As of: 11/14/2023

Plan Year Deductibles (In-Network)

Basic and Major Restorative and Orthodontics
Individual: $50
Cigna Dental Family: $150
Susan Johns
ID: U42835248 02 Plan Year Annual Maximums (In-Network)
Plan: Dental PPO Diagnostic and Preventive, Basic and Major
Account Number: 3333665 Restorative
Individual: $2000
Network: Total Cigna Dppo
Coverage effective date: 07/31/2018 Lifetime Maximums (In-Network)
Orthodontics
Individual: $2000

Your Coinsurance (In-Network)

Diagnostic and Preventive: No charge
Basic Restorative: 20%
Major Restorative: 50%
Orthodontics: 50%

You may be asked to present this card when you access care; it does not guarantee coverage. For
coverage, you must meet all plan terms and conditions. Willful misuse of this card is considered
fraud.
Cigna Dental refers to the following operating subsidiaries of Cigna Corporation: Connecticut
General Life Insurance Company, Cigna Health and Life Insurance Company and Cigna Dental
Health, Inc., and its operating subsidiaries. The Cigna Dental PPO is underwritten or administered
by Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company with
network management services provided by Cigna Dental Health, Inc., and certain of its operating
subsidiaries. In Texas, the Cigna Dental PPO product is referred to as the Cigna Dental Choice
Plan. In Arizona and Louisiana, the Cigna Dental PPO product is referred to as the CG Dental PPO.

Customer Support Number: Send Dental Claims to:

1 (800) 244-6224 Cigna
PO Box 188037
Chattanooga, TN 37422-8037