What Is Not Covered

A gold restoration or crown, unless:
It is treatment for decay or traumatic injury, and teeth can't be restored with a filling material; or
The tooth is an abutment to a covered partial denture or fixed bridge.
An appliance — or modification of one — if an impression for it was made before the person became covered.
Any of the following services incurred more than 31 days after the date the person's coverage ends:
A crown, bridge, or gold restoration for which the tooth was prepared while the person was covered;
An appliance — or alteration of one — for which an impression was made while the person was covered; or
Root canal therapy for which the pulp chamber was opened while the person was covered.
Charges in connection with:
A service to the extent that it is more than the usual charge made by the provider for the service when there is no insurance;
Appliances or restorations needed to alter vertical dimensions or restore occlusion, or for the purposes of splinting or correcting attrition, abrasion, or erosion; or
Replacement of lost, missing, or stolen appliances or appliances that have been damaged due to abuse, misuse, or neglect.
Treatment for problems of the jaw joint, including:
Craniomandibular disorder;
Temporomandibular joint syndrome (TMJ), other than what is noted in "SPD Box Regular EndMarkerWhat Is Covered
What Is Covered"; and
Other conditions of the joint linking the jaw bone and skull, and of the complex of muscles, nerves, and other tissues related to that joint.
Expenses submitted later than December 31 of the year following the year in which services were provided.
Installation of prosthetic devices (including bridges and crowns) while not covered or which were installed more than 31 days after coverage ends.
Loss — or portion of a loss — for which mandatory automobile no-fault benefits are recovered or recoverable.
Partial or full removable denture, removable bridge, or fixed bridgework if it includes replacement of one or more natural teeth (including congenitally missing teeth) missing before the person became covered under this Plan. The exclusion does not apply if the denture, bridge, or bridgework also includes replacement of a natural tooth that:
Is removed while the person is covered; and
Was not an abutment to a partial denture, removable bridge, or fixed bridge installed during the prior five years.
Procedures related to occupational illness or injury.
Replacement or modification of a partial or full removable denture, a removable bridge or fixed bridgework, or for a replacement or modification of a crown or gold restoration or inlay/onlay within five years after that denture, bridgework, crown, inlay/onlay, or gold restoration was installed.
Expenses or charges with respect to services rendered by hospitals, clinics, laboratories (except dental X-rays are covered), or other institutions.
Services and supplies included as covered medical expenses under:
Any other employer-sponsored plan that covers you, including Medicare;
Any other governmental health program, except the U.S. Medicaid program; or
The Expatriate Medical Plan.
Services and supplies rendered in a veteran's facility or government hospital, or services furnished in whole or in part under the laws of the United States or any of its state or political subdivisions.
Services furnished for cosmetic purposes. Facings on crowns or pontics — which are behind the second bicuspid — will always be considered cosmetic. This limitation does not apply if the service is needed as a result of accidental injuries sustained while a person is covered.
Services not reasonably necessary as determined by Cigna Global Health Benefits.
Services to the extent that a benefit for those services is provided under any other program paid in full or in part, directly or indirectly, by JPMorgan Chase. This includes insured and uninsured programs. If a program provides benefits in the form of services, the cash value of each service rendered is considered the benefit provided for that charge.
Services to the extent that the charges are above the prevailing charge in the area for dental care of a comparable nature. A charge is above the prevailing charge to the extent that it's above the range of charges generally made in the area for dental care of a comparable nature. The area and that range are determined by Cigna Global Health Benefits.
Treatment by a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, a labor union, a trustee, or a similar person or group.
Expenses in connection with services, procedures, drugs, or other supplies that are determined by Cigna Global Health Benefits to be experimental, or still under clinical investigation by health professionals.
Charges for oral hygiene programs, completion of claim forms by the provider on your behalf, and broken appointments.
Services provided by a relative, or for which a charge would not normally be made.
Treatment by anyone except a licensed dentist (except for cleaning or scaling of teeth and topical application of fluoride performed by a licensed dental hygienist, if rendered under the supervision and guidance of a licensed dentist).