University Hospitals

You have two dental plan options. Both plans are administered by CIGNA.

Dental PPO Plan		Dental Care (DHMO) Plan
You can visit any licensed dentist in or out of the network – the choice is yours. Regardless of the provider you choose, the plan covers all or part of your costs for eligible expenses (after meeting your deductible), up to the annual dollar maximum. Most in-network preventive procedures are covered at no cost to you – there is no deductible for preventive care. Your out-of-pocket costs are lower and you do not have to file a claim form if you use an in-network dentist. See a summary of benefits.		You choose a dentist from the CIGNA DHMO network and when you seek treatment from that in-network dentist, there is no deductible to meet, no annual dollar maximum, no claim forms to file, and no waiting period for coverage. You must use the in-network dentist you have specified to have benefits paid, but you can choose a different network dentist for each covered member of your family, and you can change your dentist at any time. Most preventive services are covered, including two exams and cleanings per year, x-rays, and two fluoride treatments for children up to age 19. Orthodontia is covered for children and adults. For other dental care services, you pay a flat dollar amount based on the Dental Care Plan Schedule.

Locating an
In-Network Dentist

Use the online dental directory at CIGNA’s website.

How the Dental Plan Works

Plan ID# 3215260	In-network	Out-of-network	Only in-network services are covered
Annual deductible (per person)	$25 individual; $75 family	$50 individual; $150 family	None
Annual (non-ortho) maximum	$1,200 individual	$1,000 individual	None
Optional services
Implants	$1,000 calendar year max.	$1,000 calendar year max.	Not covered
Orthodontia maximum	$1,000 lifetime	$1,000 lifetime	24 month maximum benefit
Your Cost for Covered Services
Preventive (includes oral exams, cleanings and fluoride treatments, sealants and x-rays)	0%	10%	$5 office visit fee
Basic restorative (includes fillings and extractions, anesthetics and root canal therapy)	20% after deductible	30% after deductible*	Covered; see schedule
Major restorative (includes crowns, bridges and dentures)	50% after deductible	60% after deductible*	Covered; see schedule
Orthodontia (Adult)	Not covered	Not covered	Covered; see schedule
Orthodontia (Dependents under age 19)	50% after deductible	60% after deductible*	Covered; see schedule
Implants	50% after deductible	60% after deductible*	Not covered

*May be subject to higher out-of-pocket costs

Predetermination of Benefits

Before you receive extensive dental work, or dental work that is likely to cost more than $200, it’s a good idea to ask your dentist to provide a complete description of the treatment on a dental claim form and mail it to the address provided on the form. You and your dentist will be informed what will be covered.
If the dentist makes a major change in the course of treatment, you should send a revised dental claim form for a revised predetermination.