Cigna Dental Care DHMO) Patient Charge Schedule · 2018-11-05 · Patient Charge Schedule (K1-08)-7-Code Procedure Description Patient Charge Implant Supported Prosthetics – All

K1-08

830561 10/11 K1-0892151

This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Important Highlights

Cigna Dental Care® (*DHMO)Patient Charge Schedule

• ThisPatientChargeScheduleappliesonlywhencovereddentalservicesareperformedbyyourNetworkDentist,unlessotherwiseauthorizedbyCignaDentalasdescribedinyourplandocuments.NotallNetworkDentistsperformalllistedservicesanditissuggestedtocheckwithyourNetworkDentistinadvanceofreceiving services.

• ThisPatientChargeScheduleappliestoSpecialtyCarewhenanappropriatereferralismadetoaNetworkSpecialtyPeriodontist,OrthodontistorOralSurgeon.YoumustverifywiththeNetworkSpecialtyDentistthatyourtreatmentplanhasbeenauthorizedforpaymentbyCignaDental.PriorauthorizationisnotrequiredforspecialtyreferralsforPediatricandEndodonticservices.YoumayselectaNetworkPediatricDentistforyourchildundertheageof7bycallingCustomerServiceat1.800.Cigna24togetalistofNetworkPediatricDentistsinyourarea.CoveragefortreatmentbyaPediatricDentistendsonyourchild’s7thbirthday;however,exceptionsformedicalreasonsmaybeconsideredonanindividualbasis.YourNetworkGeneralDentistwillprovidecareuponyourchild’s7thbirthday.

• Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient’s responsibility at the dentist’s usual fees.

• TheadministrationofIVsedation,generalanesthesia,and/orNitrousOxideisnotcoveredexceptasspecificallylistedonthisPatientChargeSchedule.Theapplicationoflocalanestheticiscoveredaspartofyourdentaltreatment.

• CignaDentalconsidersinfectioncontroland/orsterilizationtobeincidentaltoandpartofthechargesforservicesprovidedandnotseparatelychargeable.

• ThisPatientChargeScheduleissubjecttoannualchangeinaccordancewiththeterms of the group agreement.

• ProcedureslistedonthePatientChargeSchedulearesubjecttotheplanlimitationsandexclusionsdescribedinyourplanbook/certificateofcoverageand/orgroupcontract.

Cigna Dental Care®Patient Charge Schedule (K1-08)

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Code Procedure Description Patient Charge

Diagnostic/Preventive –Oralevaluationsarelimitedtoacombinedtotalof4ofthefollowingevaluationsduringa12consecutivemonthperiod:PeriodicOralEvaluations(D0120),ComprehensiveOralEvaluations(D0150),ComprehensivePeriodontalEvaluations(D0180),andOralEvaluationsforPatientsUnder3YearsofAge(D0145).

D9310 Consultation(DiagnosticServiceProvidedbyDentistorPhysicianOtherthanRequestingDentistorPhysician)

$0.00

D9430 OfficeVisitforObservation–NoOtherServicesPerformed $0.00

D9450 CasePresentation–DetailedandExtensiveTreatmentPlanning

$0.00

D0120 PeriodicOralEvaluation–EstablishedPatient $0.00

D0140 LimitedOralEvaluation–ProblemFocused $0.00

D0145 OralEvaluationforaPatientUnder3YearsofAgeandCounselingwithPrimaryCaregiver

$0.00

D0150 ComprehensiveOralEvaluation–NeworEstablishedPatient $0.00

D0170 Re-evaluation–Limited,ProblemFocused(NotPostoperativeVisit)

$0.00

D0210 X-RaysIntraoral–CompleteSeries(IncludingBitewings)(Limit 1 Every 3 Years)

$0.00

D0220 X-RaysIntraoral–Periapical–FirstFilm $0.00

D0230 X-RaysIntraoral–Periapical–EachAdditionalFilm $0.00

D0240 X-RaysIntraoral–OcclusalFilm $0.00

D0270 X-Rays(Bitewing)–SingleFilm $0.00

D0272 X-Rays(Bitewings)–2Films $0.00

• AllpatientchargesmustcorrespondtothePatientChargeScheduleineffectonthedate the procedure is initiated.

• TheAmericanDentalAssociationmayperiodicallychangeCDTCodesordefinitions.Differentcodesmaybeusedtodescribethesecoveredprocedures.

