Topical application of fluoride (excluding prophylaxis) – Limited to persons less than 19 years old. Only 2 per person per calendar year. Topical application of sealant, per tooth, on a posterior tooth for a person covered to age 16 years old - Only 1 treatment per tooth in any 36 consecutive months. Space Maintainers, fixed unilateral – Limited to persons less than 19 years old. Limited to nonorthodontic treatment.
I.V. Sedation – Paid as a separate benefit only when medically or dentally necessary, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under this plan.
HC-DEN163
04-10
V1
Class III Services - Major Restorations, Dentures and Bridgework Crowns Note: Crown restorations are Dental Services only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration. Porcelain Fused to High Noble Metal Full Cast, High Noble Metal Three-Fourths Cast, Metallic Removable Appliances Complete (Full) Dentures, Upper or Lower Partial Dentures Lower, Cast Metal Base with Resin Saddles (including any conventional clasps, rests and teeth) Upper, Cast Metal Base with Resin Saddles (including any conventional clasps rests and teeth) Fixed Appliances Bridge Pontics - Cast High Noble Metal Bridge Pontics - Porcelain Fused to High Noble Metal Bridge Pontics - Resin with High Noble Metal Retainer Crowns - Resin with High Noble Metal Retainer Crowns - Porcelain Fused to High Noble Metal Retainer Crowns - Full Cast High Noble Metal Prosthesis Over 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 60 consecutive months old, is not serviceable and cannot be repaired.
HC-DEN3
04-10
V5 M
Class II Services – Basic Restorations, Periodontics, Endodontics, Oral Surgery, Prosthodontic Maintenance Amalgam Filling Composite/Resin Filling Root Canal Therapy – Any x-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and not a separate Dental Service. Osseous Surgery – Flap entry and closure is part of the allowance for osseous surgery and not a separate Dental Service. Periodontal Scaling and Root Planing – Entire Mouth Adjustments – Complete Denture Any adjustment of or repair to a denture within 6 months of its installation is not a separate Dental Service. Recement Bridge Routine Extractions Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth Removal of Impacted Tooth, Soft Tissue Removal of Impacted Tooth, Partially Bony Removal of Impacted Tooth, Completely Bony Local anesthetic, analgesic and routine postoperative care for extractions and other oral surgery procedures are not separately reimbursed but are considered as part of the submitted fee for the global surgical procedure. General Anesthesia – Paid as a separate benefit only when medically or dentally necessary, as determined by Cigna, and when administered in conjunction with complex oral surgical procedures which are covered under this plan.
HC-DEN172
07-14
V1
12
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