixedpartialdenture 0%

D6950 Precisionattachment 50%

Endodontics (root canal treatment, excluding final restorations)

D3110 Pulpcap–Direct(excludingfinalrestoration) 0%

D3120 Pulpcap–Indirect(excludingfinalrestoration) 0%

D3220 Pulpotomy–Removalofpulp,notpartofarootcanal 0%

D3221 Pulpaldebridement(nottobeusedwhenrootcanalisdoneonthesameday)

0%

D3222 Partialpulpotomyforapexogenesis–Permanenttoothwithincompleterootdevelopment

0%

D3230 Pulpaltherapy(resorbablefilling)–Anterior,primarytooth(excludingfinalrestoration)

0%

D3240 Pulpaltherapy(resorbablefilling)–Posterior,primarytooth(excludingfinalrestoration)

0%

D3310 Anteriorrootcanal–Permanenttooth(excludingfinalrestoration)

0%

D3320 Bicuspidrootcanal–Permanenttooth(excludingfinalrestoration)

0%

D3330 Molarrootcanal–Permanenttooth(excludingfinalrestoration)

50%

D3331 Treatmentofrootcanalobstruction–Nonsurgicalaccess 0%

D3332 Incompleteendodontictherapy–Inoperable,unrestorableorfracturedtooth

0%

D3333 Internalrootrepairofperforationdefects 0%

(Q5-00)

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D3346 Retreatmentofpreviousrootcanaltherapy–Anterior 0%

D3347 Retreatmentofpreviousrootcanaltherapy–Bicuspid 0%

D3348 Retreatmentofpreviousrootcanaltherapy–Molar 50%

D3351 Apexification/recalcification–Initialvisit(apicalclosure/calcificrepairofperforations,rootresorption,etc.)

0%

D3352 Apexification/recalcification–Interimmedicationreplacement(apicalclosure/calcificrepairofperforations,rootresorption,etc.)

0%

D3353 Apexification/recalcification–Finalvisit(includescompletedrootcanaltherapy–apicalclosure/calcificrepairofperforations,rootresorption,etc.)

0%

D3410 Apicoectomy/periradicularsurgery–Anterior 0%

D3421 Apicoectomy/periradicularsurgery–Bicuspid(firstroot) 0%

D3425 Apicoectomy/periradicularsurgery–Molar(firstroot) 0%

D3426 Apicoectomy/periradicularsurgery(eachadditionalroot) 0%

D3430 Retrogradefilling–Perroot 0%

D3450 Rootamputation–Perroot 0%

D3920 Hemisection(includinganyrootremoval),notincludingrootcanaltherapy

0%

Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the patient charge schedule.

D4210 Gingivectomyorgingivoplasty–4ormoreteethperquadrant

0%

D4211 Gingivectomyorgingivoplasty–1to3teethperquadrant 0%

D4212 Gingivectomyorgingivoplastytoallowaccessforrestorativeprocedure,pertooth

0%

D4240 Gingivalflap(includingrootplaning)–4ormoreteethperquadrant

0%

(Q5-00)

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D4241 Gingivalflap(includingrootplaning)–1to3teethperquadrant

0%

D4245 Apicallypositionedflap 0%

D4249 Clinicalcrownlengthening–Hardtissue 0%

D4260 Osseoussurgery–4ormoreteethperquadrant 50%

D4261 Osseoussurgery–1to3teethperquadrant 50%

D4263 Bonereplacementgraft–Firstsiteinquadrant 0%

D4264 Bonereplacementgraft–Eachadditionalsiteinquadrant 0%

D4265 Biologicmaterialstoaidinsoftandosseoustissueregeneration

0%

D4266 Guidedtissueregeneration–Resorbablebarrierpersite 0%

D4267 Guidedtissueregeneration–Nonresorbablebarrierpersite(includesmembraneremoval)

0%

D4270 Pediclesofttissuegraftprocedure 0%

D4273 Subepithelialconnectivetissuegraftprocedures,pertooth 0%

D4274 Distalorproximalwedgeprocedure(whennotperformedinconjunctionwithsurgicalproceduresinthesameanatomicalarea)

0%

D4275 Softtissueallograft 0%

D4277 Freesofttissuegraftprocedure(includingdonorsitesurgery),firsttoothoredentulous(missing)toothpositioningraft

0%

D4278 Freesofttissuegraftprocedure(includingdonorsitesurgery),eachadditionalcontiguoustoothoredentulous(missing) toothpositioninsamegraftsite

0%

D4341 Periodontalscalingandrootplaning–4ormoreteethperquadrant(limit 4 quadrants per consecutive 12 months)

0%

D4342 Periodontalscalingandrootplaning–1to3teethperquadrant(limit 4 quadrants per consecutive 12 months)

0%

D4355 Fullmouthdebridementtoallowevaluationanddiagnosis(1 per lifetime)

0%

(Q5-00)

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D4381 Localizeddeliveryofantimicrobialagentspertooth 0%

D4910 Periodontalmaintenance(limit 4 per calendar year) (only covered after active periodontal therapy)

0%

Additionalperiodontalmaintenanceprocedures(beyond 4 per calendar year)

$50.00

Periodontalchartingforplanningtreatmentofperiodontaldisease

0%

Periodontalhygieneinstruction 0%

Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years.

