How the DHMO Option Pays Benefits

Like the DMO Option, the Cigna DHMO Option is a managed care dental option that offers access to a national network of dentists. If you enroll in this option, you agree to receive care solely from dentists participating in the network. Limited out-of-network coverage may be available based on state mandates or in the case of certain, out-of-area emergencies, as noted below. If you receive any out-of-network care, you must file a claim to receive benefits. Check your Cigna DHMO coverage certificate or contact customer service at the number on your ID card for details.


Benefit Provision	Coverage
Annual deductible
Preventive	None
Restorative	None
Orthodontia	None
Preventive	100% coverage
Oral exams	Oral evaluations are limited to a combined total of four of the following evaluations during a 12 consecutive month period: Periodic oral evaluations; Comprehensive oral evaluations; Comprehensive periodontal evaluations; and Oral evaluations for patients under three years of age
Fluoride	Maximum two per calendar year Topical fluoride applications in excess of the two per calendar year are covered for a $15 copayment.
Prophylaxis (cleaning)	Maximum two per calendar year Cleanings in excess of the two per calendar year are covered for a $40 copayment for an adult and a $30 copayment for children.
Full mouth X-ray	Maximum one every three years
Bitewing X-ray	100% coverage
Sealants	100% coverage
Basic restorative (fillings, extractions, root canal, periodontal, oral surgery, anesthesia)	90% coverage (with the exception of certain oral surgery services covered at 50% or 60%)
Major restorative (dentures, inlays, onlays, crowns, bridges)	60% coverage (a few procedures, such as recementations, adjustments, tissue conditioning, and repairs are covered at 90%)
Surgical placement of Implant body	90% coverage, limited to one per year
Orthodontia	50% coverage
Maximum Benefits
Combined annual for preventive and restorative	No maximum
Lifetime for orthodontia	24 months of interceptive and/or comprehensive treatment (cases beyond 24 months or atypical cases require additional payment by the patient)
Emergency Care Away From Home If you have an emergency while you are out of your service area or unable to contact your in-network general dentist, you may receive emergency covered services as defined above from any general dentist. Routine restorative procedures or definitive treatment (e.g., root canal) are not considered emergency care. You should return to your in-network general dentist for these procedures. For emergency covered services, you will be responsible for the patient charges listed on your patient charge schedule. Cigna Dental will reimburse you the difference, if any, between the dentist's usual fee for emergency covered services and your patient charge, up to a total of $100 per incident (where allowable by state law). To receive reimbursement, send appropriate mycigna.com reports and X-rays to Cigna Dental.	100% coverage for reasonable and customary charges, up to a maximum benefit of $100 per incident. If you receive any out-of-network care, you must file a claim to receive benefits.