Important Highlights (continued)


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D0277 X-Rays(Bitewings,Vertical)–7to8Films $0.00

D0330 X-Rays(PanoramicFilm)–(Limit 1 Every 3 Years) $0.00

D0431 OralCancerScreeningUsingaSpecialLightSource $50.00

D0460 PulpVitalityTests $13.00

D0470 Diagnostic Casts $0.00

D0472 PathologyReport–GrossExaminationofLesion (OnlyWhenToothRelated)

$0.00

D0473 PathologyReport–MicroscopicExaminationofLesion (OnlyWhenToothRelated)

$0.00

D0474 PathologyReport–MicroscopicExaminationofLesionandArea(OnlyWhenToothRelated)

$0.00

D1110 Prophylaxis(Cleaning)–Adult(Limit 2 per Calendar Year) $0.00

AdditionalProphylaxis(Cleaning)–InAdditiontothe 2Prophylaxes(Cleanings)AllowedperCalendarYear

$45.00

D1120 Prophylaxis(Cleaning)–Child(Limit 2 per Calendar Year) $0.00

AdditionalProphylaxis(Cleaning)–InAdditiontothe 2Prophylaxes(Cleanings)AllowedperCalendarYear

$30.00

D1203 TopicalApplicationofFluoride–Child(Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.

$0.00

D1206 TopicalFluorideVarnish–TherapeuticApplicationforModeratetoHighCariesRiskPatients–Child(Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.

$0.00

D1330 OralHygieneInstructions $0.00

D1351 Sealant – Per Tooth $11.00

D1352 PreventiveResinRestorationinaModeratetoHighCariesRiskPatient – Permanent Tooth

$11.00

D1510 SpaceMaintainer–Fixed–Unilateral $105.00

D1515 SpaceMaintainer–Fixed–Bilateral $165.00

D1555 RemovalofFixedSpaceMaintainer $0.00


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Restorative (Fillings)

D2140 Amalgam–1Surface,PrimaryorPermanent $0.00

D2150 Amalgam–2Surfaces,PrimaryorPermanent $0.00

D2160 Amalgam–3Surfaces,PrimaryorPermanent $0.00

D2161 Amalgam–4orMoreSurfaces,PrimaryorPermanent $0.00

D2330 Resin-BasedComposite–1Surface,Anterior $0.00

D2331 Resin-BasedComposite–2Surfaces,Anterior $0.00

D2332 Resin-BasedComposite–3Surfaces,Anterior $0.00

D2335 Resin-BasedComposite–4orMoreSurfacesorInvolvingIncisalAngle,Anterior

$85.00

D2390 Resin-BasedCompositeCrown,Anterior $85.00

D2391 Resin-BasedComposite–1Surface,Posterior $45.00

D2392 Resin-BasedComposite–2Surfaces,Posterior $57.00

D2393 Resin-BasedComposite–3Surfaces,Posterior $79.00

D2394 Resin-BasedComposite–4orMoreSurfaces,Posterior $110.00

Crown and Bridge – Allchargesforcrownandbridge(fixedpartialdenture)areperunit(eachreplacementorsupportingtoothequals1unit)–Replacementlimit1every5years.

D2510 Inlay–Metallic–1Surface $400.00

D2520 Inlay–Metallic–2Surfaces $400.00

D2530 Inlay–Metallic–3orMoreSurfaces $400.00

D2542 Onlay–Metallic–2Surfaces $460.00

D2543 Onlay–Metallic–3Surfaces $460.00

D2544 Onlay–Metallic–4orMoreSurfaces $460.00

D2740 Crown–Porcelain/CeramicSubstrate $490.00

D2750 Crown–PorcelainFusedtoHighNobleMetal $450.00

D2751 Crown–PorcelainFusedtoPredominantlyBaseMetal $400.00

D2752 Crown–PorcelainFusedtoNobleMetal $425.00

D2780 Crown–3/4CastHighNobleMetal $450.00


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D2781 Crown–3/4CastPredominantlyBaseMetal $400.00

D2782 Crown–3/4CastNobleMetal $425.00

D2790 Crown–FullCastHighNobleMetal $450.00

D2791 Crown–FullCastPredominantlyBaseMetal $400.00

D2792 Crown–FullCastNobleMetal $425.00

D2794 Crown–Titanium $450.00

D2910 RecementInlay–OnlayorPartialCoverageRestoration $42.00

D2915 RecementCastorPrefabricatedPostandCore $42.00

D2920 RecementCrown $42.00

D2930 PrefabricatedStainlessSteelCrown–PrimaryTooth $100.00

D2931 PrefabricatedStainlessSteelCrown–PermanentTooth $100.00

D2932 PrefabricatedResinCrown $130.00

D2933 PrefabricatedStainlessSteelCrownwithResinWindow $160.00

D2934 PrefabricatedEstheticCoatedStainlessSteelCrown– PrimaryTooth

$160.00

D2940 ProtectiveRestoration $12.00

D2950 CoreBuildup–IncludingAnyPins $130.00

D2951 PinRetention–PerTooth–InAdditiontoRestoration $12.00

D2952 PostandCore–InAdditiontoCrown,IndirectlyFabricated $160.00

D2954 PrefabricatedPostandCore–InAdditiontoCrown $130.00

D2960 LabialVeneer(ResinLaminate)–Chairside $91.00

D6210 Pontic–CastHighNobleMetal $450.00

D6211 Pontic–CastPredominantlyBaseMetal $400.00

D6212 Pontic–CastNobleMetal $425.00

D6214 Pontic – Titanium $450.00

D6240 Pontic–PorcelainFusedtoHighNobleMetal $450.00

D6241 Pontic–PorcelainFusedtoPredominantlyBaseMetal $400.00

D6242 Pontic–PorcelainFusedtoNobleMetal $425.00

D6245 Pontic–Porcelain/Ceramic $445.00

D6602 Inlay–CastHighNobleMetal,2Surfaces $450.00


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D6603 Inlay–CastHighNobleMetal,3orMoreSurfaces $450.00