D5110 Fullupperdenture 50%

D5120 Fulllowerdenture 50%

D5130 Immediatefullupperdenture 50%

D5140 Immediatefulllowerdenture 50%

D5211 Upperpartialdenture–Resinbase(includingclasps,restsandteeth)

50%

D5212 Lowerpartialdenture–Resinbase(includingclasps,restsandteeth)

50%

D5213 Upperpartialdenture–Castmetalfamework(includingclasps,restsandteeth)

50%

D5214 Lowerpartialdenture–Castmetalframework(includingclasps,restsandteeth)

50%

D5225 Upperpartialdenture–Flexiblebase(includingclasps,restsandteeth)

50%

D5226 Lowerpartialdenture–Flexiblebase(includingclasps,restsandteeth)

50%

D5281 Removableunilateralpartialdenture–Onepiececastmetalincludingclaspsandteeth)

50%

D5410 Adjustcompletedenture–Upper 0%

D5411 Adjustcompletedenture–Lower 0%

(Q5-00)

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D5421 Adjustpartialdenture–Upper 0%

D5422 Adjustpartialdenture–Lower 0%

D5850 Tissueconditioning–Upper 0%

D5851 Tissueconditioning–Lower 0%

D5862 Precisionattachment–Byreport 50%

Repairs to prosthetics

D5510 Repairbrokencompletedenturebase 0%

D5520 Replacemissingorbrokenteeth–Completedenture(eachtooth)

0%

D5610 Repairresindenturebase 0%

D5620 Repaircastframework 0%

D5630 Repairorreplacebrokenclasp 0%

D5640 Replacebrokenteeth–Pertooth 0%

D5650 Addtoothtoexistingpartialdenture 0%

D5660 Addclasptoexistingpartialdenture 0%

D5670 Replaceallteethandacryliconcastmetalframework–Upper

0%

D5671 Replaceallteethandacryliconcastmetalframework–Lower

0%

Denture relining (limit 1 every 36 months)

D5710 Rebasecompleteupperdenture 0%

D5711 Rebasecompletelowerdenture 0%

D5720 Rebaseupperpartialdenture 0%

D5721 Rebaselowerpartialdenture 0%

D5730 Relinecompleteupperdenture–Chairside 0%

D5731 Relinecompletelowerdenture–Chairside 0%

D5740 Relineupperpartialdenture–Chairside 0%

(Q5-00)

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D5741 Relinelowerpartialdenture–Chairside 0%

D5750 Relinecompleteupperdenture–Laboratory 0%

D5751 Relinecompletelowerdenture–Laboratory 0%

D5760 Relineupperpartialdenture–Laboratory 0%

D5761 Relinelowerpartialdenture–Laboratory 0%

Interim dentures (limit 1 every 5 years)

D5810 Interimcompletedenture–Upper 50%

D5811 Interimcompletedenture–Lower 50%

D5820 Interimpartialdenture–Upper 50%

D5821 Interimpartialdenture–Lower 50%

Implant/abutment supported prosthetics – All charges for crown and bridge (fixed partial denture) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years.

Nomorethan$150pertoothchargeforcrowns,inlays,onlays,postandcoresandveneersifyourdentistusessamedayin-officeCAD/CAM(ceramic)services.Samedayin-officeCAD/CAM(ceramic)servicesrefertodentalrestorationsthatarecreatedinthedentalofficebytheuseofadigitalimpressionandanin-officeCAD/CAMmillingmachine

Complexrehabilitationonimplant/abutmentsupportedprostheticprocedures–Anadditional$125chargeperunitformultiplecrownunits/complexrehabilitation(6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for theguidelines)

D6053 Implant/abutmentsupportedremovabledentureforcompletelyedentulousarch

50%

D6054 Implant/abutmentsupportedremovabledentureforpartiallyedentulousarch

50%

D6058 Abutmentsupportedporcelain/ceramiccrown 50%

(Q5-00)

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D6059 Abutmentsupportedporcelainfusedtometalcrown(highnoblemetal)

50%

D6060 Abutmentsupportedporcelainfusedtometalcrown(predominantlybasemetal)

50%

D6061 Abutmentsupportedporcelainfusedtometalcrown(noblemetal)

50%

D6062 Abutmentsupportedcastmetalcrown(highnoblemetal) 50%

D6063 Abutmentsupportedcastmetalcrown(predominantlybasemetal)

