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| DENTAL |
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| Coverage
Rules |
Coverage under the Dental Plans is subject to the following
rules:
Replacement Rule
Basic or Buy-Up Plan Details: There is no coverage for 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 or removal of an
existing implant.
A prosthetic device, supported by an implant or implant abutment, is
a covered expense. Replacement of any type of prosthesis with a prosthesis
supported by an implant or implant abutment is only payable if the existing
prosthesis is at least 84 consecutive months old, is not serviceable
and cannot be repaired.
DMO Plan Details: Implants and services directly related to
implants are not covered under the DMO plan.
Tooth Missing But Not Replaced Rule
Basic or Buy-Up Plan Details: Coverage is provided for initial
installation of dentures or fixed bridgework for replacing a newly lost
tooth if the tooth was removed while the individual was insured under
the Dental Plan. If there are other missing teeth within the same arch,
then the plan will allow coverage for the replacement of all missing
teeth with a partial or full denture. If the teeth are being replaced
with a bridge, then the pontic covering the tooth that was extracted
prior to the effective date of coverage will be paid based on the plan’s
missing tooth limitation. The pontic covering the tooth extracted after
the effective date will be paid without regard to the missing tooth
limitation.
DMO Plan Details: These services are not covered under the DMO
plan.
Alternate Treatment Rule
If more than one covered service will treat a dental condition, payment
is limited to the least costly service provided it is a professionally
accepted, necessary and appropriate treatment. If covered person requests
or accepts a more costly covered service, he or she is responsible for
expenses that exceed the amount covered for the least costly service.
Therefore, Cigna recommends Predetermination of Benefits before major
treatment begins.
Coordination of Benefits Rule
If you or a dependent is covered under this plan and another plan, the
benefits payable under the second plan are used in determining benefits
under the Cigna plan. When this reduces the total of benefits payable
during a calendar year, each benefit will be reduced proportionately.
Such reduced amount will be charged against any applicable benefit limit
of this plan. Generally, the plan covering the person as an associate
is the primary plan and pays benefits first. Dependent children are
primarily covered by the plan of the parent whose birthday occurs first
in the year.
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