D6604 Inlay–CastPredominantlyBaseMetal,2Surfaces $390.00

D6605 Inlay–CastPredominantlyBaseMetal,3orMoreSurfaces $390.00

D6606 Inlay–CastNobleMetal,2Surfaces $415.00

D6607 Inlay–CastNobleMetal,3orMoreSurfaces $425.00

D6610 Onlay–CastHighNobleMetal,2Surfaces $440.00

D6611 Onlay–CastHighNobleMetal,3orMoreSurfaces $450.00

D6612 Onlay–CastPredominantlyBaseMetal,2Surfaces $390.00

D6613 Onlay–CastPredominantlyBaseMetal,3orMoreSurfaces $390.00

D6614 Onlay–CastNobleMetal,2Surfaces $415.00

D6615 Onlay–CastNobleMetal,3orMoreSurfaces $425.00

D6624 Inlay–Titanium $450.00

D6634 Onlay–Titanium $450.00

D6740 Crown–Porcelain/Ceramic $490.00

D6750 Crown–PorcelainFusedtoHighNobleMetal $450.00

D6751 Crown–PorcelainFusedtoPredominantlyBaseMetal $400.00

D6752 Crown–PorcelainFusedtoNobleMetal $425.00

D6780 Crown–3/4CastHighNobleMetal $450.00

D6781 Crown–3/4CastPredominantlyBaseMetal $400.00

D6782 Crown–3/4CastNobleMetal $425.00

D6790 Crown–FullCastHighNobleMetal $450.00

D6791 Crown–FullCastPredominantlyBaseMetal $400.00

D6792 Crown–FullCastNobleMetal $425.00

D6794 Crown–Titanium $450.00

ComplexRehabilitation–ADDITIONALCHARGEPERUNIT FORMULTIPLECROWNUNITS/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)

$135.00

D6930 RecementFixedPartialDenture $59.00


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Implant Supported Prosthetics – Allchargesforcrownandbridge(fixedpartialdenture)areperunit(eachreplacementonasupportingimplant(s)equals1unit)–Replacementlimit1every5years.Allchargesforanimplantsupporteddenturearelimitedtoreplacementof1every5years.

D6053 Implant/AbutmentSupportedRemovableDentureforCompletelyEdentulousArch

$925.00

D6054 Implant/AbutmentSupportedRemovableDentureforPartiallyEdentulousArch

$1,015.00

D6058 AbutmentSupportedPorcelain/CeramicCrown $790.00

D6059 AbutmentSupportedPorcelainFusedtoMetalCrown(HighNobleMetal)

$750.00

D6060 AbutmentSupportedPorcelainFusedtoMetalCrown(PredominantlyBaseMetal)

$700.00

D6061 AbutmentSupportedPorcelainFusedtoMetalCrown(NobleMetal)

$725.00

D6062 AbutmentSupportedCastMetalCrown(HighNobleMetal) $750.00

D6063 AbutmentSupportedCastMetalCrown(PredominantlyBaseMetal)

$700.00

D6064 AbutmentSupportedCastMetalCrown(NobleMetal) $725.00

D6065 ImplantSupportedPorcelain/CeramicCrown $790.00

D6066 ImplantSupportedPorcelainFusedtoMetalCrown(Titanium,TitaniumAlloy,HighNobleMetal)

$750.00

D6067 ImplantSupportedMetalCrown(Titanium,TitaniumAlloy,HighNobleMetal)

$750.00

D6068 AbutmentSupportedRetainerforPorcelain/CeramicFixedPartial Denture

$790.00

D6069 AbutmentSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(HighNobleMetal)

$750.00

D6070 AbutmentSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(PredominantlyBaseMetal)

$700.00

D6071 AbutmentSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(NobleMetal)

$725.00

D6072 AbutmentSupportedRetainerforCastMetalFixedPartialDenture(HighNobleMetal)

$750.00


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D6073 AbutmentSupportedRetainerforCastMetalFixedPartialDenture(PredominantlyBaseMetal)

$700.00

D6074 AbutmentSupportedRetainerforCastMetalFixedPartialDenture(NobleMetal)

$725.00

D6075 ImplantSupportedRetainerforCeramicFixedPartialDenture $790.00

D6076 ImplantSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(Titanium,TitaniumAlloy,HighNobleMetal)

