Student Health
UConn Medical, Dental, Law Students and Graduate Assistants
Dental Preferred Provider Organization Benefit Summary
This is a summary of benefits for your Dental Preferred Provider Organization plan. All deductibles, plan maximums and service specific maximums (dollar and occurrence) cross
accumulate between in and out-of network.
Benefits
|
CIGNA HealthCare
Preferred Provider Organization
Dental Plan
|
In-Network
|
Out-of-Network
|
| Calendar Year Maximum (Class I, II, III Expenses) |
$1,000 per person |
$1,000 per person |
| Calendar Year Deductible Individual
Aggregate Family Maximum |
$50 per person
$150 maximum per family |
$50 per person
$150 maximum per family |
| Class I Expenses - Preventive and Diagnostic Care Oral Exams (Two per Calendar Year)
Cleanings (Two per Calendar Year)
Full Mouth X-rays (One complete set per every three Calendar Years)
Bitewing X-rays (Two per Calendar Year)
Panoramic X-ray (One per every three Calendar Years)
Fluoride Application (One per Calendar Year for persons under 19 years old)
Sealants (Limited to posterior teeth for a person less than 14 years old/One
treatment per tooth per every three Calendar Years)
Spaces Maintainers (Limited to non-orthodontic treatment)
Emergency Care to relieve pain |
100% no deductible |
100% no deductible Emergency services are paid at in-network levels |
| Class II Expenses - Basic Restorative Care
Fillings
Root Canal Therapy
Denture Adjustments and Repairs Osseous Surgery
Periodontal Scaling and Root Planing Extractions
Anesthetics
Oral Surgery |
80% after deductible |
80% after deductible |
| Class III Expenses - Major Restorative Care Crowns
Dentures
Bridges |
50% after deductible |
50% after deductible |
| Optional Services Class IV Expenses - Orthodontia |
Not covered |
Not covered |
| Missing Tooth Provision |
Individual is not covered until insured for 24 months; thereafter covered as a Class III expense. |
| Pretreatment Review |
Available on a voluntary basis when extensive dental work in excess of $200 is proposed. |
Benefit Exclusions |
|
By way of example, but not limited to: |
- Services performed solely for cosmetic reasons
- Replacement of a lost or stolen appliance
- Replacement of a bridge or denture within five years following the date of its original installation
- Replacement of a bridge or denture which can be made useable according to dental standards
- Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally
involved teeth, or restore occlusion
- Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars
- Bite registrations; precision or semi-precision attachments; splinting
- Surgical implant of any type including any prosthetic device attached to it
- Instruction for plaque control, oral hygiene and diet
|
- Dental Services that do not meet common dental standards
- Services that are deemed to be medical services
- Services and supplies received from a hospital
- Charges which the person is not legally required to pay
- Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service
- Experimental or investigational procedures and treatments
- Any injury resulting from, or in the course of, any employment for wage or profit
- Any sickness covered under any workers compensation or similar law
- Charges in excess of the reasonable and customary allowances
- Reasonable and customary other than the 80th percentile
|
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This Benefit Summary highlights some of the benefits which are available under your plan. A complete description regarding the terms of coverage, exclusions and limitations, including
legislated benefits, will be provided in your insurance certificate or plan description. |
“CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries, including Connecticut
General Life Insurance Company, Intracorp®, and CIGNA Behavioral Health, Inc., and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. Copyright
1994 CIGNA Health Corporation. |