50%

D6064 Abutmentsupportedcastmetalcrown(noblemetal) 50%

D6065 Implantsupportedporcelain/ceramiccrown 50%

D6066 Implantsupportedporcelainfusedtometalcrown(titanium,titaniumalloy,highnoblemetal)

50%

D6067 Implantsupportedmetalcrown(titanium,titaniumalloy,highnoblemetal)

50%

D6068 Abutmentsupportedretainerforporcelain/ceramicfixedpartialdenture

50%

D6069 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(highnoblemetal)

50%

D6070 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(predominantlybasemetal)

50%

D6071 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(noblemetal)

50%

D6072 Abutmentsupportedretainerforcastmetalfixedpartialdenture(highnoblemetal)

50%

D6073 Abutmentsupportedretainerforcastmetalfixedpartialdenture(predominantlybasemetal)

50%

D6074 Abutmentsupportedretainerforcastmetalfixedpartialdenture(noblemetal)

50%

D6075 Implantsupportedretainerforceramicfixedpartialdenture 50%

D6076 Implantsupportedretainerforporcelainfusedtometalfixedpartialdenture(titanium,titaniumalloy,highnoblemetal)

50%

(Q5-00)

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D6077 Implantsupportedretainerforcastmetalfixedpartialdenture(titanium,titaniumalloy,highnoblemetal)

50%

D6078 Implant/abutmentsupportedfixeddentureforcompletelyedentulousarch

50%

D6079 Implant/abutmentsupportedfixeddentureforpartiallyedentulousarch

50%

D6092 Recementimplant/abutmentsupportedcrown 50%

D6093 Recementimplant/abutmentsupportedfixedpartialdenture 50%

D6094 Abutmentsupportedcrown(titanium) 50%

D6194 Abutmentsupportedretainercrownforfixedpartialdenture(titanium)

50%

Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.

D7111 Extractionofcoronalremnants–Deciduoustooth 0%

D7140 Extraction,eruptedtoothorexposedroot–Elevationand/orforcepsremoval

0%

D7210 Surgicalremovaloferuptedtooth–Removalofboneand/orsectionoftooth

0%

D7220 Removalofimpactedtooth–Softtissue 0%

D7230 Removalofimpactedtooth–Partiallybony 50%

D7240 Removalofimpactedtooth–Completelybony 50%

D7241 Removalofimpactedtooth–Completelybony,unusualcomplications(narrativerequired)

50%

D7250 Surgicalremovalofresidualtoothroots–Cuttingprocedure 0%

D7251 Coronectomy-Intentionalpartialtoothremoval 50%

D7260 Oroantralfistulaclosure 0%

D7261 Primaryclosureofasinusperforation 0%

D7270 Toothstabilizationofaccidentallyevulsedordisplacedtooth 0%

D7280 Surgicalaccessofanuneruptedtooth(excludingwisdomteeth)

50%

(Q5-00)

-18-



D7283 Placementofdevicetofacilitateeruptionofimpactedtooth 50%

D7285 Biopsyoforaltissue–Hard(bone,tooth)(toothrelated–notallowedwheninconjunctionwithanothersurgicalprocedure)

0%

D7286 Biopsyoforaltissue–Soft(allothers)(toothrelated–notallowedwheninconjunctionwithanothersurgicalprocedure)

0%

D7287 Exfoliativecytologicalsamplecollection 0%

D7288 Brushbiopsy–Transepithelialsamplecollection 0%

D7310 Alveoloplastyinconjunctionwithextractions–4ormoreteethortoothspacesperquadrant

0%

D7311 Alveoloplastyinconjunctionwithextractions–1to3teethortoothspacesperquadrant

0%

D7320 Alveoloplastynotinconjunctionwithextractions–4ormoreteethortoothspacesperquadrant

0%

D7321 Alveoloplastynotinconjunctionwithextractions–1to3teethortoothspacesperquadrant

0%

D7450 Removalofbenignodontogeniccystortumor–Upto1.25cm

0%

D7451 Removalofbenignodontogeniccystortumor–Greaterthan1.25cm

0%

D7471 Removaloflateralexostosis–Maxillaormandible 0%

D7472 Removaloftoruspalatinus 0%

D7473 Removaloftorusmandibularis 0%

D7485 Surgicalreductionofosseoustuberosity 0%

D7510 Incisionanddrainageofabscess–Intraoralsofttissue 0%

D7511 Incisionanddrainageofabscess–Intraoralsofttissuecomplicated

0%

D7520 Incisionanddrainageofabscess–Extraoralsofttissue 0%

D7521 Incisionanddrainageofabscess–Extraoralsofttissue–Complicated(includesdrainageofmultiplefascialspaces)

0%

(Q5-00)

-19-



D7880 Occlusalorthoticdevice,byreport(limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment)

50%

D7910 Sutureofrecentsmallwoundsupto5cm 0%

D7960 Frenulectomy–Alsoknownasfrenectomyorfrenotomy–Separateprocedurenotincidentaltoanotherprocedure

0%

D7963 Frenuloplasty 0%

Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.)