$750.00

D6077 ImplantSupportedRetainerforCastMetalFixedPartialDenture(Titanium,TitaniumAlloy,HighNobleMetal)

$750.00

D6078 Implant/AbutmentSupportedFixedDentureforCompletelyEdentulousArch

$925.00

D6079 Implant/AbutmentSupportedFixedDentureforPartiallyEdentulousArch

$1,015.00

D6092 RecementImplant/AbutmentSupportedCrown $82.00

D6093 RecementImplant/AbutmentSupportedFixedPartialDenture

$99.00

D6094 AbutmentSupportedCrown(Titanium) $750.00

D6194 AbutmentSupportedRetainerCrownforFixedPartialDenture (Titanium)

$750.00

ComplexRehabilitationonImplantSupportedProstheticProcedures–ADDITIONALCHARGEPERUNITFORMULTIPLECROWNUNITS/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)

$135.00

Endodontics (RootCanalTreatment,ExcludingFinalRestorations)

D3110 PulpCap–Direct(ExcludingFinalRestoration) $13.00

D3120 PulpCap–Indirect(ExcludingFinalRestoration) $13.00

D3220 Pulpotomy–RemovalofPulp,NotPartofaRootCanal $68.00

D3221 PulpalDebridement(Nottobeusedwhenrootcanalisdoneonthesameday)

$68.00

D3222 PartialPulpotomyforApexogenesis–PermanentToothwithIncompleteRootDevelopment

$68.00


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D3310 AnteriorRootCanal–PermanentTooth(ExcludingFinalRestoration)

$210.00

D3320 BicuspidRootCanal–PermanentTooth(ExcludingFinalRestoration)

$245.00

D3330 MolarRootCanal–PermanentTooth(ExcludingFinalRestoration)

$335.00

D3331 TreatmentofRootCanalObstruction–NonsurgicalAccess $92.00

D3332 IncompleteEndodonticTherapy–Inoperable,UnrestorableorFracturedTooth

$92.00

D3333 InternalRootRepairofPerforationDefects $92.00

D3346 RetreatmentofPreviousRootCanalTherapy–Anterior $285.00

D3347 RetreatmentofPreviousRootCanalTherapy–Bicuspid $325.00

D3348 RetreatmentofPreviousRootCanalTherapy–Molar $410.00

D3410 Apicoectomy/PeriradicularSurgery–Anterior $260.00

D3421 Apicoectomy/PeriradicularSurgery–Bicuspid(FirstRoot) $290.00

D3425 Apicoectomy/PeriradicularSurgery–Molar(FirstRoot) $320.00

D3426 Apicoectomy/PeriradicularSurgery(EachAdditionalRoot) $105.00

D3430 RetrogradeFillingperRoot $68.00

Periodontics(TreatmentofSupportingTissues[GumandBone]oftheTeeth) Periodontal regenerative procedures are limited to 1 regenerative procedure per site(orpertooth,ifapplicable),whencoveredonthePatientChargeSchedule.TheRelevantProcedureCodesareD4263,D4264,D4266andD4267.Localizeddeliveryofantimicrobialagentsislimitedto8Teeth(or8sites,ifapplicable)per12consecutivemonths,whencoveredonthePatientChargeSchedule.

D0180 ComprehensivePeriodontalEvaluation–NeworEstablishedPatient

$32.00

D4210 GingivectomyorGingivoplasty–4orMoreTeethperQuadrant $170.00

D4211 GingivectomyorGingivoplasty–1to3TeethperQuadrant $86.00

D4240 GingivalFlap(IncludingRootPlaning)–4orMoreTeeth perQuadrant

$220.00

D4241 GingivalFlap(IncludingRootPlaning)–1to3Teeth perQuadrant

$115.00

D4245 ApicallyPositionedFlap $220.00


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D4249 ClinicalCrownLengthening–HardTissue $240.00

D4260 OsseousSurgery–4orMoreTeethperQuadrant $400.00

D4261 OsseousSurgery–1to3TeethperQuadrant $225.00

D4263 BoneReplacementGraft–FirstSiteinQuadrant $290.00

D4264 BoneReplacementGraft–EachAdditionalSiteinQuadrant $225.00

D4266 GuidedTissueRegeneration–ResorbableBarrierperSite $380.00

D4267 GuidedTissueRegeneration–NonresorbableBarrierperSite(IncludesMembraneRemoval)

$430.00

D4270 PedicleSoftTissueGraftProcedure $285.00

D4271 FreeSoftTissueGraftProcedure(IncludingDonorSiteSurgery)

$295.00

D4275 SoftTissueAllograft $295.00

D4341 PeriodontalScalingandRootPlaning–4orMoreTeethperQuadrant(Limit 4 Quadrants per Consecutive 12 Months)

