Procedures and Services That Are Not Covered

Citi Benefits Handbook

Listed below are the services or expenses that are not covered under the Cigna Dental HMO (this list is not exhaustive, and other exclusions may apply). These services are your responsibility and are billed by the dentist at his or her usual fee:

Services not listed on your Patient Charge Schedule;

Services provided by an out-of-network dentist without Cigna Dental's prior approval (except emergencies, as explained under "Emergencies");

Services related to an injury or illness covered under Workers' Compensation, occupational disease or similar laws (for Florida residents, this exclusion relates to such services paid under Workers' Compensation, occupational disease or similar laws);

Services provided or paid by or through a federal or state governmental agency or authority, political subdivision, or public program other than Medicaid;

Services required while serving in the armed forces of any country or international agency or authority, or relating to a declared or undeclared war or acts of war;

Cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance) unless specifically listed on your Patient Charge Schedule;

General anesthesia, sedation and nitrous oxide unless specifically listed on your Patient Charge Schedule; when listed on your Patient Charge Schedule, general anesthesia and IV sedation are covered when medically necessary and provided in conjunction with covered services performed by an oral surgeon or periodontist (for Maryland residents, general anesthesia is covered when medically necessary and authorized by your physician);

Prescription drugs;

Procedures, appliances or restorations if the main purpose is to change vertical dimension (degree of separation of the jaw when teeth are in contact); to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ) unless TMJ therapy is specifically listed on your Patient Charge Schedule; or to restore teeth damaged by attrition, erosion, abrasion and/or abfraction (for California residents, the word "attrition" is modified as follows: except for medically necessary treatment where functionality of teeth has been impaired);

Replacement of fixed and/or removable prosthodontic appliances that have been lost, stolen or damaged due to patient abuse, misuse or neglect;

Services considered unnecessary or experimental in nature (for Pennsylvania residents, this exclusion applies only to services considered experimental in nature; for California and Maryland residents, this exclusion applies only to services considered unnecessary);

Procedures or appliances for minor tooth guidance or to control harmful habits;

Hospitalization, including any associated incremental charges for dental services performed in a hospital; benefits are available for network dentist charges for covered services performed at a hospital; other associated charges are not covered and should be submitted to your medical carrier for benefit determination;

Services to the extent you are compensated for them under any group medical plan, no-fault auto insurance policy or insured motorist policy (for Arizona and Pennsylvania residents, this exclusion does not apply; for Kentucky and North Carolina residents, this exclusion does not apply to services compensated under a no-fault auto or insured motorist policy; for Maryland residents, this exclusion does not apply to services compensated under group medical plans);

Crowns and bridges used solely for splinting; and

Resin-bonded retainers and associated pontics.

Except for the limitations listed above, pre-existing conditions are not excluded.