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Benefit Summary for:

AAA Southern New England Members

Here is a summary of the plan selected for you and your covered dependents (if any). The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental’s treatment guidelines. All services must be performed in a dental office. These benefits are listed according to the level of coverage (i.e. 100%, 70%).

Annual maximum: $1,000 per person, per calendar year
Orthodontic lifetime maximum: $1,000 per dependent child
Annual deductible: $0 per person In-Network / $25 per person Out-of-Network
The maximum lifetime cap is: Unlimited

Note: Pre-treatment Estimates are recommended for underlined procedures.

Preventive/Diagnostic Services
Plan pays 100%; your coinsurance is 0%

• One oral exam per calendar year
  
• Cleaning 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

Basic/Minor Restorative Services
Plan pays 70%; your coinsurance is 30%

• Sealants for children under age 14 once per unrestored permanent molar every 24 months
  
• 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.
  
• Space maintainers for lost deciduous (baby) teeth, replacement limited to once every 60 months
  
• Extractions and other routine oral surgery when not covered by a patient’s medical plan
  
• General anesthesia or intravenous (IV) sedation for certain complex surgical procedures
  
• Root canal therapy
  
• 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
  
• Periodontal maintenance following active therapy - two per year

Major Restorative Services - There is a 12-month waiting period for Major Restorative services for each eligible member. Pre-treatment estimate is recommended.
Plan pays 50%; your coinsurance 50%; a 12 month waiting period applies

• Crowns over natural teeth, build-ups, post and cores – replacement limited to once every 60 months
  
• Bridges, build-ups, posts and cores – 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 (bone grafts are not covered)
  
• Gingivectomies once per site every 24 months
  
• Soft tissue grafts once per site every 60 months
  
• Crown lengthening once per site every 60 months

Orthodontics - There is a 12-month waiting period for orthodontic services for each eligible dependent child enrolled in a Delta Dental family plan.
Plan pays 50%; your coinsurance 50%

• Braces and related services for dependent children under the age of 19
  

Note: Orthodontic services are only available for children under the age of 19 who are enrolled in an Delta Dental of Rhode Island family plan through AAA Southern New England prior to beginning orthodontic treatment.

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

To review exclusions & limitations click here.