$83.00

D4342 PeriodontalScalingandRootPlaning–1to3Teeth–perQuadrant(Limit 4 Quadrants per Consecutive 12 Months)

$42.00

D4355 FullMouthDebridementtoAllowEvaluationandDiagnosis (1 per Lifetime)

$62.00

D4381 LocalizedDeliveryofAntimicrobialAgentsperTooth–ByReport

$45.00

D4910 PeriodontalMaintenance(Limited to 2 per Calendar Year) (Only Covered after Active Therapy)

$50.00

D9940 OcclusalGuard–ByReport(Limit 1 per 24 Months) $195.00

D9951 OcclusalAdjustmentLimited $38.00

D9952 OcclusalAdjustmentComplete $200.00

Prosthetics(RemovableToothReplacement–Dentures)Includesupto4adjustmentswithinfirst6monthsafterinsertion–Replacementlimit1every5years.

D5110 FullUpperDenture $625.00

D5120 FullLowerDenture $625.00

D5130 ImmediateFullUpperDenture $645.00

D5140 ImmediateFullLowerDenture $645.00


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D5211 UpperPartialDenture–ResinBase(IncludingClasps, RestsandTeeth)

$525.00

D5212 LowerPartialDenture–ResinBase(IncludingClasps, RestsandTeeth)

$525.00

D5213 UpperPartialDenture–CastMetalFamework(IncludingClasps,RestsandTeeth)

$715.00

D5214 LowerPartialDenture–CastMetalFramework(IncludingClasps,RestsandTeeth)

$715.00

D5225 UpperPartialDenture–FlexibleBase(IncludingClasps, RestsandTeeth)

$575.00

D5226 LowerPartialDenture–FlexibleBase(IncludingClasps, RestsandTeeth)

$575.00

D5410 AdjustCompleteDenture–Upper $43.00

D5411 AdjustCompleteDenture–Lower $43.00

D5421 AdjustPartialDenture–Upper $43.00

D5422 AdjustPartialDenture–Lower $43.00

Repairs to Prosthetics

D5510 RepairBrokenCompleteDentureBase $84.00

D5520 ReplaceMissingorBrokenTeeth–CompleteDenture (EachTooth)

$72.00

D5610 RepairResinDentureBase $84.00

D5630 RepairorReplaceBrokenClasp $105.00

D5640 ReplaceBrokenTeeth–PerTooth $77.00

D5650 AddToothtoExistingPartialDenture $84.00

D5660 AddClasptoExistingPartialDenture $105.00

Denture Relining(Limit1Every36Months)

D5710 RebaseCompleteUpperDenture $235.00

D5711 RebaseCompleteLowerDenture $235.00

D5720 RebaseUpperPartialDenture $235.00

D5721 RebaseLowerPartialDenture $235.00

D5730 RelineCompleteUpperDenture–Chairside $135.00


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D5731 RelineCompleteLowerDenture–Chairside $135.00

D5740 RelineUpperPartialDenture–Chairside $135.00

D5741 RelineLowerPartialDenture–Chairside $135.00

D5750 RelineCompleteUpperDenture–Laboratory $200.00

D5751 RelineCompleteLowerDenture–Laboratory $200.00

D5760 RelineUpperPartialDenture–Laboratory $200.00

D5761 RelineLowerPartialDenture–Laboratory $200.00

Interim Dentures(Limit1Every5Years)

D5810 InterimCompleteDenture–Upper $300.00

D5811 InterimCompleteDenture–Lower $300.00

D5820 InterimPartialDenture–Upper $265.00

D5821 InterimPartialDenture–Lower $265.00

Oral Surgery (IncludesRoutinePostoperativeTreatment)SurgicalRemovalofImpactedTooth–Notcoveredforagesbelow15unlesspathology(disease) exists.

D7111 ExtractionofCoronalRemnants–DeciduousTooth $12.00

D7140 Extraction,EruptedToothorExposedRoot–Elevation and/orForcepsRemoval

$12.00

D7210 SurgicalRemovalofEruptedTooth–RemovalofBone and/orSectionofTooth

$50.00

D7220 RemovalofImpactedTooth–SoftTissue $43.00

D7230 RemovalofImpactedTooth–PartiallyBony $86.00

D7240 RemovalofImpactedTooth–CompletelyBony $115.00

D7241 RemovalofImpactedTooth–CompletelyBony,UnusualComplications(NarrativeRequired)

$115.00

D7250 SurgicalRemovalofResidualToothRoots–CuttingProcedure $50.00

D7251 Coronectomy-IntentionalPartialToothRemoval $86.00

D7260 OroantralFistulaClosure $115.00

D7261 PrimaryClosureofaSinusPerforation $115.00


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D7270 ToothStabilizationofAccidentallyEvulsedorDisplacedTooth $13.00

D7280 SurgicalAccessofanUneruptedTooth(Excluding Wisdom Teeth)

