What Is Not Covered

It is important to understand what your plan covers and how much of your benefits it will pay. Advance claim review helps you understand what your copayment will be and any other cost for which you may be responsible.

The following is a list of exclusions and limitations under your dental plan. Please refer to the actual plan documents or contact Cigna at 1-800-345-4511 for more details on limitations and exclusions:

• Services that are not considered reasonable and customary
• Services not performed by a dentist, with the exception of licensed dental hygienists and routine x-rays
• Services performed by or for the government unless payment of the charge is required by law
• Services that would have been covered by the government, except for Medicaid
• Replacement or modification of dentures, bridges, crowns, or gold restoration within five years of installation
• Dentures or bridges that replace natural teeth when the teeth were missing before you were covered. This does not apply if the denture or bridge also replaces a natural tooth that was removed while you are covered and was not an abutment to a partial denture or bridge installed in the last five years.
• Appliances, services, or supplies ordered while you were not covered
• Cosmetic services including crown facing or the facing of artificial teeth behind the second bicuspid, except for certain eligible expenses. Eligible expenses include cosmetic services needed as a result of accidental injuries suffered while you are covered.
• Treatment for jaw joint problems if you are covered by the DMO® under Plan B
• Appliances, restorations, or procedures needed to alter vertical dimensions, restore biting, or correct attrition or abrasion
• Replacement of lost or stolen dental appliances
• Injuries or diseases covered by workers’ compensation or other occupational laws
• Charges for treatment that is deemed not medically necessary
• Any charge above the copayment percentage based on reasonable and customary charges. Where benefits are based on a schedule, the dental plans do not pay any amount that exceeds the scheduled benefits.