CIGNA Dental Plan

In This Section:

• Summary of Benefits
• Emergencies - Reimbursement
• Limitations on Coverage
• Extension of Benefits
• Exclusions

The following Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Important Highlights

• This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by CIGNA Dental as described in your plan documents
• This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Dentist (Endodontist, Periodontist, Orthodontist, Oral Surgeon or Pediatric Dentist (up to 7^th birthday unless medical reasons justify an exception).  You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by CIGNA Dental.
• Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient’s responsibility at the dentist’s usual fees.
• The administration of I.V. sedation, general anesthesia and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule.  The application of local anesthetic is covered as part of your dental treatment.
• This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.
• All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.
• The American Dental Association may periodically change CDT Codes or definitions.  Different codes may be used to describe these covered procedures.