Exclusions

Listed below are the services or expenses which are NOT covered under the Dental Plan and which are the Covered Person's responsibility at the dentist's Usual Fees.  There is no coverage for:

1. Services not listed on the Patient Charge Schedule.
2. Services provided by a non-Network Dentist without CIGNA Dental Health's prior approval (except emergencies, as described in Section 8 of the Group Contract).
3. Services related to an injury or illness covered under workers' compensation, occupational disease or similar laws.
4. Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program other than Medicaid.
5. Services relating to injuries, which are intentionally self-inflicted.
6. Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war.
7. Cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance).
8. General anesthesia, sedation and nitrous oxide.
9. Prescription drugs.
10. Procedures, appliances or restorations if the main purpose is to:  (1) change vertical dimension (degree of separation of the jaw when teeth are in contact) or (2) diagnose or treat abnormal conditions of the temporomandibular joint, except as specifically listed on the Patient Charge Schedule.
11. The completion of crown and bridge, dentures or root canal treatment already in progress on the date Covered Person becomes covered by the Dental Plan.
12. Replacement of fixed and/or removable prosthodontic appliances that have been lost; stolen; or damaged due to patient abuse, misuse or neglect.
13. Services associated with the placement or prosthodontic restoration of a dental implant.
14. Services considered to be unnecessary or experimental in nature.
15. Procedures or appliances for minor tooth guidance or to control harmful habits.
16. Hospitalization, including any associated incremental charges for dental services performed in a hospital.
17. Services to the extent Covered Person is compensated for them under any group medical plan, no-fault auto insurance policy, or insured motorist policy.