Citi Benefits Handbook
Patient Charge Schedule
Your Patient Charge Schedule lists the benefits of the Cigna Dental HMO, including covered procedures and patient charges. Patients pay the patient charges listed only when the procedures are performed by a network dentist. Procedures performed by an out-of-network dentist are generally not covered, and patients will be charged the dentist's usual fee for those procedures. Please see your Patient Charge Schedule (according to your state of residence) for a complete list of exclusions and exceptions. Procedures not listed on your Patient Charge Schedule are not covered and are the patient's responsibility at the dentist's usual fees. You may request your Patient Charge Schedule when you enroll in the Cigna Dental HMO by calling Cigna Dental at 1 (800) Cigna24 (1 (800) 244-6224) or by visiting (if you are already a member). It is also available under the Forms and Documents section of