$13.00

D7283 PlacementofDevicetoFacilitateEruptionofImpactedTooth $7.00

D7285 BiopsyofOralTissue–Hard(Bone,Tooth)(Tooth Related – Not allowed when in conjunction with another surgical procedure)

$74.00

D7286 BiopsyofOralTissue–Soft(AllOthers)(Tooth Related – Not allowed when in conjunction with another surgical procedure)

$62.00

D7287 ExfoliativeCytologicalSampleCollection $74.00

D7288 BrushBiopsy–TransepithelialSampleCollection $74.00

D7310 AlveoloplastyinConjunctionwithExtractions– 4orMoreTeethorToothSpacesperQuadrant

$55.00

D7311 AlveoloplastyinConjunctionwithExtractions– 1to3TeethorToothSpacesperQuadrant

$31.00

D7320 AlveoloplastyNotinConjunctionwithExtractions– 4orMoreTeethorToothSpacesperQuadrant

$74.00

D7321 AlveoloplastyNotinConjunctionwithExtractions– 1to3TeethorToothSpacesperQuadrant

$38.00

D7450 RemovalofBenignOdontogenicCystorTumor– Upto1.25cm

$13.00

D7451 RemovalofBenignOdontogenicCystorTumor– Greaterthan1.25cm

$13.00

D7471 RemovalofLateralExostosis–MaxillaorMandible $13.00

D7472 RemovalofTorusPalatinus $13.00

D7473 RemovalofTorusMandibularis $13.00

D7485 SurgicalReductionofOsseousTuberosity $74.00

D7510 IncisionandDrainageofAbscess–IntraoralSoftTissue $13.00

D7511 IncisionandDrainageofAbscess–IntraoralSoftTissueComplicated

$19.00

D7960 Frenulectomy–AlsoKnownasFrenectomyorFrenotomy–SeparateProcedureNotIncidentaltoAnother

$13.00

D7963 Frenuloplasty $19.00


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Orthodontics (ToothMovement)OrthodonticTreatment(Maximumbenefitof24monthsofinterceptiveand/orcomprehensivetreatment.Atypicalcasesorcasesbeyond24monthsrequireanadditionalpaymentbythepatient.)

D8050 InterceptiveOrthodonticTreatmentofthePrimary Dentition–Banding

$480.00

D8060 InterceptiveOrthodonticTreatmentoftheTransitionalDentition–Banding

$480.00

D8070 ComprehensiveOrthodonticTreatmentoftheTransitionalDentition–Banding

$500.00

D8080 ComprehensiveOrthodonticTreatmentoftheAdolescentDentition–Banding

$515.00

D8090 ComprehensiveOrthodonticTreatmentoftheAdult Dentition–Banding

$515.00

D8660 Pre-OrthodonticTreatmentVisit $67.00

D8670 PeriodicOrthodonticTreatmentVisit–AsPartofContract

Children–Upto19thBirthday:

24-MonthTreatmentFee $2,045.00

ChargeperMonthfor24Months $85.00

Adults:

24-MonthTreatmentFee $2,385.00

ChargeperMonthfor24Months $99.00

D8680 OrthodonticRetention–RemovalofAppliances,ConstructionandPlacementofRetainer(s)

$345.00

D8999 UnspecifiedOrthodonticProcedure–ByReport(Orthodontic Treatment Plan and Records)

$195.00


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General Anesthesia/IV Sedation –GeneralanesthesiaiscoveredwhenperformedbyanOralSurgeonwhenmedicallynecessaryforcoveredprocedureslistedonthePatientChargeSchedule.IVsedationiscoveredwhenperformedbyaPeriodontistorOralSurgeonwhenmedicallynecessaryforcoveredprocedureslistedonthePatientCharge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is nocoverageforgeneralanesthesiaorintravenoussedationwhenusedforthepurposeofanxietycontrolorpatientmanagement.

D9220 GeneralAnesthesia–First30Minutes $180.00

D9221 GeneralAnesthesia–EachAdditional15Minutes $80.00

D9241 IVConsciousSedation–First30Minutes $180.00

D9242 IVConsciousSedation–EachAdditional15Minutes $73.00

Emergency Services

D9110 Palliative(Emergency)TreatmentofDentalPain–MinorProcedure

$0.00

D9440 OfficeVisit–AfterRegularlyScheduledHours $53.00

Miscellaneous Services–ExternalBleaching(D9972)islimitedtotheuseoftake-homebleachingtrays.Allotherbleachingmethodsarenotcovered.

D9972 ExternalBleachingperArch $175.00

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

* 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” and “Cigna Dental” 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 exclusively by such operating subsidiaries, including 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, and not by Cigna Corporation. 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.

830561 10/11 © 2011 Cigna

Afteryourenrollmentiseffective:CallthedentalofficeidentifiedinyourWelcomeKit.Ifyouwishtochangedentaloffices,atransfercanbearrangedatnochargebycallingCignaDentalatthetoll-freenumberlistedonyourIDcardorplanmaterials.

