State Policy Disclosures, Exclusions and Limitations 2015

Health Insurance Plans

Rates will vary by plan design and the plan deductible, copay, coinsurance, and out-of-pocket maximums selected. Rates vary based on age, family size, geographic location (residential zip code) and tobacco use, except in CA.

Rates for new medical policies with an effective date on or after 01/01/2015 are guaranteed through 12/31/2015. Thereafter, medical rates are subject to change upon 30 days’ notice in CT, MO and TN, 31 days’ notice in SC, 45 days’ notice in FL, MD and NC, and 60 days’ notice in AZ, CA, CO, GA, and TX.

The policy may be cancelled by Cigna due to failure to pay premium, fraud, ineligibility, when the insured no longer lives in the service area, or when we cease to offer policies of this type or cease to offer any plans in the individual market in the state, in accordance with applicable law. you may cancel the policy, on the first of the month following our receipt of your written notice. We reserve the right to modify the policy, including policy provisions, benefits and coverages, consistent with state or federal law. Policies renew on a calendar year basis.

Major medical insurance policies (CACHIND012015, 49375CO20001-11, CTINDCH052013, INDFLCH042013, INDGACH052013, MDINDCH052014, MOINDCH072014, NCINDCH052013, INDSCCH052013, INDTNCH042013, INDTXCH042013) have exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. Medical applications are accepted during the annual open enrollment period, or within 60 calendar days of a qualifying life event. Benefits are provided only for those services that are medically necessary as defined in the policy and for which the insured person has benefits.

For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446).

Additional State Specific Information

Arizona
Exclusions and Limitations

Medical Plan Exclusions & Limitations

For policies insured by Cigna Health and Life Insurance Company (LocalPlus and Open Access Plus Network plans), covered medical expenses do not include expenses incurred for:

  • Any amounts in excess of maximum amounts of covered expenses stated in this policy.
  • Services not specifically listed in this policy as covered services.
  • Services or supplies that are not medically necessary.
  • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
  • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or occupational disease law, even if the insured person does not claim those benefits.
  • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person's commission of, or attempt to commit a felony or as a direct result of the insured person being engaged in an illegal occupation.
  • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • If the insured person is enrolled in Medicare Part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
  • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person's home, or that person's employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person's employer.
  • Custodial care.
  • Inpatient or outpatient services of a private duty nurse.
  • Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
  • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic services, braces and other orthodontic appliances including orthodontic services for temporomandibular joint dysfunction.
  • Dental implants: dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs) except for coverage of one hearing aid per ear per year, new or replacement hearing aids no longer under warranty (precertification required), cleaning or repair, and batteries for cochlear implants as specifically stated in this policy. A hearing aid is any device that amplifies sound.
  • Routine hearing tests and exams except as specifically provided in this policy under "Comprehensive Benefits, What the Plan Pays For."
  • Genetic screening or preimplantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Outpatient speech therapy, except as specifically stated in this policy.
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one's appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
  • Nonmedical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities and developmental delays.
  • Services for redundant skin surgery, removal of skin tags, acupressure, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
  • Treatment of sexual dysfunction, impotence and/or inadequacy except if this is a result of an Accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • All services related to infertility once diagnosed, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in the "Comprehensive Benefits: What the Policy Pays For" and "What's Covered", section in this policy.
  • Cryopreservation of sperm or eggs or storage of sperm for artificial insemination (including donor fees).
  • All nonprescription Drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA) and smoking cessation products that are available over the counter or without a prescription.
  • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the prescription drug benefits of this policy.
  • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the prescription drug benefits of this policy.
  • Any Infusion or Injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
  • Self-administered injectable drugs, except as stated in the Benefit Schedule and in the Prescription Drug Benefits section of this policy.
  • Syringes, except as stated in the policy.
  • Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthodic devices except as required by law for diabetic patients.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment, except preventive services that include weight and nutrition counseling, or surgery for obesity and co-morbid conditions, as otherwise stated in the policy.
  • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this plan.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long-term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Telephone, email, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
  • Massage therapy.
  • Educational services except for diabetes self-management training; counseling/ educational services for breastfeeding; physician counseling regarding alcohol misuse, preventive medication, obesity, nutrition, tobacco cessation and depression; preventive counseling and educational services specifically required under the Patient Protection and Affordable Care Act (PPACA); and as specifically provided or arranged by Cigna.
  • Nutritional counseling except nutritional evaluation and counseling from a participating provider when a dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to: morbid obesity, diabetes, cardiovascular disease, hypertension, kidney disease, eating disorders, gastrointestinal disorders, food allergies and hyperlipidemia. All other services for the purpose of diet control and weight reduction are not covered unless required by a specifically identified condition of disease etiology. Services not covered include but not limited to: gastric surgery, intra oral wiring, gastric balloons, dietary formulae, hypnosis, cosmetics, health and beauty aids or food supplements except as stated in this policy.
  • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
  • Physical, and/or occupational therapy/medicine except when provided during an inpatient Hospital confinement or as specifically stated in the Benefit Schedule and under 'Physical and/or Occupational Therapy/Medicine' in the section of this policy titled "Comprehensive Benefits, What the Policy Pays For."
  • All foreign country provider charges are excluded under this policy except as specifically stated under "Treatment received from Foreign Country Providers" in the section of this policy titled "Comprehensive Benefits, What the Policy Pays For."
  • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person's condition.
  • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet except as otherwise stated in this policy.
  • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for the services of a standby physician.
  • Charges for animal to human organ transplants.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
LocalPlus Network

Cigna medical plans in Arizona offer the freedom to use health care professionals in the LocalPlus Network. When outside of the LocalPlus Network areas we offer in-network access to providers in the Open Access Plus Network. The Cigna LocalPlus® Network of participating health care professionals offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus health care professionals in the LocalPlus Network area (where you live)
  • LocalPlus health care professionals in other LocalPlus Network areas (when traveling)
  • In areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
  • Any visit considered an emergency as defined by your policy

Out-of-network

  • Any professional in your LocalPlus area that is not part of the LocalPlus Network
  • Professionals in other LocalPlus areas that are not part of the LocalPlus Network
  • Non-Cigna contracted professionals in any area

For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

HMO PLAN AVAILABILITY

In Arizona, HMO plans are offered by Cigna HealthCare of Arizona, Inc. Please call 1.877.484.5967 for further details regarding Individual and Family HMO plans, including exclusions and limitations.

California
Exclusions and Limitations
  • Any amounts in excess of maximum amounts of Covered Expenses stated in this policy.
  • Services or supplies that are not medically necessary, except for voluntary family planning and preventive care services or treatment.
  • Services or supplies for experimental procedures or investigative procedures.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
  • Any condition for which benefits are recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law.
  • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
  • If the insured person is eligible for Medicare part A or B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid or Medi-Cal). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • Professional services or supplies received or purchased directly or on your behalf by anyone, including a Physician from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person’s home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • Physical exams and other services required on court order or required for parole or probation. This exclusion does not apply to medically necessary services.
  • Assistance with activities of daily living (for example: walking, getting in and out of bed, bathing, dressing, feeding, toileting, and taking medicine). This exclusion does not apply to assistance with activities of daily living that is provided as part of covered Hospice, Skilled Nursing Facility, or inpatient Hospital care.
  • Inpatient or outpatient services of a private duty nurse. Cigna excludes private duty nursing for the following reasons: a) When an insured person is confined to a Hospital or other covered facility, the facility provides 24-hour nursing care, b) When an insured person is home and requires nursing care, licensed nurses are covered to provide Home Health Care benefits. In-home private duty nursing includes care that is not covered, such as assistance with activities of daily living, and an insured person who requires 24-hour nursing care is normally admitted to a facility appropriate to the level of care required.
  • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed on an outpatient basis, unless the Hospital stay is medically necessary.
  • Dental services for adults age 19 and over, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as otherwise stated in this policy under “Dental Care”.
  • Orthodontic Services for adults age 19 and over, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction. However, Orthodotic Services which are an integral part of reconstructive surgery for Cleft Palate are covered.
  • Dental Implants for adults age 19 and over unless they are an integral part of reconstructive surgery for Cleft Palate, Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids except for internally-implanted devices. A hearing aid is any device that amplifies sound.
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, and eye exams for refraction for adults age 19 and over.
  • An eye surgery for insured persons age 19 and above solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Cosmetic Services: Services that are intended primarily to change or maintain one’s appearance. The exclusion shall not apply to any of the following: Reconstructive Surgery (Please see page 19: “Definitions – Cosmetic and Reconstructive Surgery”) or Mastectomy (Please see page 60: “Mastectomy and Related Procedures”); Durable Medical Equipment, Prosthetics, and Orthotic devices incident to a reconstructive surgery or mastectomy, including testicular implants implanted as part of a covered reconstructive surgery, breast prostheses needed after a mastectomy, and prostheses to replace all or part of an external facial body part.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
  • Non-Medical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety.
  • Gender/sex reassignment surgery is not covered unless the health care services involved are otherwise available under the policy. This exclusion does not permit the denial of coverage if the health care services involved are otherwise available under the policy, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training. Also, this exclusion does not permit the denial of coverage for health care services available to a covered person of one sex due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, a gender transition.
  • Treatment for impotence and/or inadequacy, except if this is a result of an Accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization.
  • Any Infusion or Injectable Specialty Prescription Drugs that require physician supervision, if not provided by a Participating Provider.
  • All non-prescription Drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA), that are available over the counter or without a prescription.
  • Cryopreservation of sperm or eggs.
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics except for diabetic shoes and inserts, including off-the-shelf depthinlay shoes, custom- molded shoes, custom-molded multiple density inserts, fitting, modification, and follow-up care for podiatric devices. Coverage will include fitting and adjustment, repair or replacement (but not for loss or misuse), and services to determine whether an insured needs a prosthetic or orthotic device.
  • Telephone, e-mail, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters, unless provided via an approved internet-based intermediary.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs, etc.).
  • Services primarily for weight reduction or treatment of obesity except morbid obesity, or any care which involves weight reduction as a main method for treatment.
  • Educational services except for Bariatric surgery related health education, health education for tobacco cessation and stress management, chemical dependency and substance abuse disorder, preventive dental, post-natal, preventive health, Diabetes Self- Management Training Program, Pediatric Asthma Training, and as specifically provided or arranged by Cigna.
  • Outpatient oral nutrition, such as dietary supplements, herbal supplements, weight loss aids, formulas, and food.
  • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; correction appliances or support appliances and supplies such as stockings, disposable supplies as follows: Bandages, gauze, tape, antiseptics, dressings, Ace type bandages, and diapers, underpads, and other incontinence supplies. This exclusion shall not apply to disposable supplies covered as “Durable Medical Equipment,” “Home Health Care,” “Hospice Care,” “Ostomy and Urological Supplies,” and “Prescription Drug Benefits”.
  • All Foreign Country Provider charges other than emergency or urgent care services.
  • Growth Hormone Treatment, except when such treatment is medically necessary to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be medically necessary and effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition.
  • Routine foot care, such as nail clipping or corn removal that is not medically necessary.
  • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for animal to human organ transplants.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
LocalPlus Network

