State Policy Disclosures 2014

State Policy Disclosures for Cigna Medical, Dental and Pediatric Dental 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 (medical plans only; not applicable in CA).

Rates for new medical policies with an effective date on or after 01/01/2014 are guaranteed through 12/31/2014. Thereafter, medical rates are subject to change upon 30 days’ notice in CT and TN, 31 days’ notice in SC, 45 days’ notice in FL and NC, and 60 days’ notice in AZ, CA, CO, GA, and TX. 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 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. 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.

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

Major medical insurance policies (CACHIND2013/042013, 49375CO20001-11, CTINDCH052013, INDFLCH042013, INDGACH052013, NCINDCH052013, INDSCCH052013, INDTNCH042013, INDTXCH042013), dental preferred provider insurance policies (AL, CO, CT, DE, IL, MA, MI, and PA: HC-NOT11 et al., AR: HC-NOT36 et al., CA: INDDENTPOLCA0713 et al., FL: HC-NOT15 et al., GA: HC-NOT25 et al., KS: HC-NOT49 et al., LA: INDENTPOLLA0713, MS: HC-NOT48 et al., MO: INDENTPOLMO0713, NC: HC-NOT18 et al., NV: HC-NOT39 et al., OH: INDENPOLOH et al., OK: HC-NOT26 et al., OR: INDENTPOLOR0713., SC: HC-NOT19 et al., TN: HC-NOT20 et al., TX: HC-NOT21 et al., VA: HC-NOT17 et al.), and pediatric dental insurance policies (FL, GA, SC, TN, TX: INDDENPEDI, CO: 49375CO0030001) 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 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
Medical Plan Exclusions & Limitations

Medical insurance policies and Service Agreements have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. For policies insured by CHLIC (OAP and LocalPlus 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 cfonsiders 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 noninjectable 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

This medical plan uses the Cigna LocalPlus Network of participating health care providers which offers referral-free access to a smaller network of participating health care providers (physicians, hospitals, etc.) than the larger Cigna Open Access Plus (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 provider 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 provider except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus Network providers in the LocalPlus Network for this plan
  • LocalPlus Network providers in other LocalPlus Network areas
  • Participating OAP Network providers in an area that is not part of the LocalPlus Network
  • Any visit considered an emergency as defined by the plan

Out-of-network

  • Providers in your LocalPlus Network area that are not part of the LocalPlus Network
  • Providers in other LocalPlus Network areas that are not part of the LocalPlus Network
  • Providers that are not contracted (or participating) with Cigna.

For more detailed information or to find providers in the LocalPlus network, including participating providers when you are away from home, please review the LocalPlus Network flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna24.

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

Standalone 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 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.
Pediatric Dental Plan Exclusions and Limitations

Pediatric Dental insurance policies have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Covered Pediatric 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.
  • 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 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 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 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.
  • 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

LocalPlus

This medical plan uses the Cigna LocalPlus Network of participating health care providers which offers referral-free access to a smaller network of participating health care providers (physicians, hospitals, etc.) than the larger Cigna Open Access Plus (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 provider 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 provider except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus Network providers in the LocalPlus Network for this plan
  • LocalPlus Network providers in other LocalPlus Network areas
  • Participating OAP Network providers in an area that is not part of the LocalPlus Network
  • Any visit considered an emergency as defined by the plan

Out-of-network

  • Providers in your LocalPlus Network area that are not part of the LocalPlus Network
  • Providers in other LocalPlus Network areas that are not part of the LocalPlus Network
  • Providers that are not contracted (or participating) with Cigna.

For more detailed information or to find providers in the LocalPlus network, including participating providers when you are away from home, please review the LocalPlus Network flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna24.

Colorado

LocalPlus

This medical plan uses the Cigna LocalPlus Network of participating health care providers which offers referral-free access to a smaller network of participating health care providers (physicians, hospitals, etc.) than the larger Cigna Open Access Plus (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 provider 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 provider except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus Network providers in the LocalPlus Network for this plan
  • LocalPlus Network providers in other LocalPlus Network areas
  • Participating OAP Network providers in an area that is not part of the LocalPlus Network
  • Any visit considered an emergency as defined by the plan

Out-of-network

  • Providers in your LocalPlus Network area that are not part of the LocalPlus Network
  • Providers in other LocalPlus Network areas that are not part of the LocalPlus Network
  • Providers that are not contracted (or participating) with Cigna.

For more detailed information or to find providers in the LocalPlus network, including participating providers when you are away from home, please review the LocalPlus Network flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna24.

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.

Florida

LocalPlus

This medical plan uses the Cigna LocalPlus Network of participating health care providers which offers referral-free access to a smaller network of participating health care providers (physicians, hospitals, etc.) than the larger Cigna Open Access Plus (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 provider 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 provider except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus Network providers in the LocalPlus Network for this plan
  • LocalPlus Network providers in other LocalPlus Network areas
  • Participating OAP Network providers in an area that is not part of the LocalPlus Network
  • Any visit considered an emergency as defined by the plan

Out-of-network

  • Providers in your LocalPlus Network area that are not part of the LocalPlus Network
  • Providers in other LocalPlus Network areas that are not part of the LocalPlus Network
  • Providers that are not contracted (or participating) with Cigna.

For more detailed information or to find providers in the LocalPlus network, including participating providers when you are away from home, please review the LocalPlus Network flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna24.

Tennessee

LocalPlus

This medical plan uses the Cigna LocalPlus Network of participating health care providers which offers referral-free access to a smaller network of participating health care providers (physicians, hospitals, etc.) than the larger Cigna Open Access Plus (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 provider 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 provider except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus Network providers in the LocalPlus Network for this plan
  • LocalPlus Network providers in other LocalPlus Network areas
  • Participating OAP Network providers in an area that is not part of the LocalPlus Network
  • Any visit considered an emergency as defined by the plan

Out-of-network

  • Providers in your LocalPlus Network area that are not part of the LocalPlus Network
  • Providers in other LocalPlus Network areas that are not part of the LocalPlus Network
  • Providers that are not contracted (or participating) with Cigna.

For more detailed information or to find providers in the LocalPlus network, including participating providers when you are away from home, please review the LocalPlus Network flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna24.

Texas

LocalPlus

This medical plan uses the Cigna LocalPlus Network of participating health care providers which offers referral-free access to a smaller network of participating health care providers (physicians, hospitals, etc.) than the larger Cigna Open Access Plus (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 provider 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 provider except for emergency services, will also increase your OON costs.

In-network

  • LocalPlus Network providers in the LocalPlus Network for this plan
  • LocalPlus Network providers in other LocalPlus Network areas
  • Participating OAP Network providers in an area that is not part of the LocalPlus Network
  • Any visit considered an emergency as defined by the plan

Out-of-network

  • Providers in your LocalPlus Network area that are not part of the LocalPlus Network
  • Providers in other LocalPlus Network areas that are not part of the LocalPlus Network
  • Providers that are not contracted (or participating) with Cigna.

For more detailed information or to find providers in the LocalPlus network, including participating providers when you are away from home, please review the LocalPlus Network flyer, visit www.Cigna.com/ifp-providers or call 1.800.Cigna24.

In Texas, LocalPlus plans are considered Preferred Provider plans with certain managed care features; Health Savings LocalPlus plans are considered Preferred Provider plans with certain managed care features and are compatible with Health Savings Accounts; and the Dental plan is known as Cigna Dental Choice.

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.