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PROVISIONS OF THE UFT/SIDS PARTICIPATING DENTIST PROGRAM

There is no annual deductible
There is no maximum annual payment

PATIENT CO-PAYMENTS:
$50 for each crown, bridge pontic, denture or partial, root therapy,
quadrant of osseous surgery; IV sedation/GA
$100 for initial orthodontic appliance and retainer; space maintainer;
treatment appliance, night guard, biteplate, autorepositioning appliance
$5 for each month of active orthodontic treatment

PLAN LIMITATIONS:
Examination - once in six months
Full mouth series or Panoramic x-ray - one in 36 months
Bitewing film – maximum of 4 in a six month period
Prophylaxis - once in three months, not paid on same day as scaling
Pit & Fissure Sealants – unrestored permanent molars, to age 16 one time
Therapeutic Pulpotomy – not on same day of restoration
Scaling and root planing –maximum of 2 quadrants per visit;
once in 24 months
Replacement of prosthetic appliance - once in five years
Permanent Denture – inserted within 12 months of immediate denture
Denture reline –6 months after delivery, once in a three year period
Orthodontic treatment - $2,075.00 lifetime maximum benefit
Palliative treatment - if there is no other service is rendered that day
Periodontal Maintenance Procedure - following active therapy,
in any combination of four with prophylaxis

Payment of all SIDS PPO claims are automatically assigned to the dentist.
Non-covered services are paid directly to the dentist
in accordance with his/her usual fee.
Non-reimbursable covered services (services that are listed in the Schedule that are
not payable due to plan limitations and exclusions)
are paid by the patient in accordance with Plan allowances.
The Plan allowance for a crown over an Implant is
partial payment toward the dentist’s usual fee
If, by mutual agreement between you and your dentist, a more costly treatment
option than the one provided by the Plan is agreed upon
(e.g. upgraded metals, composites fillings on posterior teeth and other
special esthetic restorations), the Plan payment will be based on the
less costly service, and you will be responsible to pay the difference.
In addition to specified copayments for orthodontic services, you may be
responsible for up to 6 months additional active orthodontic treatment
should the case require more than 24 months of treatment.

PRE-CERTIFICATION REQUIREMENTS:
Inlays, Crowns, Laminates
Fixed and Removable Bridges
Periodontal surgery
Orthodontic treatment

CLAIM INQUIRIES:
Cigna Healthcare Customer Service: 1-800-577-0576
SIDS 516-396-5501 (voice) 516-396-5594 (fax)

CLAIM SUBMISSIONS:
Cigna Healthcare
P.O. Box 188003
Chattanooga, TN 37422

COORDINATION OF BENEFITS:
If you are eligible to receive benefits under another group dental plan other than the UFT Dental Plan, the dentist is entitled to the benefits payable by both plans. Payment from the second plan must be applied first to reduce or eliminate your co-payments.