This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
  • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
  • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
  • Any visit considered an emergency as defined by your policy

Out-of-network

  • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
  • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
  • Non-Cigna contracted professionals in any area

For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

Colorado
Exclusions and Limitations

In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

  • Any amounts in excess of maximum amounts of covered expenses stated in this policy.
  • Services not specifically listed as covered services in this policy.
  • Services or supplies that are not medically necessary.
  • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
  • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the insured person does not claim those benefits.
  • Conditions caused by: (a) an act of war (declared or un-declared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation.
  • Any services provided by a local, state or federal government agency, except (a) when payment under this policy is expressly required by federal or state law.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid or medical assistance benefits under the Colorado Medical Assistance Act, Title 25.5, Articles 4, 5, and 6, C.R.S.). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation. If the insured person is eligible for Medicare part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
    • Court-ordered treatment or hospitalization, unless such treatment is medically necessary and listed as covered in this plan.
    • Professional services or supplies received or purchased from yourself.
    • Custodial care.
    • Inpatient or outpatient services of a private duty nurse, except as specifically stated in the section of this policy titled “Benefits/Coverage (What is Covered)”.
    • Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
    • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
    • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
    • Treatment of mental, emotional or functional nervous disorders or psychological testing, except as specifically provided in this policy. However, medical conditions that are caused by behavior of the insured person and that may be associated with these mental conditions are not subject to these limitations.
    • Smoking cessation programs, except prescription smoking cessation products as specifically provided in this policy.
    • Treatment of substance abuse, except as specifically provided in this policy.
    • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
    • Orthodontic services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction.
    • Dental implants: dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
    • Hearing aids, except as specifically stated in this policy, including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs). A hearing aid is any device that amplifies sound.
    • Routine hearing tests except as specifically provided in this policy under “Benefits/Coverage (What is Covered)”.
    • Genetic screening or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
    • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
    • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
    • Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
    • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty; and blepharoplasty,. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by Injury, medically necessary surgery or congenital defect of a Newborn child, or to treat congenital hemangioma (port wine stains) on the face and neck of an insured person 18 years and younger, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
    • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
    • Nonmedical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities and developmental delays, except as specifically stated in this policy. This exclusion does not apply to health education services for chronic diseases and self-care on topics such as stress management and nutrition.
    • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
    • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
    • Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies.
    • All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in this policy.
    • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
    • All non-prescription drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA), that are available over the counter or without a prescription,
    • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
    • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
    • Any infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy, if not provided by an approved participating provider specifically designated to supply that specialty prescription. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
    • Self-administered Injectable drugs, except as stated in the Benefit Schedule and in the Prescription Drug Benefits section of this policy.
    • Syringes, except as stated in the policy.
    • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
    • Blood administration for the purpose of general improvement in physical condition
    • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthotic devices.
    • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
    • Charges by a provider for telephone or email consultations, except as specifically stated in this policy.
    • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
    • Massage therapy
    • Educational services except for diabetes self-management training program, and as specifically provided or arranged by Cigna.
    • Nutritional counseling or food supplements, except as stated in this policy.
    • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
    • Physical, and/or occupational therapy/medicine except when provided during an inpatient hospital confinement or as specifically stated in the Benefit Schedule and ‘under Physical and/or Occupational Therapy/Medicine’ in the section of this policy titled “Benefits/Coverage (What is Covered)”.
    • All foreign country provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the section of this policy titled “Benefits/Coverage (What is Covered)”.
    • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition; growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
    • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet, except as otherwise stated in this policy.
    • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
    • Charges for the services of a standby physician.
    • Charges for animal to human organ transplants.
    • Charges for elective abortions.
    • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
LocalPlus Network

This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
  • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
  • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
  • Any visit considered an emergency as defined by your policy

    Out-of-network

    • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
    • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
    • Non-Cigna contracted professionals in any area

    For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

Access Plan

If you would like more information on: (1) who participates in our provider network; (2) how we ensure that the network meets the health care needs of our members; (3) how our provider referral process works; (4) how care is continued if providers leave our network; (5) what steps we take to ensure medical quality and customer satisfaction; (6) where you can go for information on other policy services and features. You may request a copy of our Access Plan. The Access Plan is designed to disclose all the policy information required under Colorado law, and is available for review upon request.

Connecticut
Exclusions and Limitations
  • Any amounts in excess of maximum amounts of Covered Expenses stated in this policy.
  • Services not specifically listed as Covered Services in this policy.
  • Services or supplies that are not medically necessary.
  • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures, except as described in the policy.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
  • For or in connection with an Injury or Illness arising out of, or in the course of, any employment for wage or profit. For Medical Benefits, this will not apply to any of the policyholder’s partners, proprietors or corporate officers. However, if payment is made for expenses in the event that third-party liability is determined and satisfied (whether by settlement, judgment, arbitration or otherwise), Cigna shall be refunded the lesser of: (a) the amount of Cigna's payment for such expenses; or (b) the amount actually received from the third party for such expenses. In the event that a workers’ compensation claim is filed, Cigna shall have a lien on the proceeds of any award or settlement to the extent of its payment of benefits.
  • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • If the insured person is enrolled for Medicare part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
  • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
  • yourself or your employer;
  • a person who lives in the insured person’s home, or that person’s employer;
  • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • Custodial care.
  • Inpatient or outpatient services of a private duty nurse, except as specifically stated under Home Health Care in the section of this policy titled “Comprehensive Benefits What the Policy Pays For”.
  • Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other Custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
  • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction, except as described in the policy.
  • Dental Implants: dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids including but not limited to semi-implantable hearing devices, audient bone conductors and Bone Anchored Hearing Aids (BAHAs), except as specifically provided in this policy. For the purposes of this exclusion, a hearing aid is any device that amplifies sound.
  • Routine hearing tests except as specifically provided in this policy under Preventive Care and Newborn Hearing Benefits.
  • Genetic screening or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Outpatient speech therapy, except as specifically stated in this policy.
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy. Cosmetic surgery and therapy does not include gender reassignment services consistent with World Professional Association for Transgender Health (WPATH) recommendations.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books, except as specifically stated in this policy.
  • Non-Medical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities and developmental delays.
  • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an Accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • Reversal of male or female voluntary Sterilization.
  • Infertility services such as Donor charges and services; Gestational carriers and surrogate parenting arrangements; and experimental, investigational or unproven infertility procedures or therapies.
  • All non-prescription Drugs, devices and/or supplies, except as described in the Prescription Drug Benefits section of the policy.
  • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
  • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
  • Any Infusion or Injectable Specialty Prescription Drugs that require physician supervision, except as otherwise stated in this policy. Infusion and Injectable Specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
  • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics, except for insureds with the diagnosis of diabetes.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
  • Routine physical exams or tests, that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this Plan.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Telephone, e-mail, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters. Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs except as specifically provided in the treatment of cancer, etc.).
  • Massage therapy.
  • Educational services except for Diabetes Self-Management Training Program, and as specifically provided or arranged by Cigna.
  • Nutritional counseling or food supplements, except as stated in this policy.
  • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
  • Physical, Occupational and/or Speech Therapy/ Medicine except when provided during an inpatient Hospital confinement or as specifically stated in the Benefit Schedule and under ‘Services for Short Term Rehabilitation Therapy’ in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
  • Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
  • Syringes, except as stated in the policy.
  • All Foreign Country Provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
  • Growth Hormone Treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
  • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet, except for the treatment of diabetes.
  • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for the services of a standby physician.
  • Charges for animal to human organ transplants.
  • Charges for elective abortions.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
Open Access Plus Network

This medical plan uses the Cigna Open Access Plus (OAP) Network which provides access to health care professionals nationwide. When you receive care from a health care professional or hospital in the OAP Network the visit is considered in-network which helps you save with lower out-of-pocket expenses. You also have the freedom to see any health care professional not in the OAP Network, and coverage for that service will be paid at the out-of-network benefit. You will be responsible for the out-of-network benefit cost in addition to any difference in the amount that Cigna reimburses for such services and the amount charged by the health care professional, except for emergency services, as defined by your plan.

Florida
Exclusions and Limitations

In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

  • Any amounts in excess of maximum amounts of covered expenses stated in this policy.
  • Services not specifically listed in this policy as covered services.
  • Services or supplies that are not medically necessary.
  • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if
  • you did not have health plan or insurance coverage.
  • Any condition for which benefits are paid, recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or occupational disease law, even if the insured person does not claim those benefits.
  • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person's commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation; (f ) an insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by physician.
  • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • Professional services or supplies received or purchased directly or on your behalf from any of the following:
  • yourself or your employer;
  • a person who lives in the insured person's home, or that person's employer;
  • a person who is related to the insured person by blood, marriage or adoption, or that person's employer.
  • If the insured person is eligible for Medicare part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
  • Custodial care.
  • Inpatient or outpatient services of a private duty nurse.
  • Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
  • Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Smoking cessation programs.
  • Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction, except as specifically provided in this policy.
  • Dental implants: dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids including but not limited to semi implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs), except as specifically stated in this policy. For the purposes of this exclusion, a hearing aid is any device that amplifies sound.
  • Routine hearing tests except as specifically provided in this policy under “Comprehensive Benefits, What the Policy Pays For”.
  • Genetic screening or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Outpatient speech therapy, except as specifically stated in this policy.
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one's appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty; and blepharoplasty. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books except as specifically stated in this policy.
  • Nonmedical counseling or ancillary services, including but not limited to: education, vocational rehabilitation, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety.
  • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy, and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
  • Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an Accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in this plan.
  • All non-prescription Drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA), that are available over the counter or without a prescription.
  • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthotic devices.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
  • Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this plan.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Telephone, e-mail, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
  • Massage therapy.
  • Educational services except for Diabetes Self- Management Training Program, and as specifically provided or arranged by Cigna.
  • Nutritional counseling or food supplements, except as stated in this policy.
  • Durable medical equipment not specifically listed as covered services in the covered services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
  • Physical, and/or occupational therapy/medicine except when provided during an inpatient hospital confinement or as specifically stated in the Benefit Schedule and under ‘Physical and/or Occupational Therapy/Medicine' in the section of the policy titled “Comprehensive Benefits What the Policy Pays For.”
  • Self-administered injectable drugs, except as stated in the Benefit Schedule and in the Prescription Drug Benefits section of this policy.
  • Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
  • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
  • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self- administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
  • Any Infusion or Injectable Specialty Prescription Drugs that require physician supervision, except as otherwise stated in this policy. Infusion and Injectable Specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
  • Syringes, except as stated in the policy.
  • All Foreign Country Provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the Benefits section of this policy titled “Comprehensive Benefits What the policy Pays For.” In the event an insured person dies outside of the United States, charges for medical evacuation and repatriation of his or her remains to the United States are not covered.
  • Growth Hormone Treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person's condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
  • Routine foot care including the pairing and removing of corns and calluses or trimming of nails except as otherwise stated in this policy. However, services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary.
  • Charges for which we are unable to determine our liability because the insured person failed, within 90 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for the services of a standby physician.
  • Charges for animal to human organ transplants.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
LocalPlus Network