Multiplewaystolocatea*DHMONetworkGeneralDentist:

• Onlineproviderdirectoryatwww.Cigna.com

• OnlineproviderdirectoryonmyCigna.com

• CallthenumberlocatedonyourIDcardto:

– UsetheDentalOfficeLocatorviaSpeechRecognition

– SpeaktoaCustomerServiceRepresentative

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

City of Cleveland - Low CIGNA Dental Benefit Summary Effective 04/01/2013 All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network. Benefits Cigna Dental PPO

In-Network Out-of-Network

Network Cigna DPPO -Radius Cigna Savings -Radius Plan Year Maximum (Class I, II and III expenses)

$750

$750

Annual Deductible Individual Family

$150 per person $450 per family


Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and Customary Allowances

Plan Pays You Pay Plan Pays You Pay Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Full Mouth X-rays Bitewing X-rays Panoramic X-ray Periapical X-rays Fluoride Application Space Maintainers Emergency Care to Relieve Pain Histopathologic Exams

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Sealants Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Denture Adjustments and Repairs Oral Surgery – Simple Extractions Oral Surgery – all except simple extractions Anesthetics Surgical Extractions of Impacted Teeth Repairs to Bridges, Crowns and Inlays

80%* 20%* 80%* 20%*

Class III - Major Restorative Care Crowns Dentures Bridges Inlays/Onlays Prosthesis Over Implant

60%* 40%* 60%* 40%*

Class IV - Orthodontia Not covered 100% of your dentist’s usual fees

Not covered 100% of your dentist’s usual fees

Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

· 100% coverage for certain dental procedures · guidance on behavioral issues related to oral health · discounts on prescription and non-prescription dental products

For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

http://www.mycigna.com/

Cigna Dental PPO Exclusions and Limitations Procedure Exclusions and Limitations Exams Two per Plan year Prophylaxis (Cleanings) Two per Plan year Fluoride 2 per Plan year for children and adults Histopathologic Exams Various limits per Plan year depending on specific test X-Rays (routine) Bitewings: 2 per Plan year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workupMinor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-

precious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna

HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions: · Services performed primarily 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 accepted 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 · A surgical implant of any type · 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 · To the extent that payment is unlawful where the person resides when the expenses are incurred; · Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children,

grandparents, and the spouse’s siblings and parents); · For charges which would not have been made if the person had no insurance; · For charges for unnecessary care, treatment or surgery; · To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than

Medicaid; · To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”

insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

· In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions andlimitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. BSD30279 © 2013 Cigna

City of Cleveland -High CIGNA Dental Benefit Summary Effective 04/01/2013All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network. Benefits Cigna Dental PPO

In-Network Out-of-Network

Network Cigna DPPO -Radius Cigna Savings -Radius Plan Year Maximum (Class I, II and III expenses)

$1,000

$1,000

Annual Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and Customary Allowances

Plan Pays You Pay Plan Pays You Pay Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Full Mouth X-rays Bitewing X-rays Panoramic X-ray Periapical X-rays Fluoride Application Space Maintainers Emergency Care to Relieve Pain Histopathologic Exams

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Sealants Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Denture Adjustments and Repairs Oral Surgery – Simple Extractions Oral Surgery – all except simple extractions Anesthetics Surgical Extractions of Impacted Teeth Repairs to Bridges, Crowns and Inlays

80%* 20%* 80%* 20%*

Class III - Major Restorative Care Crowns Dentures Bridges Inlays/Onlays Prosthesis Over Implant

60%* 40%* 60%* 40%*

Class IV - Orthodontia

Lifetime Maximum

60%*

$1,200 Covered for Children & Adults

40%* 60%*

$1,200 Covered for Children & Adults

40%*

Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

· 100% coverage for certain dental procedures · guidance on behavioral issues related to oral health · discounts on prescription and non-prescription dental products

For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

http://www.mycigna.com/

Cigna Dental PPO Exclusions and Limitations Procedure Exclusions and Limitations Exams Two per Plan year Prophylaxis (Cleanings) Two per Plan year Fluoride 2 per Plan year for children and adults Histopathologic Exams Various limits per Plan year depending on specific test X-Rays (routine) Bitewings: 2 per Plan year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-

precious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna

HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions: · Services performed primarily 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 accepted 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 · A surgical implant of any type · 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 · To the extent that payment is unlawful where the person resides when the expenses are incurred; · Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children,

grandparents, and the spouse’s siblings and parents); · For charges which would not have been made if the person had no insurance; · For charges for unnecessary care, treatment or surgery; · To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than

Medicaid; · To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”

insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

· In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions andlimitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. BSD30278 © 2013 Cigna

1 of 6

City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2018 – 03/31/2019

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family| Plan Type: Drug

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. .

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.caremark.com or by calling 1-800-552-8159.

