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Dental Program Detailed Table of Contents
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Table of Contents
Detailed Table of Contents
Index

Introduction

Who Is Eligible

Glossary of Key Terms – Eligibility

General Information

Your Eligible Dependents

Extended Coverage for Full-Time Status Students Age 19 and Older

Extended Coverage for Disabled Children

Qualified Medical Child Support Order (QMCSO)

If You Are Reemployed

For Employees of New Participating Subsidiaries and/or Participating Employers

Enrolling for Coverage

General Information

Your Contributions

Enrolling Yourself and Your Eligible Dependents

When Coverage Begins

Adding Dependents

If You Are Not Actively at Work

If You Do Not Enroll by the Deadline

Qualified Status Changes

Special Enrollment Opportunities

Significant Cost or Coverage Change

Annual Enrollment

Your Rights and Responsibilities

General Information

Your Rights

Your Responsibilities

How the Program Works

Glossary of Key Terms – CIGNA Dental PPO Options

General Information

Key Features

Passive PPOs

Deductibles

Coinsurance

Annual Maximum

Orthodontic Lifetime Maximum

Pretreatment Review

A Summary Chart of the CIGNA Dental PPO Options

What Is Covered – CIGNA Dental PPO Options

Class I: Preventive and Diagnostic Services

Class II: Basic Services

Class III: Major Services

Class IV: Orthodontic Services

What Is Not Covered – CIGNA Dental PPO Options

How to File a Claim

General Information

Program Claims

When Coverage Ends

General Information

Extension of Benefits

If You Leave the Company, Retire, or Are No Longer Eligible for Coverage

If Your Employee Group Goes on Strike

Special Extensions of Coverage

General Information

During a Leave of Absence

Uniformed Services Employment and Reemployment Rights Act of 1994

If You Receive Disability Benefits

Your Legal Right to Continuation Coverage Under COBRA

General Information

Notification

Election Procedure

Disability Extension

Other Extension

Payment

When Continuation Coverage Ends

Trade Act Implications

Coordinating Benefits With Other Programs

General Information

How Coordination of Benefits Works

Claims and Appeals Procedures

General Information

Procedure for Filing a Claim

Defective Claims

Initial Claim Review

Initial Benefit Determination

Claim Involving Urgent Care

Concurrent Care Decision

Pre-Service Claim

Post-Service Claim

Manner and Content of Notification of Denied Claim

Review of Initial Benefit Denial

Procedure for Filing an Appeal of a Denial

Review Procedures for Denials

Timing of Notification of Benefit Determination on Review

Manner and Content of Notification of Benefit Determination on Review

Legal Action

Situations Affecting Your Benefits

General Information

Right of Recovery

Right to Reimbursement, Assignment of Rights, and Duty to Notify

Right to Reimbursement

Assignment of Rights

Duty to Notify

If the Group Benefits Plan Is Modified or Ended

Administrative and Contact Information

General Information

Type of Plan

Plan Sponsor

Employer Identification Number of Plan Sponsor

Plan Name and Number

Plan Year End

Agent for Service of Legal Process

Benefits Committee and Plan Administrator

Eligibility Administration

Claims Administrator

Claims Administrator for Eligibility Claims

COBRA Administrator for Continuation Coverage

Allocation and Delegation of Fiduciary Responsibilities by the Benefits Committee

Trust and Insurance

Self-Funded Benefits

Your ERISA Rights

General Information

Receive Information About Your Program and Benefits

Continue Group Health Plan Coverage

Prudent Actions by Plan Fiduciaries

Enforce Your Rights

Assistance With Your Questions

Dental Program

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How the Program Works

General Information

Coinsurance

Coinsurance is the percentage of covered expenses you and the Program are responsible for paying. Percentages apply after any applicable deductible. The percentage you pay depends on the option you elect and the type of service you receive.

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