This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
  • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
  • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
  • Any visit considered an emergency as defined by your policy

Out-of-network

  • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
  • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
  • Non-Cigna contracted professionals in any area

For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

Georgia
Exclusions and Limitations

In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

  • Any amounts in excess of maximum amounts of covered expenses stated in this policy.
  • Services or supplies not specifically listed as covered expenses in the section “Comprehensive Benefits, What the Policy Pays For.”
  • Services or supplies that are not medically necessary.
  • Services or supplies that are experimental or investigational, except as outlined in the section “Comprehensive Benefits, What the Policy Pays For.”
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends, unless provided under continuation.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
  • Any condition for which benefits are recovered or can be recovered, either by any workers’ compensation law, employer’s liability law or work related disease law.
  • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation; (f ) an insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by physician.
  • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veteran’s Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • If the insured person is eligible for Medicare Part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
  • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person’s home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • Non-duplication of Medicare: Any services for which Medicare benefits are actually paid. Any services for which payment may be obtained from any local, state or federal government agency. Veteran’s Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • Professional services received or supplies purchased from the insured person, a person who lives in the insured person’s home or who is related to the insured person by blood, marriage or adoption.
  • Custodial care.
  • Inpatient or outpatient services of a private duty nurse, except as specifically stated under Home Health Care in the section of this policy titled “Comprehensive Benefits, What the Policy Pays For.”
  • Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
  • Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Smoking cessation programs, except as specifically provided in this policy.
  • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic services, braces and other orthodontic appliances including orthodontic services for temporomandibular joint dysfunction.
  • Dental implants: dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone-Anchored Hearing Aids (BAHAs), except as specifically stated in this policy. For purposes of this exclusion, a hearing aid is any device that amplifies sound.
  • Routine hearing tests except as specifically provided in this policy under “Comprehensive Benefits, What the Policy Pays For.”
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under pediatric vision.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Outpatient speech therapy, except as specifically stated in this policy.
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, personal digital assistants (PDAs), braille typewriters, visual alert systems for the deaf and memory books, except as specifically stated in this policy.
  • Nonmedical counseling or ancillary services, including but not limited to: Education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return-to-work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities and developmental delays.
  • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Procedures, surgeries or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
  • Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • All services related to the treatment of fertility and/ or infertility, including, but not limited to, all tests, examinations, except for tests and examinations required for the diagnosis of infertility, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in this policy.
  • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
  • Treatment for infertility or reduced fertility that results from a prior sterilization procedure or a normal physiological change such as menopause.
  • All nonprescription Drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA) that are available over the counter or without a prescription.
  • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
  • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
  • Any infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy Infusion and Injectable Specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
  • Self-administered injectable drugs, except as stated in the benefit schedule and in the prescription drug benefits section of this policy.
  • Syringes, except as stated in the policy.
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Orthopedic shoes (except when joined to braces) shoe inserts, foot orthodic devices.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
  • Routine physical exams or tests required by employment or government authority, including physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this Plan.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Telephone, email, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, swimming pools, elevators and supplies for hygiene or beautification, including wigs, etc.).
  • Massage therapy.
  • Educational services except for diabetes self- management training program, and as specifically provided or arranged by Cigna.
  • Nutritional counseling or food supplements, except as stated in this policy.
  • Durable medical equipment not meeting the criteria outlined in the “Comprehensive Benefits, What the Policy Pays For” section of this policy. Examples include: Orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; swimming pools: Elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies, other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
  • Physical, and/or occupational therapy/medicine except when provided during an inpatient hospital confinement or as specifically stated in the benefit schedule and under ‘physical and/or occupational therapy/medicine’ in the section of this policy titled “Comprehensive Benefits, What the Policy Pays For.”
  • Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
  • All foreign country provider charges are excluded under this policy except as specifically stated under “Treatment received from foreign country providers” in the section of this policy titled “Comprehensive Benefits, What the Policy Pays For.”
  • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition. Growth hormone treatment for idiopathic short stature, or improved athletic performance is not covered under any circumstances.
  • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet except as otherwise stated in this policy.
  • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for the services of a standby physician.
  • Charges for animal to human organ transplants.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
LocalPlus Network

This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
  • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
  • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
  • Any visit considered an emergency as defined by your policy

Out-of-network

  • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
  • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
  • Non-Cigna contracted professionals in any area

For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

Maryland
Exclusions and Limitations

In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

  • Services or supplies that are not medically necessary.
  • Services performed or prescribed under the direction of a person who is not a licensed health care practitioner.
  • Services that are beyond the scope of practice of the Provider performing the service.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
  • The purchase, examination or fitting of eyeglasses or contact lenses, except for aphakic patients and also for rigid gas permeable lenses or sclera shells intended for use in the treatment of a disease or injury.
  • Personal care services and domiciliary care services.
  • Custodial Care.
  • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person’s home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • Services or supplies that are considered to be for experimental procedures or investigative procedures.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Reversal of male or female voluntary sterilization; sterilization or reversal of sterilization of a dependent minor.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment except as otherwise specifically stated in this policy.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends, including any extension of benefits.
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of [varicose veins;] abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
  • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, to the extent the insured person is required to be covered by a workers’ compensation law.
  • Services rendered from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar persons or groups.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including cranial prostheses, etc.).
  • Telephone, e-mail, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters, charges for a missed visit or for completion of any form.
  • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Purchase, examination or fitting of Hearing aids and supplies including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs), except as specifically stated in this policy. For the purposes of this exclusion, a hearing aid is any device that amplifies sound.
  • Except for covered ambulance services or as otherwise stated in this policy, travel, whether or not recommended by a health care practitioner.
  • Any services received while the covered person is outside the United States except for emergency services.
  • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer or for school, or sports physicals, and immunizations related to foreign travel, except as otherwise specifically stated in this Plan.
  • Unless otherwise specified in this Plan, dental work or treatment which includes hospital or professional care in connection with:
  • The operation or treatment for the fitting or wearing of dentures,
  • Orthodontic care or malocclusion,
  • Operations on or for the treatment of or to the teeth or supporting tissues of the teeth, except for removal of tumors and cysts or treatment of injury to natural teeth due to an accident if the treatment is received within 6 months of the accident;
  • Dental implants – Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Accidents occurring while and as a result of chewing.
  • Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic services, braces and other orthodontic appliances including orthodontic services for temporomandibular joint dysfunction, except as specifically stated in this policy under “Congenital Birth Defects” in the section titled “Comprehensive Benefits – What the Plan Pays For.”
  • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet.
  • Orthopedic shoes (except when joined to braces), arch supports, shoe inserts, foot orthotic devices.
  • Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
  • Treatment of sexual dysfunction, impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • Services that duplicate benefits provided under federal, State or local laws, regulations or programs.
  • Organ transplants, except as otherwise stated in this plan.
  • Charges for animal to human organ transplants.
  • Fees for nonreplacement of blood and blood products; associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Lifestyle improvements, nutritional counseling or food supplements, except as stated in this policy, physical fitness programs.
  • Wigs or cranial prosthetics, except as specifically stated in this policy.
  • Weekend admission charges, except for emergencies and maternity, unless authorized by Cigna.
  • Outpatient orthomolecular therapy, including nutrients, vitamins and food supplements.
  • Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy.
  • Any services required by state or federal law to be supplied by a public school system, school district or other public institutions.
  • Treatment for mental health or substance abuse not authorized by Cigna through its managed care system, or a mental health or substance abuse condition determined by Cigna through its managed care system to be untreatable.
  • Any amounts in excess of maximum amounts of Covered Expenses stated in this policy.
  • Services not specifically listed as Covered Services in this policy.

Limitations Covered under pharmacy benefits.

  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Excluded services

    The following services are covered under the Prescription Drug Benefits (not under medical benefits) of this Plan:

    • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
    • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
    • Any infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
    • Self-administered injectable drugs, except as stated in the Benefit Schedule and in the Prescription Drug Benefits section of this policy.
    • Syringes, except as stated in the policy.
    Open Access Plus Network

    This medical plan uses the Cigna Open Access Plus (OAP) Network which provides access to health care professionals nationwide. When you receive care from a health care professional or hospital in the OAP Network the visit is considered in-network which helps you save with lower out-of-pocket expenses. You also have the freedom to see any health care professional not in the OAP Network, and coverage for that service will be paid at the out-of-network benefit. You will be responsible for the out-of-network benefit cost in addition to any difference in the amount that Cigna reimburses for such services and the amount charged by the health care professional, except for emergency services, as defined by your plan.

