CIGNA Delta HMO

Northrop Grumman CorporationBenefits Summary - Plan Year 7/1/10 - 6/30/11Plan FactsWeb siteMember servicesDomestic partner benefitsCoverageGeneral Dental ExpensesAnnual deductibleDeductible waived for preventive/diagnosticcareAnnual maximum coverage per personExclusions/limitationsPreventive CarePrimary covered servicesPreventive care benefitsAnnual service limits--preventive careCIGNA Dental HMOmycigna.com1-800-244-6224; enrolled members encouragedto use www.mycigna.comYesCIGNA Dental HMO$0 Individual; $0 FamilyCheck with PlanMaximum does not applyCheck with Plan$10 copay; pulp vitality test; $30 copayadditional cleaning child; $45 copay additionalcleaning adults; $50 copay oral cancerscreening100% coveredVaries by type of service; check with Plan fordetailsBasic ServicesFillings100% covered; some resin-based compositefillings require copays; check with Plan fordetailsRoutine extractionsCopays vary for erupted or impacted toothextractions; surgical removal of impacted toothmust be medically necessary; some limitationsapply; check with Plan for detailsEndodontics (root canal therapy)$10-$25 copays; most root canals; $230 copayfor molar root canal; all root canals exclude finalrestorationPeriodontics $35 copay; evaluation and treatment; $50copay for maintenance; $40-$80 copays forscaling and root planing; $65 copay for fullmouth debridementGingivoplasty or gingivectomy$80 copay; 1-3 teeth per quadrant; $165 copayfor 4 or more teeth per quadrantEmergency treatment for dental pain100% covered; regularly scheduled officehours; $60 copay after regularly scheduledhoursAnnual service limits--basic servicesVaries by type of service; check with Plan fordetailsMajor ServicesInlays/onlays$320 copay; inlay metallic; $370 copay foronlay metallic

CrownsCopays vary based upon materials; check withPlan for detailsDentures$425 copay; complete maxillary or mandibulardenture; $490 copay for partial maxillary ormandibular dentureBridgesCopays vary based upon materials; check withPlan for detailsDental implantsNot coveredOsseous surgery $205 copay; 1-3 teeth per quadrant; $390copay for 4 or more teeth per quadrantOral surgeryCopays vary for surgical removal of impactedteeth; some limitations apply; check with Planfor detailsBruxism$185 copay; occlusal night guardAnesthesia for dental care$145 copay; first 30 minutes; $65 copay pereach additional 15 minutesAnnual service limits--major servicesVaries by type of service; check with Plan fordetailsOrthodontia ServicesPrimary covered orthodontia servicesEvaluation; treatment plan; removable and/orfixed interceptive appliance; banding;interceptive treatment and retentionCoverage available for child? Adult?Child and AdultStart-up fees$55 copay; evaluation; $160 copay fortreatment plan and records; $315 copay forremovable and/or fixed insert for interceptivetreatmentOrthodontia benefits$1,800 copay; interceptive treatment forchildren; $2,400 copay interceptive treatmentfor adults; $315 copay for retention includingretainerService limits and maximums--orthodontia Limited to 24 months of treatment per lifetime;atypical cases beyond 24 months requireadditional paymentTMJTMJ benefitsNot coveredThe comparison charts are compiled using information that applies to a large number of health plan usersand is commonly reported by the health plans. Depending on the chart type, such as charts for dental andvision plans, certain information and/or sections won't appear because the necessary data isn't available. Ifyou have questions about a topic that isn't covered in the charts, refer to the plan's SPD or contact thehealth provider's member services department for additional information. Also, keep in mind that theinformation on access and quality of care is provided by the health plans. Neither Northrop Grumman norHewitt Associates is responsible for the accuracy of this information. If there is a discrepancy between theinformation displayed on these charts and the official plan documents, the official plan documents willcontrol. Northrop Grumman reserves the right to amend, suspend, or terminate the plan(s) or program(s)at any time