example of cigna dental 1500

• Oral exams
• Routine cleanings
• Routine x-rays
• Sealants
• Fluoride treatment
• Space Maintainers(non-orthodontic)

Class IPreventive

Class IIBasic

Class IIIMajor

Class IVOrtho

Plan pays 100%

• Non-routinex-rays1
• Routine tooth extraction
• Emergency treatment to relieve pain

Plan pays 80%

Plan pays 60%

• Periodontal (deep)
• Dentures/partials, Bridges & Repairs
• Complex/Impacted tooth extraction

• Orthodontia2

Plan pays 50%

No Waiting Period

6 MonthWaiting Period3

12 MonthWaiting Period3

12 MonthWaiting Period

1 For plan details, refer to your full summary of benefits2 Orthodontia services are offered under the Cigna Dental 1500 plan only. Orthodontia waiting period is not eligible for waiver.3 Waiting periods may vary by state. You may be eligible to waive the waiting period for Classes II & III if you have a continuous 12 months of prior coverage from a valid dental insurance plan which included coverage for Class III, Major Restorative services and not more than 63 days has lapsed between the prior coverage and this plan. Any prior dental insurance plan that did not include Class III services will not count toward waiting period waiver. Dentals plans that cover preventive services only will not apply toward waiting period waiver (Cigna Preventive Dental plans included).

Procedures Covered

Benefit Class

Coinsurance

Waiting Period