    Missouri
    Exclusions and Limitations

    In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

    • Any amounts in excess of maximum amounts of Covered Expenses stated in this policy.
    • Services not specifically listed as Covered Services in this policy.
    • Services or supplies that are not medically necessary.
    • Services or supplies that are considered to be for experimental procedures or investigative procedures.
    • Services received before the effective date of coverage.
    • Services received after coverage under this policy ends.
    • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
    • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the insured person does not claim those benefits.
    • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation; (f ) an insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by physician.
    • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
    • Any services required by state or federal law to be supplied by a public school system or school district.
    • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
    • If the insured person is eligible for Medicare Part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
    • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
    • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
      • yourself or your employer;
      • a person who lives in the insured Person’s home, or that person’s employer;
      • a person who is related to the Insured Person by blood, marriage or adoption, or that person’s employer.
    • Custodial Care.
    • Inpatient or outpatient services of a private duty nurse, except as specifically stated under Home Health Care in the section of this policy titled “Comprehensive Benefits: What the Policy Pays For.” Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
    • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other Custodial Care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
    • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
    • Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
    • Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction.
    • Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
    • Hearing aids including but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs), except as provided under Preventive Care and Newborn Hearing Benefits. For the purposes of this exclusion, a hearing aid is any device that amplifies sound.
    • Routine hearing tests except as provided under Preventive Care and Newborn Hearing Benefits which include necessary rescreening, audiological assessment and follow-up, and initial amplification. The screening will include the use of at least one of the following physiological technologies: automated or diagnostic brainstem response (ABR); otacoustic emissions (OAE); or other technologies approved by the Missouri Department of Health.
    • Genetic screening or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
    • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
    • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
    • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a Newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
    • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
    • Non-medical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities and developmental delays.
    • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
    • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
    • Treatment of sexual dysfunction, impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
    • All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT).
    • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
    • All non-prescription drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA), that are available over the counter or without a prescription, except for Insulin.
    • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
    • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self- administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
    • Any Infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
    • Self-administered Injectable Drugs, except as stated in the Benefits Schedule and in the Prescription Drug benefits section of this policy.
    • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
    • Blood administration for the purpose of general improvement in physical condition.
    • Orthopedic shoes (except when joined to braces or as required by law for diabetic patients), shoe inserts, foot orthotic devices.
    • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
    • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer or for school, or sports physicals, except as otherwise specifically stated in this Plan.
    • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
    • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs (except as specifically provided in the treatment of cancer), etc.).
    • Massage therapy.
    • Educational services except for diabetes self-management training program, and as specifically provided or arranged by Cigna.
    • Nutritional counseling or food supplements, except as stated in this policy.
    • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
    • Physical, and/or occupational therapy/medicine except when provided during an inpatient hospital confinement or as specifically stated in the Benefit Schedule and under ‘Physical and/or Occupational Therapy/Medicine’ in the section of this policy titled “Comprehensive Benefits: What the Policy Pays For.”
    • All Foreign country provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the section of this policy titled “Comprehensive Benefits: What the Policy Pays For.”
    • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
    • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet except as otherwise stated in this policy.
    • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
    • Charges for the services of a standby physician.
    • Charges for animal to human organ transplants.
    • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
    LocalPlus Network

    This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

    In-network

    • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
    • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
    • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
    • Any visit considered an emergency as defined by your policy

    Out-of-network

    • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
    • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
    • Non-Cigna contracted professionals in any area

    For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

    North Carolina
    Exclusions and Limitations

    Your plan does not provide coverage for the following except as required by law:

    • Any amounts in excess of maximum amounts of Covered Expenses stated in this policy.
    • Services not specifically\listed as Covered Expenses in this policy.
    • Services or supplies that are not medically necessary.
    • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures, except as specifically stated in the sections of this policy titled “Clinical Trials.”
    • Services received before the effective date of coverage.
    • Services received after coverage under this policy ends.
    • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage.
    • Services or supplies for the treatment of an occupational injury or Sickness which are paid under the North Carolina Worker’s Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act.
    • Conditions caused by: (a) an act of war (declared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation; (f ) an insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by a physician.
    • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
    • Any services required by state or federal law to be supplied by a public school system or school district.
    • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
    • If the insured person is eligible for Medicare Part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
    • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
    • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
      • yourself or your employer;
      • a person who lives in the insured person’s home, or that person’s employer;
      • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
    • Custodial Care.
    • Inpatient or outpatient services of a private duty nurse, except as specifically stated under Home Health Care in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
    • Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
    • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
    • Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
    • Smoking cessation programs, except as specifically provided in this policy.
    • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
    • Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction.
    • Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
    • Hearing aids including but not limited to semi-implantable hearing devices, audient bone conductors and Bone Anchored Hearing Aids (BAHAs), except as specifically covered in this policy. For the purposes of this exclusion, a hearing aid is any device that amplifies sound.
    • Routine hearing tests except as provided in this policy under Preventive Care and Newborn Hearing Benefits.
    • Genetic screening or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
    • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
    • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
    • Outpatient speech therapy, expect as specifically stated in this policy.
    • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn, adopted or foster child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
    • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books except as specifically stated in this policy.
    • Non-medical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities and developmental delays.
    • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
    • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
    • Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
    • Surgical services related to treatment of fertility and/ or Infertility and any artificial means of conception, including, but not limited to, surgical procedures, artificial insemination, in-vitro fertilization (IVF), ovum or embryo placement, intracytoplasmic sperm injection (ICSI), and gamete intrafallopian transfer (GIFT) and associated services.
    • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
    • The collection and storage of blood and stem cells taken from the umbilical cord and placenta for future use in fighting a disease.
    • Treatment for Infertility or reduced fertility that results from a prior sterilization procedure or a normal physiological change such as menopause.
    • All non-prescription drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA), that are available over the counter or without a prescription, except for Insulin.
    • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
    • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self- administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
    • Any Infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
    • Self-administered injectable drugs, except as stated in the Benefits Schedule and in the Prescription Drug benefits section of this policy.
    • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
    • Blood administration for the purpose of general improvement in physical condition.
    • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthotic devices, except for insureds with the diagnosis of diabetes.
    • Medical and surgical services, initial and repeat, intended for the treatment or control of obesity, except for treatment of clinically severe (morbid) obesity as shown in the policy. Medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision are not covered, even when they are related to covered treatment for morbid obesity.
    • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this Plan.
    • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
    • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
    • Massage therapy.
    • Educational services except for Diabetes Self- Management Training Program, and as specifically provided or arranged by Cigna.
    • Nutritional counseling or food supplements, except as stated in this policy.
    • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and Consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
    • Physical, and/or Occupational Therapy/Medicine except when provided during an inpatient Hospital confinement or as specifically stated in the Benefit Schedule and under ‘Physical and/or Occupational Therapy/Medicine’ in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
    • Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
    • All Foreign Country Provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
    • Growth Hormone Treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
    • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet except for insureds with the diagnosis of diabetes.
    • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
    • Charges for the services of a standby physician.
    • Charges for animal to human organ transplants.
    • Claims received by Cigna after 18 months from the date service was rendered, except in the event of a legal incapacity.
    Open Access Plus Network

    This medical plan uses the Cigna Open Access Plus (OAP) Network which provides access to health care professionals nationwide. When you receive care from a health care professional or hospital in the OAP Network the visit is considered in-network which helps you save with lower out-of-pocket expenses. You also have the freedom to see any health care professional not in the OAP Network, and coverage for that service will be paid at the out-of-network benefit. You will be responsible for the out-of-network benefit cost in addition to any difference in the amount that Cigna reimburses for such services and the amount charged by the health care professional, except for emergency services, as defined by your plan.

    South Carolina
    Exclusions and Limitations

    In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

    • Services or supplies that are not medically necessary.
    • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures.
    • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the insured person does not claim those benefits.
    • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation; (f ) an insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by physician.
    • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
    • Any services required by state or federal law to be supplied by a public school system or school district.
    • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
    • If the insured person is eligible for Medicare part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
    • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
    • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
      • yourself or your employer;
      • a person who lives in the insured person’s home, or that person’s employer;
      • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
    • Custodial care.
    • Inpatient or outpatient services of a private duty nurse.
    • Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
    • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
    • Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
    • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
    • Orthodontic services, braces and other orthodontic appliances including orthodontic services for temporomandibular joint dysfunction.
    • Medical treatment for tempomandibular joint dysfunction.
    • Dental implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
    • Hearing aids including but not limited to semi- implantable hearing devices, audiant bone conductors and bone anchored hearing aids (BAHAs). For the purposes of this exclusion, a hearing aid is any device that amplifies sound.
    • Routine hearing tests except as specifically provided in this policy under “Comprehensive Benefits What the Plan Pays For.”
    • Genetic screening or preimplantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
    • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision Services.
    • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
    • Outpatient speech therapy, expect as specifically stated in this policy.
    • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
    • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, personal digital assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
    • Non-medical counseling or ancillary services, including but not limited to: education, vocational rehabilitation, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety.
    • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
    • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
    • Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
    • All services related to the evaluation or treatment of fertility and/or infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) except as specifically stated in this policy.
    • All non-prescription drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA) that are available over the counter or without a prescription. For additional information please refer to the following website: www.healthcare.gov/center/ regulations/prevention/recommendations.htm l
    • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the prescription drug benefits of this policy.
    • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
    • Any infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
    • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
    • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
    • Blood administration for the purpose of general improvement in physical condition.
    • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthotic devices.
    • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
    • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, those required by employment or government authority, including physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this plan.
    • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long-term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
    • Telephone, e-mail, and internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters.
    • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
    • Educational services except for Diabetes Self- Management Training Program, and as specifically provided or arranged by Cigna.
    • Massage therapy.
    • Nutritional counseling or food supplements, except as stated in this policy.
    • Durable medical equipment not specifically listed as covered services in the covered services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
    • Physical, and/or occupational therapy/medicine except when provided during an inpatient hospital confinement or as specifically stated in the Benefit Schedule and under ‘Physical and/or Occupational Therapy/Medicine’ in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
    • Self-administered injectable drugs, except as stated in the Benefit Schedule and in the Prescription Drug Benefits section of this policy.
    • Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
    • Syringes, except as stated in the policy.
    • All foreign country provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
    • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
    • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet except as otherwise stated in this policy.
    • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
    • Charges for the services of a standby physician.
    • Charges for animal to human organ transplants.
    • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
    Open Access Plus Network

    This medical plan uses the Cigna Open Access Plus (OAP) Network which provides access to health care professionals nationwide. When you receive care from a health care professional or hospital in the OAP Network the visit is considered in-network which helps you save with lower out-of-pocket expenses. You also have the freedom to see any health care professional not in the OAP Network, and coverage for that service will be paid at the out-of-network benefit. You will be responsible for the out-of-network benefit cost in addition to any difference in the amount that Cigna reimburses for such services and the amount charged by the health care professional, except for emergency services, as defined by your plan.

