Dental PPO Plan

USI Affinity CIGNA Dental Choice (PPO) Plan offers IBOs many advantages, including:

• Having the freedom to visit a dental provider of your choice - within the network or not in the network. The plan benefits are the same; however, you save more when you select a dental provider in the network. CIGNA Dental Choice network providers agree to accept discounts when treating CIGNA dental members and are not allowed to charge more than their contracted fee for covered services.
• Easily locating a CIGNA dental provider within the network near you, please call 1-800-CIGNA24 (1-800-244-6224), or visit the CIGNA website and select the “PPO” option.
• Not needing a referral from a dental provider to see a specialist.
• Being reimbursed for all, or part, of the costs for covered procedures (up to your maximum annual benefit), after satisfying your annual deductible, whether you use the services of a dental provider within the network or out of the network.
• Having your claims filed for you (offered by most network dental providers).
• Orthodontic coverage for dependent children (up to age 19 years old).

There is no waiting period to start using the dental insurance benefits; however, once you are enrolled and your dental coverage is terminated, for any reason, there will be a 12-month waiting period to re-enroll for the insurance benefits.

Nominate your dental provider to be part of the CIGNA network.

Please note: USI Affinity is not an insurance company. Insurance plans and services are provided by insurance companies and other licensed insurance-related providers. USI Affinity represents these insurance companies and is paid a commission and may also receive other performance-based compensation for the services provided to you.

Benefit Descriptions

Benefits		CIGNA Dental Choice (PPO) In Network* or Out of Network**
Deductibles		$50 per individual
		$150 per family
Calendar Year Maximum		$1,000 per individual
Class I – Preventive and diagnostic services:		90% (no deductible)
Oral exams
Routine Cleanings
Bitewing x-rays
Fluoride application
Sealants
Space maintainers
(limited to non-orthodontic treatment)
Class II – Basic restorative services:		60% (after deductible)
Fillings
Oral surgery (simple extractions)
Periapical x-rays
Anesthetics
Full mouth x-rays
Panoramic x-rays
Emergency care to relieve pain
Class III – Major restorative services:		50% (after deductible)
Anesthetics Crowns
Dentures
Bridges
Oral surgery (except simple extractions)
Surgical extraction of impacted teeth
Minor periodontics Osseous Surgery
Root canal therapy/Endodontics
Relines, rebases, and adjustments
Repairs to bridges, crowns, and inlays Inlays/Onlays
Denture repairs
Class IV – Orthodontia Coverage for eligible children only		40% (no separate deductible)
Lifetime maximum		$1,000 (separate from annual maximum)

*The network percentage of benefits is based on the discounted fee negotiated with the provider.

**The out of network percentage of benefits is based on the usual and customary rates prevailing in the geographic areas in which the expenses are incurred the dentist may balance up to their usual fees.

Your Monthly Premiums

IBO only $46.77
IBO plus spouse $93.51
IBO plus dependent children* $103.85
IBO, spouse, and dependent children* $151.40
The above rates are valid until December 31, 2024.

*Dependent Children Eligibility: any unmarried child of yours who is less than 26 years old. Dependent children eligibility and age limits may vary by state – refer to the CIGNA insurance certificate for specific state variations. This rate applies to all eligible dependent children regardless of the number of children covered under your plan.

Eligibility for enrollment: You are eligible to enroll in our CIGNA Dental Choice (PPO) Plan if you are a current IBO and a member of the Independent Business Owners Benefits Association (IBOBA) or spouse and/or dependent child, a U.S. citizen living in the United States and hold a social security number, you may enroll.

Once you are enrolled under this CIGNA group plan, should your coverage terminate for any reason, you (and your eligible spouse and/or dependent children) will have to satisfy a 12-month waiting period to re-enroll.

Please note: This is not a certificate of insurance. This page highlights the coverage of dental benefits available through CIGNA Dental and does not include all exclusions and limitations**.

Benefits are underwritten or administered by CIGNA Health and Life Insurance Company. This information is intended as a summary of benefits only. It does not describe all the terms, provisions and limitations of your plan. A complete description of the terms of coverage, exclusions and limitations, including benefits, will be provided in the insurance certificate. In case of discrepancy between this brochure and the plan documents, the plan documents will prevail. Services started prior to your plan becoming effective may not be covered.

**There is a 24 month waiting period beginning with your policy effective date in which no benefit payment(s) will be made to replace any missing teeth that were missing on the effective date of coverage.

Instructions on how to enroll in the CIGNA Dental Choice (PPO) plan and to download the CIGNA Dental Choice Enrollment Form.

IBOBA: When you register or renew as an IBO, you also become a member of the Independent Business Owners Benefits Association (IBOBA). The IBOBA is a non-profit association which promotes the interests of its members at the local, state and federal government levels, to use the power of group buying to make available to the members benefits and services such as travel programs, including automobile rental and hotel discounts, insurance, non-insurance healthcare discounts, and to provide educational information and forums. This insurance is just one benefit arranged through the IBOBA.