Eligibility

• Full or part time Federal Employees are eligible for Wright USA’s CIGNA Dental Care® (DHMO) Premier Plan.

Limitations

• There may be a fixed number of times (i.e., a frequency limit) that your plan will cover a specific dental procedure (e.g., cleanings) during a plan year. If you receive a service more often than the plan allows, your costs may be higher.
  
  
• Most specialty care is available with an approved referral from your CIGNA DHMO Primary Care Dentist. No referral is required to visit a CIGNA DHMO network orthodontist or for children under age 7 to visit a CIGNA DHMO network pediatric dentist.
  
  
• Surgical removal of an impacted wisdom tooth is not covered if the tooth is not diseased or if the removal is only for orthodontic reasons.

Exclusions (i.e. Services Not Covered Under the Plan)

• Services not listed on the Premier Plan Patient Charge Schedule; services provided by a non-network dentist without CIGNA Dental Care’s prior approval.
  
  
• Services related to an injury or illness covered under workers' comp, occupational disease or similar laws.
  
  
• Services provided or paid by/through a federal/state governmental agency/authority, political subdivision, or a public program other than Medicaid.
  
  
• Services relating to injuries which are intentionally self-inflicted.
  
  
• 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.
  
  
• Cosmetic dentistry/cosmetic dental surgery (performed solely to improve appearance.)
  
  
• General anesthesia, sedation and nitrous oxide (MD-covered when medically necessary and authorized by the covered person's physician.)
  
  
• Prescription drugs; 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 Premier Plan Patient Charge Schedule.
  
  
• Completion of crown and bridge, dentures or root canal treatment already in progress on the date covered person becomes covered by this plan (TX-this exclusion does not apply to Texas residents.)
  
  
• Replacement of fixed and/or removable prosthodontic appliances that have been lost, stolen, or damaged due to patient abuse, misuse or neglect.
  
  
• Services associated with the placement or prosthodontic restoration of a dental implant; services considered to be unnecessary or experimental in nature (PA -delete 'unnecessary'.)
  
  
• Procedures or appliances for minor tooth guidance or to control harmful habits; hospitalization, including any associated incremental charges for dental services performed in a hospital.
  
  
• Services to the extent covered person is compensated for them under any group medical plan, no-fault auto insurance policy, or insured motorist policy (AZ - This exclusion does not apply to Arizona residents. KY and NC services compensated under no-fault auto or insured motorist policies not excluded. MD - services compensated under group medical plans not excluded.) Except as set forth above, pre-existing conditions are not excluded (TX-delete "Except as set forth above".)

Note: The information above is provided as a courtesy. Always review your plan documents carefully before receiving dental services. If the treatment you want is not covered by your plan, your costs may be higher.

Additional Information

The Civil Service Employee Benefit Association (CSEBA) and Special Agents Trust for Insurance (SATI) are group policyholders of this insurance program. Both organizations make available voluntary risk management products and services, other voluntary benefits, and educational services to current and former federal employees. Wright USA acts as the program administrator for both CSEBA and SATI.