    Tennessee
    Exclusions and Limitations

    In addition to any other exclusions and limitations described in this policy, there are no benefits provided for the following:

  • Any amounts in excess of maximum amounts of Covered Expenses stated in this policy.
  • Services not specifically listed as Covered Services in this policy.
  • Services or supplies that are not medically necessary.
  • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage except for expenses incurred in connection with the patient’s hospitalization for hospital, medical or surgical services rendered by a non-governmental, charitable research hospital that bills all patients for services rendered but does not enforce by judicial proceedings payment from an individual patient in the absence of insurance coverage.
  • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the insured person does not claim those benefits.
  • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation; (f ) an insured person being intoxicated, as defined by applicable state law in the state where the illness occurred or under the influence of illegal narcotics or non-prescribed controlled substances unless administered or prescribed by physician.
  • Any services provided by a local, state or federal government agency, except when payment under this policy is expressly required by federal or state law.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • If the insured person is eligible for Medicare Part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
  • Professional services or supplies received or purchased directly or on your behalf by anyone, including a physician, from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person’s home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • Custodial care.
  • Inpatient or outpatient services of a private duty nurse.
  • Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
  • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Smoking cessation programs.
  • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction.
  • Dental implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids, including but not limited to: semi- implantable hearing devices, audiant bone conductors, Bone Anchored Hearing Aids (BAHAs), batteries, cords and other assistive devices such as FM systems.
  • Routine hearing tests except as specifically provided under Preventive Care and Newborn Hearing Benefits.
  • Genetic screening or preimplantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Outpatient speech therapy, expect as specifically stated in this policy.
  • Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty; and blepharoplasty. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a Newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books except as specifically stated in this policy.
  • Nonmedical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities and developmental delays.
  • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
  • Treatment of sexual dysfunction, impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • All services related to the evaluation or treatment of fertility and/or infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in this plan.
  • All nonprescription drugs, devices and/or supplies, except drugs designated as preventive by the Patient Protection and Affordable Care Act (PPACA), that are available over the counter or without a prescription.
  • Any infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
  • Self-administered injectable drugs, except as stated in the Benefit Schedule and in the Prescription Drug Benefits section of this policy.
  • Syringes, except as stated in the policy.
  • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthotic devices except as required by law for diabetic patients.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
  • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this Plan.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long-term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Telephone, email, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters, except as specifically stated in this policy.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
  • Massage therapy.
  • Educational services except for diabetes self-management training program, and as specifically provided or arranged by Cigna.
  • Nutritional counseling or food supplements, except as stated in this policy.
  • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
  • Physical, and/or occupational therapy/medicine except when provided during an inpatient hospital confinement or as specifically stated in the Benefit Schedule and under ‘Physical and/or Occupational Therapy/Medicine’ in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
  • All foreign country provider charges are excluded under this policy except as specifically stated under “Treatment received from Foreign Country Providers” in the section of this policy titled “Comprehensive Benefits What the Policy Pays For.”
  • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition.
  • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet.
  • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for the services of a standby physician.
  • Charges for animal to human organ transplants.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
  • LocalPlus Network

    This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

    In-network

    • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
    • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
    • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
    • Any visit considered an emergency as defined by your policy

    Out-of-network

    • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
    • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
    • Non-Cigna contracted professionals in any area

    For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

    Texas
    Exclusions and Limitations

    Your plan does not provide coverage for the following except as required by law:

  • Services or supplies that are not medically necessary.
  • Services or supplies that Cigna considers to be for experimental procedures or investigative procedures.
  • Services received before the effective date of coverage.
  • Services received after coverage under this policy ends.
  • Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage, except to the extent that the availability of insurance or health plan coverage may be considered by a tax supported institution of the State of Texas providing treatment of mental Illness or mental retardation to determine if a patient is non-indigent, as provided in Article 3196a of Vernon’s Texas Civil Statutes.
  • Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the insured Person does not claim those benefits.
  • Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy; (c) an insured person participating in the military service of any country; (d) an insured person participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person’s commission of, or attempt to commit a felony (whether or not charged) or as a direct result of the insured person being engaged in an illegal occupation.
  • Any services provided by a local, state or federal government agency, except (a) when payment under this policy is expressly required by federal or state law; or (b) services provided for the treatment of mental or nervous disorders by a tax supported institution of the State of Texas.
  • Any services required by state or federal law to be supplied by a public school system or school district.
  • If the insured person is eligible for Medicare part A, B or D, Cigna will provide claim payment according to this policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.
  • Court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan.
  • Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
  • Professional services or supplies received or purchased directly or on your behalf from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person’s home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.

    This does not apply to covered dental services provided by a dentist licensed in the state of Texas and operating within the scope of his or her licensure.

  • Custodial care.
  • Inpatient or outpatient services of a private duty nurse.
  • Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
  • Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other custodial care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
  • Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
  • Smoking cessation programs, except as specifically provided in this policy.
  • Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this policy.
  • Orthodontic services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction.
  • Dental Implants: dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
  • Hearing aids, except as specifically stated in this policy.
  • Routine hearing tests except as specifically provided in this policy under “Comprehensive Benefits, What the Plan Pays For.”
  • Genetic screening or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.
  • Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this policy under Pediatric Vision.
  • An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
  • Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one’s appearance. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a Newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy or lumpectomy.
  • Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.
  • Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books, except as specifically stated in this policy.
  • Nonmedical counseling or ancillary services.
  • Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
  • Treatment of sexual dysfunction impotence and/or inadequacy, except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
  • All services related to the evaluation or treatment of fertility and/or infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and invitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), except as specifically stated in this policy.
  • Injectable drugs (self-injectable medications) that do not require physician supervision are covered under the Prescription Drug benefits of this policy.
  • All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this policy.
  • Any Infusion or injectable specialty prescription drugs that require physician supervision, except as otherwise stated in this policy. Infusion and injectable specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin.
  • Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • Blood administration for the purpose of general improvement in physical condition.
  • Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees).
  • Orthopedic shoes (except when joined to braces), shoe inserts, foot orthotic devices except as specifically stated under External Prosthetic Appliances and Devices in the Benefits section of this policy.
  • Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the insured person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
  • Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this Plan.
  • Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long-term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.
  • Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs, etc.).
  • Massage therapy.
  • Educational services except for diabetes self-management training programs and those offered by Cigna.
  • Nutritional counseling or food supplements, except as stated in this policy.
  • Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts (except as specifically stated under External Prosthetic Appliances and Devices in the Benefits section of this policy), air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this policy.
  • Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this policy. This includes, but is not limited to, items dispensed by a physician.
  • Syringes, except as stated in the policy.
  • All foreign country provider charges are excluded under this policy except as specifically stated under Treatment received from Foreign Country Providers in the section of this policy titles “Comprehensive Benefits What the Policy Pays For.”
  • Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured person’s condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances.
  • Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized illness, injury or symptoms involving the feet, except as otherwise stated in this policy.
  • Charges for which we are unable to determine our liability because the insured person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
  • Charges for the services of a standby physician.
  • Charges for animal to human organ transplants.
  • Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity.
  • LocalPlus Network

    This medical plan uses the Cigna LocalPlus® Network of participating health care professionals which offers referral-free access to a smaller network of participating health care professionals (physicians, hospitals, etc.) than the larger Cigna OAP Network. To minimize your out-of-pocket expenses, visit health care providers in the LocalPlus Network. If you choose to visit a health care professional out-of-network (OON) you will be reimbursed at the OON benefit level. The difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or professional except for emergency services, will also increase your OON costs.

    In-network

    • LocalPlus health care professionals in the LocalPlus service area for this plan (where you live)
    • LocalPlus health care professionals in other LocalPlus service areas (when traveling)
    • In service areas where the LocalPlus Network is not available, customers can access doctors and hospitals in Cigna's national Away From Home (Open Access Plus) Network and receive coverage at the in-network level.
    • Any visit considered an emergency as defined by your policy

    Out-of-network

    • Any professional in your LocalPlus service area that is not part of the LocalPlus Network
    • Professionals in other LocalPlus service areas that are not part of the LocalPlus Network
    • Non-Cigna contracted professionals in any area

    For more detailed information or to find professionals in the LocalPlus Network, including participating professionals when you are away from home, please review the LocalPlus Network Nationwide flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna.24.

    In Texas, LocalPlus Network plans are considered Preferred Provider plans with certain managed care features and LocalPlus Health Savings Network plans are considered Preferred Provider plans with certain managed care features that is compatible with a Health Savings Account.

    RATES

    These rates are for illustrative purposes only. A person should not send money to the issuer of the health benefit plan in response to the advertisement. A person cannot obtain coverage under the health benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the health benefit plan.

    Dental Insurance Plans

    Dental plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, family size, geographic location (residential zip code), and plan design.

    Dental rates are subject to change upon 30 days’ prior notice in AK, AL, AR, AZ, CO, CT, DC, DE, HI, ID, IA, IL, IN, KS, KY, MA, ME, MI, MN, MO, MT, ND, NE, NH, NJ, NM, OH, OK, OR, PA, RI, SD, TN, UT, VT, WI and WY, 31 days’ prior notice in SC, 45 days’ prior notice in FL, and 60 days’ prior notice in CA, GA, MS, NV, TX, VA, and WV. In LA, dental rates are guaranteed for the initial 12 months of coverage, except if due to addition of a newly covered person, a change in age or geographic location, or a change in policy coverage. Thereafter, rates are subject to change upon 45 days’ notice. In MD, dental rates are subject to change upon 40 days’ prior notice. In NC, dental rates are guaranteed for a 12 month period.

    myCigna Dental Preventive and myCIgna Dental 1000 plans include a combination of insurance coverage and discounted services. The insurance coverage shall be only for the classes of services referred to in The Schedule of a purchased plan. Discounts are not available in MD, and VA. Some dental plans apply waiting periods to covered basic (6 months), major (12 months) and orthodontic (12 months) dental care services. In IL, NJ and VT, a 6 month waiting period applies to covered basic, major and orthodontic dental care services. In WV, a 3 month waiting period applies to covered basic, major and orthodontic dental care services. Waiting periods do not apply in MO and RI. Some covered services are determined by age: topical application of fluoride or sealant, space maintainers, and materials for crowns and bridges. If the plan covers replacement of teeth, there is no payment for replacement of teeth that are missing prior to coverage. In MD and OH, a 12-month limitation applies. FL applies a 24 month limitation. The policy may be cancelled by Cigna due to failure to pay premium, fraud, ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies of this type or any individual dental plans in the state, in accordance with applicable law. You may cancel the policy, on the first of the month following our receipt of your written notice. We reserve the right to modify the policy, including policy provisions, benefits and coverages, consistent with state or federal law. Individual dental plans are renewable monthly or quarterly.

