Benefit Summary for AAA Members

An Altus Dental Plan for AAA Members

Annual Maximum: $1,750 per person, per calendar year
Annual deductible: $50 individual / $150 family for out-of-network services

Services are covered up to our Maximum Allowable charge.

To be covered, services must be dentally necessary and in accordance with Altus Dental's treatment guidelines. All services must be performed in a dental office.

Preventive/Diagnostic Services
In Network: Plan pays 100%
Out-of-Network: Plan pays 80%*

Two oral exam per calendar year
Cleanings once every six months
Fluoride treatment for children under age 19; once per calendar year
One set of bitewing x-rays per calendar year
One complete x-ray series or panoramic film every 60 months
Single x-rays as required
Sealants for children under age 14, once per unrestored permanent molar every 24 months
Periodontal maintenance following active therapy - two per year

Basic/Minor Restorative Services
In Network: Plan pays 80%; 6-month waiting period applies
Out-of-Network: Plan pays 64%*; 6-month waiting period applies

Palliative treatment (minor procedures necessary to relieve acute pain), twice per calendar year
Amalgam (silver) fillings. Composite (white) fillings on front teeth only. For composite fillings on back teeth, the plan pays up to what would have been paid for an amalgam filling. Patient is responsible for the balance up to the dentist’s charge.
Space maintainers for lost deciduous (baby) teeth, replacement limited to once every 60 months
Extractions and other routine oral surgeries not covered by a patient’s medical plan
General anesthesia or intravenous (IV) sedation for certain complex surgical procedures
Repairs to existing partial or complete dentures once per calendar year
Recementing crowns or bridges
Rebasing or relining of partial or complete dentures; once every 60 months

In Network: Plan pays 50%
Out-of-Network: Plan pays 40%*

Root canal therapy

Major Restorative Services
In Network: Plan pays 50%; 12-month waiting period applies
Out-of-Network: Plan pays 40%*; 12-month waiting period applies

Crowns over natural teeth, build-ups, posts and cores - replacement limited to once every 60 months
Bridges, build-ups, posts and cores, crowns over implants - replacement limited to once every 60 months
Partial and complete dentures - replacement limited to once every 60 months
Root planing and scaling once per quadrant every 24 months
Osseous (bone) surgery once per quadrant every 24 months
Gingivectomies once per site every 24 months
Soft tissue grafts once per site every 60 months
Crown lengthening once per site every 60 months
Guided tissue regeneration and bone replacement graft once per site every 24 months
Surgical placement of endosteal implant and abutment; replacement limited to once every 60 months

Note: A pretreatment estimate is recommended for Major Restorative Services.

Dependent Coverage

Dependent children are covered up until the end of the year that they turn age 19.

*This percentage is based on the reasonable and customary dentist’s charge in a particular geographic area.

To review exclusions & limitations click here.