D8050 Interceptiveorthodontictreatmentoftheprimarydentition–Banding

50%

D8060 Interceptiveorthodontictreatmentofthetransitionaldentition–Banding

50%

D8070 Comprehensiveorthodontictreatmentofthetransitionaldentition–Banding

50%

D8080 Comprehensiveorthodontictreatmentoftheadolescentdentition–Banding

50%

D8090 Comprehensiveorthodontictreatmentoftheadultdentition–Banding

50%

D8210 Removableappliancetherapy 50%

D8220 Fixedappliancetherapy 50%

D8660 Pre-orthodontictreatmentvisit 50%

D8670 Periodicorthodontictreatmentvisit–Aspartofcontract

Children–Upto19thbirthday:24-monthtreatmentfee 50%

Adults:24-monthtreatmentfee 50%

D8680 Orthodonticretention–Removalofappliances,constructionandplacementofretainer(s)

50%

(Q5-00)

-20-



D8693 Rebondingorrecementing;and/orrepair,asrequired,offixedretainers

50%

D8999 Unspecifiedorthodonticprocedure–Byreport(orthodontictreatmentplanandrecords)

50%

General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management.

D9211 Regionalblockanesthesia 0%

D9212 Trigeminaldivisionblockanesthesia 0%

D9215 Localanesthesia 0%

D9220 Generalanesthesia–First30minutes 0%

D9221 Generalanesthesia–Eachadditional15minutes 0%

D9241 IVconscioussedation–First30minutes 0%

D9242 IVconscioussedation–Eachadditional15minutes 0%

D9610 Therapeuticparenteraldrug,singleadministration 0%

D9612 Therapeuticparenteraldrugs,2ormoreadministrations,differentmedications

0%

D9630 Otherdrugsand/ormedicaments–Byreport 0%

D9910 Applicationofdesensitizingmedicament 0%

Emergency services

D9110 Palliative(emergency)treatmentofdentalpain–Minorprocedure

0%

D9120 Fixedpartialdenturesectioning 0%

D9440 Officevisit–Afterregularlyscheduledhours 0%

(Q5-00)

-21-



Miscellaneous services

D9940 Occlusalguard–Byreport(limit 1 per 24 months) 50%

D9941 Fabricationofathleticmouthguard(limit 1 per 12 months) 50%

D9942 Repairand/orrelineofocclusalguard 0%

D9951 Occlusaladjustment–Limited 0%

D9952 Occlusaladjustment–Complete 0%

D9975 Externalbleachingforhomeapplication,perarch;includesmaterialsandfabricationofcustomtrays(all other methods of bleaching are not covered)

$165.00

ThismaycontainCDTcodesand/orportionsof,orexcerptsfromthenomenclaturecontainedwithintheCurrent Dental Terminology,acopyrightedpublicationprovidedbytheAmericanDentalAssociation.TheAmericanDentalAssociationdoesnotendorseanycodeswhicharenotincludedinitscurrentpublication.

(Q5-00)

-22-

After your enrollment is effective:

CallthedentalofficeidentifiedinyourWelcomeKit.Ifyouwishtochangedentaloffices,atransfercanbearrangedatnochargebycallingCignaDentalatthetollfreenumberlistedonyourIDcardorplanmaterials.Multiplewaystolocatea*DHMONetworkGeneralDentist:

• OnlineproviderdirectoryatCigna.com

• OnlineproviderdirectoryonmyCigna.com

• CallthenumberlocatedonyourIDcardto:

– UsetheDentalOfficeLocatorviaSpeechRecognition

– SpeaktoaCustomerServiceRepresentative

EMERGENCY:Ifyouhaveadentalemergencyasdefinedinyourgroup’splandocuments,contactyourNetworkGeneralDentistassoonaspossible.IfyouareoutofyourserviceareaorunabletocontactyourNetworkOffice,emergencycarecanberenderedbyanylicenseddentist.Definitivetreatment(e.g.,rootcanal)isnotconsideredemergencycareandshouldbeperformedorreferredbyyourNetworkGeneralDentist.Consultyourgroup’splandocumentsforacompletedefinitionofdentalemergency,youremergencybenefitandalistingofExclusionsandLimitations.

* The term “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.

“Cigna,” “Cigna Dental Care” and “GO YOU” are registered service marks, and the “Tree of Life” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI.

856593 02/13 © 2013 Cigna. Some content provided under license.

856593 q5-00 dhmo 09 pcs v11 - cigna · 24/7 at 1.800.cigna24 or the phone number on your id card....

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