    Dental preferred provider insurance policies (AL, CO, DE, CT, GA, IL, MA, MI, PA, UT, VA, WV, and WY: HC-NOT11 et al., AR: HC-NOT36 et al., CA: INDENTPOLCA0713 et al., FL: HC-NOT15 et al., ID HC-NOT51 et al, KS: HC-NOT49 et al., LA: INDDENTPOLLA0713, MS: HC-NOT48 et al., MO: INDDENTPOLMO0713, NE HC-NOT47 et al., NH INDDENPOLNH0713, NM: INDDENPOLNM0713, NV: HC-NOT39 et al., OH: INDDENTPOLOH et al., OK: HC-NOT26 et al., OR: INDDENTPOLOR0713, RI HC-NOT35 et al., SC: HC-NOT19 et al., SD HC-NOT59 et al., TN: HC-NOT20 et al., TX: HC-NOT21 et al., VT HC-NOT56 et al., WI HC-NOT54 et al.) have exclusions, limitations, reduction of benefits and terms under which a policy may be continued in force or discontinued. In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network.

    Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

    These rates are for illustrative purposes only. A person should not send money to the issuer of the dental benefit plan in response to the advertisement. A person cannot obtain coverage under the dental benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the dental benefit plan.

    For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446). In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network.

    Dental Plan Exclusions & Limitations

    Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

  • procedures which are not included in the list of Covered Dental Expenses.
  • procedures which are not necessary and which do not have uniform professional endorsement.
  • procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
  • any procedure, service, supply or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension.
  • procedures, appliances or restorations whose main purpose is to diagnose or treat jaw joint problems, including dysfunction of the temporomandibular joint and craniomandibular disorders, or other conditions of the joints linking the jawbone and skull, including the complex muscles, nerves and other tissues related to that joint.
  • the alteration or restoration of occlusion.
  • the restoration of teeth which have been damaged by erosion, attrition or abrasion.
  • bite registration or bite analysis.
  • any procedure, service, or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
  • the initial placement of a full denture or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan (the removal of only a permanent third molar will not qualify a full or partial denture for benefit under this provision).
  • the initial placement of a fixed bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. If a bridge replaces teeth that were missing prior to the date the person's coverage became effective and also teeth that are extracted after the person's effective date, benefits are payable only for the pontics replacing those teeth which are extracted while the person was insured under this plan. The removal of only a permanent third molar will not qualify a fixed bridge for benefit under this provision.
  • the initial placement of an implant unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. The removal of only a permanent third molar will not qualify an implant for benefit under this provision.
  • the surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant.
  • crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay or fracture.
  • core build-ups.
  • replacement of a partial denture, full denture, or fixed bridge or the addition of teeth to a partial denture unless: (a)replacement occurs at least 84 consecutive months after the initial date of insertion of the current full or partial denture; or (b)the partial denture is less than 84 consecutive months old, and the replacement is needed due to a necessary extraction of an additional functioning natural tooth while the person is covered under this plan (alternate benefits of adding a tooth to an existing appliance may be applied); or (c)replacement occurs at least 84 consecutive months after the initial date of insertion of an existing fixed bridge (if the prior bridge is less than 84 consecutive months old, and replacement is needed due to an additional necessary extraction of a functioning natural tooth while the person is covered under this plan. Benefits will be considered only for the pontic replacing the additionally extracted tooth).
  • The removal of only a permanent third molar will not qualify an initial or replacement partial denture, full denture or fixed bridge for benefits.
  • the replacement of crowns, cast restoration, inlay, onlay or other laboratory prepared restorations within 84 consecutive months of the date of insertion.
  • The replacement of a bridge, crown, cast restoration, inlay, onlay or other laboratory prepared restoration regardless of age unless necessitated by major decay or fracture of the underlying Natural Tooth.
  • any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards;
  • replacement of a partial denture or full denture which can be made serviceable or is replaceable.
  • replacement of lost or stolen appliances.
  • replacement of teeth beyond the normal complement of 32.
  • prescription drugs.
  • any procedure, service, supply or appliance used primarily for the purpose of splinting.
  • athletic mouth guards.
  • myofunctional therapy.
  • precision or semiprecision attachments.
  • denture duplication.
  • separate charges for acid etch.
  • labial veneers (laminate).
  • porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars;
  • Precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin for participants under 16 years old;
  • treatment of jaw fractures and orthognathic surgery.
  • orthodontic treatment, except for the treatment of cleft lip and cleft palate. Exclusion does not apply if the Plan otherwise covers services for orthodontic treatment.
  • charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
  • charges for travel time; transportation costs; or professional advice given on the phone.
  • temporary, transitional or interim dental services.
  • any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
  • diagnostic casts, diagnostic models, or study models.
  • any charge for any treatment performed outside of the United States other than for Emergency Treatment (any benefits for Emergency Treatment which is performed outside of the United States will be limited to a maximum of $100 per consecutive 12-month period);
  • oral hygiene and diet instruction; broken appointments; completion of claim forms; personal supplies (e.g., water pick, toothbrush, floss holder, etc.); duplication of x-rays and exams required by a third party;
  • any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility;
  • services that are deemed to be medical services;
  • services for which benefits are not payable according to the "General Limitations" section.
  • General Limitations

    No payment will be made for dental expenses incurred for you or any one of your dependents:

    • For services not specifically listed as Covered Services in this policy.
    • For services or supplies that are not medically/dentally necessary.
    • For services received before the effective date of coverage.
    • For services received after coverage under this policy ends.
    • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
    • For Professional services or supplies received or purchased [directly or on Your behalf by anyone, including a dentist,]from any of the following:
      • yourself or your employer;
      • a person who lives in the insured person's home, or that person’s employer;
      • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
    • for or in connection with an Injury arising out of, or in the course of, any employment for wage or profit;
    • for or in connection with a Sickness which is covered under any workers' compensation or similar law;
    • for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition;
    • services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
    • to the extent that payment is unlawful where the person resides when the expenses are incurred;
    • for charges which the person is not legally required to pay;
    • for charges which would not have been made if the person had no insurance;
    • to the extent that billed charges exceed the rate of reimbursement as described in the Schedule;
    • for charges for unnecessary care, treatment or surgery;
    • to the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;
    • for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society;
    • Procedures that are a covered expense under any other dental plan which provides dental benefits;
    • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.
    Dental Pediatric Insurance Plans

    Dental plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, number of enrolled dependents, geographic location (residential zip code), and plan design.

    Dental rates are subject to change upon 30 days’ prior notice in AZ, CO, CT, MO, TN, 31 days’ prior notice in SC, 45 days’ prior notice in FL, and 60 days’ prior notice in CA, GA, and TX. In MD, dental rates are subject to change upon 40 days’ prior notice. In NC, dental rates are guaranteed for a 12-month period.

    Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

    These dental insurance policies (CA: CACHIND012015, CO: EOC_ENG_Cigna_49375CO0030001_20150101, CT: CTINDCH052013, FL:INDDENPEDI.FL.1, GA: INDDENPEDI.GA.1, MO:INDDENPEDI.MO.1, MD:MDINDCH052014, NC: INDDENPEDI.NC.1, SC:INDDENPEDI.SC.1, TN:INDDENPEDI.TN.1, TX: INDDENPEDI.TX.1), have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna (1-866-438-2446).

    These rates are for illustrative purposes only. A person should not send money to the issuer of the dental benefit plan in response to the advertisement. A person cannot obtain coverage under the dental benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the dental benefit plan.

    For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446). In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network. These Dental plans offer the full range of Essential Health Benefit Pediatric Oral Care and satisfy the requirements under the Affordable Care Act.

    Dental Pediatric Plan Exclusions & Limitations

    Arizona, Florida, Georgia, Missouri, South Carolina, Tennessee, Texas

    Exclusions and limitations may vary by state.

    Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

    • Procedures and services which are not included in the list of “Covered Dental Expenses” in the policy.
    • Procedures which are not necessary and which do not have uniform professional endorsement.
    • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
    • Any procedure, service or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
    • The initial placement of an implant unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. The removal of only a permanent third molar will not qualify an implant for benefit under this provision. Except in cases where it is medically/dentally necessary.
    • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant. Except in cases where it is medically/dentally necessary (not applicable in AZ).
    • Replacement of lost or stolen appliances.
    • Replacement of teeth beyond the normal complement of 32.
    • Prescription drugs.
    • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
    • Orthodontic treatment, except in cases where it is medically/dentally necessary.
    • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
    • Charges for travel time, transportation costs or professional advice given on the phone.
    • Temporary, transitional or interim dental services.
    • Any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
    • Any charge for any treatment performed outside of the United States other than for emergency treatment.
    • Oral hygiene and diet instruction, broken appointments, completion of claim forms, personal supplies (water pick, toothbrush, floss holder, etc.), duplication of x-rays and exams required by a third party.
    • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
    • Services that are deemed to be medical services.
    • Services for which benefits are not payable according to the “General Limitations” section. General Limitations
    • No payment will be made for expenses incurred for you or any one of your dependents:

    • For services or supplies that are not medically/dentally necessary.
    • For services received before the effective date of coverage.
    • For services received after coverage under this policy ends.
    • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
    • For Professional services or supplies received or purchased directly or on your behalf by anyone, except a licensed dentist, from any of the following:
    • yourself or your employer;
    • a person who lives in the insured person’s home, or that person’s employer;
    • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
    • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit.
    • For or in connection with a sickness which is covered under any workers’ compensation or similar law.
    • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition.
    • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared (not applicable in FL).
    • To the extent that payment is unlawful where the person resides when the expenses are incurred.
    • For charges which the person is not legally required to pay.
    • For charges which would not have been made if the person had no insurance.
    • To the extent that billed charges exceed the rate of reimbursement as described in the schedule.
    • For charges for unnecessary care, treatment or surgery.
    • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
    • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
    • Procedures that are a covered expense under any other dental plan which provides dental benefits (not applicable in AZ or TX).
    • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.

    California

    Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

    1. services that would be covered under this medical plan.
    2. procedures and services which are not included in the list of “Covered Dental Expenses”.
    3. procedures which are not medically/dentally necessary.
    4. procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
    5. any procedure, service, or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
    6. replacement of lost or stolen appliances.
    7. replacement of teeth beyond the normal complement of 32.
    8. prescription drugs.
    9. any procedure, service, supply or appliance used primarily for the purpose of splinting.
    10. orthodontic treatment. Except in cases where it is medically/dentally necessary.
    11. charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
    12. charges for travel time; transportation costs; or professional advice given on the phone.
    13. temporary, transitional or interim dental services.
    14. any charge for any treatment performed outside of the United States other than for Emergency Treatment.
    15. oral hygiene and diet instruction; broken appointments; completion of claim forms; personal supplies (e.g., water pick, toothbrush, floss holder, etc.); duplication of x-rays and exams required by a third party.
    16. any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
    17. services for which benefits are not payable according to the “General Limitations” section.
    18. for services or supplies that are not medically/dentally necessary.
    19. for services received before the effective date of coverage.
    20. for services received after coverage under this policy ends.
    21. for services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
    22. for Professional services or supplies received or purchased directly or on your behalf by anyone, including a dentist, from any of the following:
      • yourself or your employer;
      • a person who lives in the insured person’s home, or that person’s employer;
      • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
    23. for or in connection with a Sickness which is covered under any workers’ compensation or similar law.
    24. for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition.
    25. services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
    26. to the extent that payment is unlawful where the person resides when the expenses are incurred.
    27. for or in connection with an Injury arising out of, or in the course of, any employment for wage or profit. which is covered under any workers’ compensation or similar law.
    28. for charges which the person is not legally required to pay.
    29. for charges which would not have been made if the person had no insurance.
    30. to the extent that billed charges exceed the rate of reimbursement as described in the Schedule.
    31. for charges for unnecessary care, treatment or surgery.
    32. to the extent that you or any of your dependents is in any way paid for those expenses by or through a public program, other than Medicaid.
    33. for or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
    34. to the extent that benefits are paid for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.