Important Questions Why this Matters: What is the overall deductible? $0 See the chart starting on page 2 for your costs for services this plan covers.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. $2,000 Person / $4,000 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the prescription copays.

What is not included in the out–of–pocket limit?

Medical Copays

Is there an overall annual limit on what the plan pays?

No

Does this plan use a network of providers? Yes.

For a list of retail pharmacies, log on to Caremark.com and use the Find a Pharmacy tool. For mail order prescriptions, use Start Mail Service or Refill Mail Service Prescriptions after logging on to Caremark.com. A list of specialty pharmacies is also available.

Do I need a referral to see a specialist? No

Are there services this plan doesn’t cover? Yes. For a list of excluded drugs, log on to Caremark.com and use the Understand My Plan and

Benefits tab.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

2 of 6




• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use in network providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common Medical Event Services You May Need

Your cost if you use an Limitations & Exceptions In-network

Provider Out-of-network

Provider

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness --------NA---------- --------NA---------- Specialist visit --------NA---------- --------NA---------- Other practitioner office visit --------NA---------- --------NA---------- Preventive care/screening/immunization --------NA---------- --------NA----------

If you have a test Diagnostic test (x-ray, blood work) --------NA---------- --------NA---------- Imaging (CT/PET scans, MRIs) --------NA---------- --------NA----------

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com

Generic copay – retail / Rx $10 Does Not Apply Covers up to a 30-day supply

Generic copay – mail order / Rx $20 Does Not Apply Covers up to a 90-day supply

Preferred copay – retail / Rx $25 Does Not Apply Covers up to a 30-day supply

Preferred copay – mail order / Rx $50 Does Not Apply Covers up to a 90-day supply

Non-Preferred copay – retail / Rx $40 Does Not Apply Covers up to a 30-day supply

Non-Preferred copay – mail order / Rx $80 Does Not Apply Covers up to a 90-day supply

3 of 6




Common Medical Event Services You May Need

Your cost if you use an Limitations & Exceptions In-network

Provider Out-of-network

Provider If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) --------NA---------- --------NA---------- Physician/surgeon fees --------NA---------- --------NA----------

If you need immediate medical attention

Emergency room services --------NA---------- --------NA---------- Emergency medical transportation --------NA---------- --------NA---------- Urgent care --------NA------------ --------NA----------

If you have a hospital stay

Facility fee (e.g., hospital room) --------NA---------- --------NA---------- Physician/surgeon fee --------NA---------- --------NA----------

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services --------NA---------- --------NA---------- Mental/Behavioral health inpatient services --------NA---------- --------NA---------- Substance use disorder outpatient services --------NA---------- --------NA---------- Substance use disorder inpatient services --------NA---------- --------NA----------

If you are pregnant Prenatal and postnatal care --------NA---------- --------NA---------- Delivery and all inpatient services --------NA---------- --------NA----------

If you need help recovering or have other special health needs

Home health care --------NA---------- --------NA---------- Rehabilitation services --------NA---------- --------NA---------- Habilitation services --------NA---------- --------NA---------- Skilled nursing care --------NA---------- --------NA---------- Durable medical equipment --------NA---------- --------NA---------- Hospice service --------NA---------- --------NA----------

If your child needs dental or eye care

Eye exam --------NA---------- --------NA---------- Glasses --------NA---------- --------NA---------- Dental check-up --------NA---------- --------NA----------

4 of 6




Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Please note – When a generic is available, but the pharmacy dispenses the brand-name medication for any reason, you will pay the difference between the brand-name medication and the generic plus the generic copayment.

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• --------NA---------- --------NA---------- --------NA----------

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 216-664-3496. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 216-664-3496.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

5 of 6

City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2015 – 03/31/2016 Coverage Examples


Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $7,540 Plan pays$ Patient pays Applicable Copay

Sample care costs: Hospital charges (mother) $0 Routine obstetric care $0 Hospital charges (baby) $0 Anesthesia $0 Laboratory tests $0 Prescriptions $Copay Radiology $0 Vaccines, other preventive $0 Total Copays

Patient pays: Deductibles $0 Co-pays $0 Co-insurance $0 Limits or exclusions $0 Total Copays

Amount owed to providers: $4,100 Plan pays $ Patient pays Applicable Copay

Sample care costs: Prescriptions $Copay Medical Equipment and Supplies $0 Office Visits and Procedures $0 Education $0 Laboratory tests $0 Vaccines, other preventive $0 Total Copays

Patient pays: Deductibles $0 Co-pays $0 Co-insurance $0 Limits or exclusions $0 Total Copays

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

6 of 6

City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2015 – 03/31/2016 Coverage Examples


Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?

• Costs don’t include premiums. • Sample care costs are based on national

averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Documents

Cigna Dental Care DHMO) Patient Charge Schedule · 2018-11-05 · Patient Charge Schedule (K1-08)-7-Code Procedure Description Patient Charge Implant Supported Prosthetics – All