    Colorado, Connecticut, Maryland

    Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

  • Procedures and services for persons over the age of 19
  • Procedures and services which are not included in the list of “Covered Dental Expenses.”
  • Procedures which are not necessary and which do not have uniform professional endorsement.
  • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
  • Any procedure, service, or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
  • The initial placement of an implant unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. The removal of only a permanent third molar will not qualify an implant for benefit under this provision. Except in cases where it is medically/dentally necessary.
  • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant. Except in cases where it is medically/dentally necessary.
  • Replacement of lost or stolen appliances.
  • Replacement of teeth beyond the normal complement of 32.
  • Prescription drugs.
  • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
  • Orthodontic treatment. Except in cases where it is medically/dentally necessary.
  • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
  • Charges for travel time; transportation costs; or professional advice given on the phone.
  • Temporary, transitional or interim dental services.
  • Any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
  • Any charge for any treatment performed outside of the United States other than for Emergency Treatment
  • Oral hygiene and diet instruction; broken appointments; completion of claim forms; personal supplies (e.g., water pick, toothbrush, floss holder, etc.); duplication of x-rays and exams required by a third party;
  • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility;
  • Services that are deemed to be medical services;
  • Services for which benefits are not payable according to the “General Limitations” section.
  • General Limitations

    No payment will be made for expenses incurred for you or any one of your dependents:

  • For services or supplies that are not medically/dentally necessary.
  • For services received before the effective date of coverage.
  • For services received after coverage under this policy ends.
  • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
  • For Professional services or supplies received or purchased directly or on your behalf by anyone, including a dentist, from any of the following:
  • yourself or your employer;
  • a person who lives in the insured person’s home, or that person’s employer;
  • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit;
  • For or in connection with a Sickness which is covered under any workers’ compensation or similar law;
  • For charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition;
  • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
  • To the extent that payment is unlawful where the person resides when the expenses are incurred;
  • For charges which the person is not legally required to pay;
  • For charges which would not have been made if the person had no insurance;
  • To the extent that billed charges exceed the rate of reimbursement as described in the Schedule;
  • For charges for unnecessary care, treatment or surgery;
  • To the extent that you or any of you dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;
  • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
  • Procedures that are a covered expense under any other dental plan which provides dental benefits
  • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of you dependents.
  • North Carolina

    Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

  • Procedures and services which are not included in the list of “Covered Dental Expenses.”
  • Procedures which are not necessary and which do not have uniform professional endorsement.
  • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
  • Cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance). However, for dependent children, benefits will include coverage of an injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, including cleft lip and cleft palate. Benefits are the same for congenital defects or anomalies, including individuals born with cleft lip or cleft palate, as are provided for other dental conditions that are covered by the plan.
  • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant. Except in cases where it is medically/dentally necessary.
  • Replacement of lost or stolen appliances.
  • Replacement of teeth beyond the normal complement of 32.
  • Prescription drugs.
  • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
  • Orthodontic treatment, except in cases where it is medically/dentally necessary.
  • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
  • Charges for travel time, transportation costs or professional advice given on the phone.
  • Temporary, transitional or interim dental services.
  • Any charge for any treatment performed outside of the United States other than for emergency treatment.
  • Oral hygiene and diet instruction, broken appointments, completion of claim forms, personal supplies (water pick, toothbrush, floss holder, etc.), duplication of x-rays and exams required by a third party.
  • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
  • Services that are deemed to be medical services.
  • Services for which benefits are not payable according to the “General Limitations” section.
  • General Limitations

    No payment will be made for expenses incurred for you or any one of your dependents:

  • For services or supplies that are not medically/dentally necessary.
  • For services received before the effective date of coverage.
  • For services received after coverage under this policy ends, except as provided under the Dental Benefits Extension provision.
  • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
  • For professional services or supplies received or purchased directly or on your behalf by anyone, including a dentist, from any of the following:
  • yourself or your employer;
  • a person who lives in the insured person’s home, or that person’s employer;
  • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
  • Services or supplies for the treatment of an occupational injury or sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act.
  • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition.
  • To the extent that payment is unlawful where the person resides when the expenses are incurred, that is, the expenses were incurred in connection with an unlawful, fraudulent act.
  • For charges which the person is not legally required to pay.
  • For charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan.
  • To the extent that billed charges exceed the rate of reimbursement as described in the schedule, except in the case of emergency services.
  • For charges for unnecessary care, treatment or surgery.
  • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
  • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
  • Dental Family + Pediatric Insurance Plans

    Dental plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, family size, geographic location (residential zip code), and plan design. Dental rates are subject to change upon 30 days’ prior notice in, AZ, CO & TN, 45 days’ prior notice in FL, and 60 days’ prior notice in TX.

    Notice to Buyer: This policy provides dental coverage only. Review your policy carefully.

    These dental insurance policies (AZ: INDDENCOMB.AZ.1, CO: 49375CO0030002_20150101, FL: INDDENCOMB.FL.1, TN: INDDENCOMB.TN.1, TX: INDDENCOMB.TX.1) have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued.

    These rates are for illustrative purposes only. A person should not send money to the issuer of the dental benefit plan in response to the advertisement. A person cannot obtain coverage under the dental benefit plan until the person completes an application for coverage. Benefit exclusions and limitations may apply to the dental benefit plan.

    For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 1-866-GET-Cigna. (1-866-438-2446). In Texas, the dental plan is known as Cigna Dental Choice and the plan utilizes the national Cigna Dental PPO network.

    These Dental plans offer the full range of Essential Health Benefit Pediatric Oral Care and satisfy the requirements under the Affordable Care Act.

    Dental Family + Pediatric Plan Exclusions & Limitations

    Arizona, Florida, Tennessee, Texas

    Missing Teeth Limitation – Age 19 and older
    There is no payment for replacement of teeth that are missing prior to coverage. In FL, payment limitation no longer applies after 24 months.

    Excluded Services: Age 19 and older

    Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Dental Expenses do not include expenses incurred for:

    • Procedures which are not included in the list of covered dental expenses in the policy.
    • Procedures which are not necessary and which do not have uniform professional endorsement.
    • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
    • Any procedure, service, supply or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension.
    • Procedures, appliances or restorations whose main purpose is to diagnose or treat dysfunction of the temporomandibular joint.
    • The alteration or restoration of occlusion.
    • The restoration of teeth which have been damaged by erosion, attrition or abrasion.
    • Bite registration or bite analysis.
    • Any procedure, service or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
    • The initial placement of a full denture or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan (the removal of only a permanent third molar will not qualify a full or partial denture for benefit).
    • The initial placement of a fixed bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. If a bridge replaces teeth that were missing prior to the date the person’s coverage became effective and also teeth that are extracted after the person’s effective date, benefits are payable only for the pontics replacing those teeth which are extracted while the person was insured under this plan. The removal of only a permanent third molar will not qualify a fixed bridge for benefit under this provision.
    • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant (not applicable in AZ).
    • Crowns, inlays, cast restorations or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay or fracture.
    • Core build-ups.
    • Replacement of a partial denture, full denture or fixed bridge or the addition of teeth to a partial denture unless:
    • Replacement occurs at least 84 consecutive months after the initial date of insertion of the current full or partial denture; or
    • The partial denture is less than 84 consecutive months old, and the replacement is needed due to a necessary extraction of an additional functioning natural tooth while the person is covered under this plan (alternate benefits of adding a tooth to an existing appliance may be applied); or
    • Replacement occurs at least 84 consecutive months after the initial date of insertion of an existing fixed bridge (if the prior bridge is less than 84 consecutive months old, and replacement is needed due to an additional necessary extraction of a functioning natural tooth while the person is covered under this plan. Benefits will be considered only for the pontic replacing the additionally extracted tooth).
    • The removal of only a permanent third molar will not qualify an initial or replacement partial denture, full denture or fixed bridge for benefits.
    • The replacement of crowns, cast restoration, inlay, onlay or other laboratory prepared restorations within 84 consecutive months of the date of insertion.
    • The replacement of a bridge, crown, cast restoration, inlay, onlay or other laboratory prepared restoration regardless of age unless necessitated by major decay or fracture of the underlying natural tooth.
    • Any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards.
    • Replacement of a partial denture or full denture which can be made serviceable or is replaceable.
    • Replacement of lost or stolen appliances.
    • Replacement of teeth beyond the normal complement of 32.
    • Prescription drugs.
    • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
    • Athletic mouth guards.
    • Myofunctional therapy.
    • Precision or semiprecision attachments.
    • Denture duplication.
    • Separate charges for acid etch.
    • Labial veneers (laminate).
    • Porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars.
    • Treatment of jaw fractures and orthognathic surgery.
    • Orthodontic treatment, except for the treatment of cleft lip and cleft palate. Exclusion does not apply if the plan otherwise covers services for orthodontic treatment.
    • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
    • Charges for travel time, transportation costs, or professional advice given on the phone.
    • Temporary, transitional or interim dental services.
    • Any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
    • Diagnostic casts, diagnostic models or study models.
    • Any charge for any treatment performed outside of the United States other than for emergency treatment (any benefits for emergency treatment which is performed outside of the United States will be limited to a maximum of $100 per consecutive 12-month period).
    • Oral hygiene and diet instruction, broken appointments, completion of claim forms, personal supplies (water pick, toothbrush, floss holder, etc.), duplication of x-rays and exams required by a third party.
    • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
    • Services that are deemed to be medical services.
    • Services for which benefits are not payable according to the “General Limitations” section.

    General Limitations: Age 19 and older

    No payment will be made for expenses incurred for you or any one of your dependents:

    • For services not specifically listed as covered services in the policy.
    • For services or supplies that are not medically/ dentally necessary.
    • For services received before the effective date of coverage.
    • For services received after coverage under this policy ends.
    • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
    • For professional services or supplies received or purchased directly or on your behalf by anyone, except a licensed dentist, from any of the following:
      • yourself or your employer;
      • a person who lives in the insured person’s home, or that person’s employer;
      • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
    • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit;
    • For or in connection with a sickness which is covered under any workers’ compensation or similar law;
    • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition;
    • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
    • To the extent that payment is unlawful where the person resides when the expenses are incurred;
    • For charges which the person is not legally required to pay;
    • For charges which would not have been made if the person had no insurance;
    • To the extent that billed charges exceed the rate of reimbursement as described in the schedule;
    • For charges for unnecessary care, treatment or surgery;
    • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;
    • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society;
    • Procedures that are a covered expense under any other dental plan which provides dental benefits (not applicable in TX);
    • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.

    Excluded Services: Under Age 19

    Covered Expenses do not include expenses incurred for:

    • Procedures and services which are not included in the list of “Covered Dental Expenses” in the policy.
    • Procedures which are not necessary and which do not have uniform professional endorsement.
    • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
    • Any procedure, service, or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
    • The initial placement of an implant unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. The removal of only a permanent third molar will not qualify an implant for benefit under this provision. Except in cases where it is medically/dentally necessary.
    • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant. Except in cases where it is medically/dentally necessary
    • Replacement of lost or stolen appliances.
    • Replacement of teeth beyond the normal complement of 32.
    • Prescription drugs.
    • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
    • Orthodontic treatment, except in cases where it is medically/dentally necessary.
    • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
    • Charges for travel time; transportation costs; or professional advice given on the phone.
    • Temporary, transitional or interim dental services.
    • Any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
    • Any charge for any treatment performed outside of the United States other than for emergency treatment.
    • Oral hygiene and diet instruction; broken appointments; completion of claim forms; personal supplies (water pick, toothbrush, floss holder, etc.); duplication of x-rays and exams required by a third party;
    • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility;
    • Services that are deemed to be medical services;
    • Services for which benefits are not payable according to the “General Limitations” section.
      • For services or supplies that are not medically/dentally necessary.
      • For services received before the effective date of coverage.
      • For services received after coverage under this policy ends.
      • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
      • For professional services or supplies received or purchased directly or on your behalf by anyone, except a licensed dentist, from any of the following:
        • yourself or your employer;
        • a person who lives in the insured person’s home, or that person’s employer;
        • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
        • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit;
        • For or in connection with a sickness which is covered under any workers’ compensation or similar law;
        • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition;
        • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
        • To the extent that payment is unlawful where the person resides when the expenses are incurred;
        • For charges which the person is not legally required to pay;
        • For charges which would not have been made if the person had no insurance;
        • To the extent that billed charges exceed the rate of reimbursement as described in the schedule;
        • For charges for unnecessary care, treatment or surgery;
        • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;
        • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
        • Procedures that are a covered expense under any other dental plan which provides dental benefits (not applicable in TX).
        • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.
        • Procedures which are not included in the list of “Covered Dental Expenses.”
        • Procedures which are not necessary and which do not have uniform professional endorsement.
        • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
        • Any procedure, service, supply or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension.
        • Procedures, appliances or restorations whose main purpose is to diagnose or treat jaw joint problems, including dysfunction of the temporomandibular joint and craniomandibular disorders or other conditions of the joints linking the jawbone and skull, including the complex muscles, nerves and other tissues related to that joint.
        • The alteration or restoration of occlusion.
        • The restoration of teeth which have been damaged by erosion, attrition or abrasion.
        • Bite registration or bite analysis.
        • Any procedure, service or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
        • The initial placement of a full denture or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan (the removal of only a permanent third molar will not qualify a full or partial denture for benefit).
        • The initial placement of a fixed bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. If a bridge replaces teeth that were missing prior to the date the person’s coverage became effective and also teeth that are extracted after the person’s effective date, benefits are payable only for the pontics replacing those teeth which are extracted while the person was insured under this plan. The removal of only a permanent third molar will not qualify a fixed bridge for benefit under this provision.
        • The initial placement of an implant unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. The removal of only a permanent third molar will not qualify an implant for benefit under this provision.
        • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant.
        • Crowns, inlays, cast restorations or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay or fracture.
        • Core build-ups.
        • Replacement of a partial denture, full denture or fixed bridge or the addition of teeth to a partial denture unless:
        • Replacement occurs at least 84 consecutive months after the initial date of insertion of the current full or partial denture; or
        • The partial denture is less than 84 consecutive months old, and the replacement is needed due to a necessary extraction of an additional functioning natural tooth while the person is covered under this plan (alternate benefits of adding a tooth to an existing appliance may be applied); or
        • Replacement occurs at least 84 consecutive months after the initial date of insertion of an existing fixed bridge (if the prior bridge is less than 84 consecutive months old, and replacement is needed due to an additional necessary extraction of a functioning natural tooth while the person is covered under this plan. Benefits will be considered only for the pontic replacing the additionally extracted tooth).
        • The removal of only a permanent third molar will not qualify an initial or replacement partial denture, full denture or fixed bridge for benefits.
        • The replacement of crowns, cast restoration, inlay, onlay or other laboratory prepared restorations within 84 consecutive months of the date of insertion.
        • The replacement of a bridge, crown, cast restoration, inlay, onlay or other laboratory prepared restoration regardless of age unless necessitated by major decay or fracture of the underlying natural tooth.
        • Any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards.
        • Replacement of a partial denture or full denture which can be made serviceable or is replaceable.
        • Replacement of lost or stolen appliances.
        • Replacement of teeth beyond the normal complement of 32.
        • Prescription drugs.
        • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
        • Athletic mouth guards.
        • Myofunctional therapy.
        • Precision or semiprecision attachments.
        • Denture duplication.
        • Separate charges for acid etch.
        • Labial veneers (laminate).
        • Porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars.
        • Treatment of jaw fractures and orthognathic surgery.
        • Orthodontic treatment or for the treatment of cleft lip and cleft palate.
        • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
        • Charges for travel time, transportation costs or professional advice given on the phone.
        • Temporary, transitional or interim dental services.
        • Any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
        • Diagnostic casts, diagnostic models or study models.
        • Any charge for any treatment performed outside of the United States other than for emergency treatment (any benefits for emergency treatment which is performed outside of the United States will be limited to a maximum of $100 per consecutive 12-month period).
        • Oral hygiene and diet instruction, broken appointments, completion of claim forms; personal supplies (water pick, toothbrush, floss holder, etc.), duplication of x-rays and exams required by a third party.
        • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
        • Services that are deemed to be medical services.
        • Services for which benefits are not payable according to the “General Limitations” sub-section below.
        • For services not specifically listed as Covered Services in this policy.
        • For services or supplies that are not medically/dentally necessary.
        • For services received before the effective date of coverage.
        • For services received after coverage under this policy ends.
        • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
        • For professional services or supplies received or purchased directly or on your behalf by anyone, including a dentist, from any of the following:
        • Yourself or your employer;
        • A person who lives in the insured person’s home, or that person’s employer;
        • A person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
        • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit.
        • For or in connection with a sickness which is covered under any workers’ compensation or similar law.
        • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition.
        • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
        • To the extent that payment is unlawful where the person resides when the expenses are Incurred.
        • For charges which the person is not legally required to pay.
        • For charges which would not have been made if the person had no insurance.
        • To the extent that billed charges exceed the rate of reimbursement as described in the schedule.
        • For charges for unnecessary care, treatment or surgery.
        • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
        • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
        • Procedures that are a covered expense under any other dental plan which provides dental benefits.
        • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.
        • Procedures and services which are not included in the list of “Covered Dental Expenses.”
        • Procedures which are not necessary and which do not have uniform professional endorsement.
        • Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to pay.
        • Any procedure, service or supply provided primarily for cosmetic purposes. Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.
        • The initial placement of an implant unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan. The removal of only a permanent third molar will not qualify an implant for benefit under this provision. Except in cases where it is medically/dentally necessary.
        • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant. Except in cases where it is medically/dentally necessary.
        • Replacement of lost or stolen appliances.
        • Replacement of teeth beyond the normal complement of 32.
        • Prescription drugs.
        • Any procedure, service, supply or appliance used primarily for the purpose of splinting.
        • Orthodontic treatment, except for the treatment of cleft lip and cleft palate.
        • Charges for sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.
        • Charges for travel time, transportation costs or professional advice given on the phone.
        • Temporary, transitional or interim dental services.
        • Any procedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least 3 years, as determined by Cigna.
        • Any charge for any treatment performed outside of the United States other than for emergency treatment.
        • Oral hygiene and diet instruction, broken appointments, completion of claim forms, personal supplies (water pick, toothbrush, floss holder, etc.), duplication of x-rays and exams required by a third party.
        • Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility.
        • Services that are deemed to be medical services.
        • Services for which benefits are not payable according to the “General Limitations” subsection below.
        • For services or supplies that are not medically/dentally necessary.
        • For services received before the effective date of coverage.
        • For services received after coverage under this policy ends.
        • For services for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance coverage.
        • For professional services or supplies received or purchased directly or on your behalf by anyone, including a dentist, from any of the following:
          • yourself or your employer;
          • a person who lives in the insured person’s home, or that person’s employer;
          • a person who is related to the insured person by blood, marriage or adoption, or that person’s employer.
        • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit.
        • For or in connection with a sickness which is covered under any workers’ compensation or similar law.
        • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition.
        • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
        • To the extent that payment is unlawful where the person resides when the expenses are incurred.
        • For charges which the person is not legally required to pay.
        • For charges which would not have been made if the person had no insurance.
        • To the extent that billed charges exceed the rate of reimbursement as described in the Schedule.
        • For charges for unnecessary care, treatment or surgery;
        • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
        • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society.
        • Procedures that are a covered expense under any other dental plan which provides dental benefits.
        • To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you or any one of your dependents.
      • Colorado

        Missing Teeth Limitation – Age 19 and older

        There is no payment for replacement of teeth that are missing when a person first becomes insured.

        Excluded Services: Age 19 and older

        Covered Expenses do not include expenses incurred for:

        General Limitations: Age 19 and older

        No payment will be made for expenses incurred for you or any one of your dependents:

        Excluded Services: Under Age 19

        Covered Expenses do not include expenses incurred for:

        General Limitations: Under age 19

        No payment will be made for expenses incurred for you or any one of your dependents:

    • General Limitations: Under Age 19

      No payment will be made for expenses incurred for you or any one of your dependents: