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Benefit Summary
Rates and Information
How Your Plan Works
FAQ

Benefit Summary for:

AAA Southern New England Members

Here is a summary of the plan 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.

Annual Maximum: $1,000 per person, per policy year

Annual Deductible: None

The Maximum Lifetime Cap is: Unlimited

Indicates Pre-Treatment is Estimate recommended.
	Procedure	Covered At	Waiting Period	Frequency/Limitations
Diagnostic
	Oral exam	100%	None	Once per policy year
	Bitewing x-rays	100%	None	One set per policy year
	Complete x-ray series or panoramic film	100%	None	Once every 60 months
	Single x-rays	100%	None	As required
Preventive
	Cleaning	100%	None	Once every 6 months
	Fluoride treatment	100%	None	For children under age 19 once per policy year
	Sealants	80%	None	For children under age 14, once every 24 months on unrestored permanent molars
	Space maintainers	80%	None	Once every 60 months for lost deciduous (baby) teeth
Restorative
	Amalgam (silver) fillings	80%	None	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.
	Recementing crowns or bridges	80%	None
	Crowns over natural teeth, build ups, posts and cores	50%	12 months	Replacement limited to once every 60 months
Endodontics
	Root canal therapy	80%	None
Periodontics
	Periodontal maintenance following active therapy	80%	None	Two per policy year
	Root planing and scaling	80%	None	Once per quadrant every 24 months
	Osseous (bone) surgery	50%	12 months	Once per quadrant every 24 months
	Gingivectomies	50%	12 months	Once per site every 24 months
	Soft tissue grafts	50%	12 months	Once per site every 60 months
	Crown lengthening	50%	12 months	Once per site every 60 months
Prosthodontics
	Repairs to existing partial or complete dentures	80%	None	Once per policy year
	Rebasing or relining of partial or complete dentures	80%	None	Once every 60 months
Extractions and Oral Surgery
	Extractions and other routine oral surgery when not covered by a patient's medical plan	80%	None
Other Services
	Palliative treatment (minor procedures necessary to relieve acute pain)	80%	None	Twice per policy year
	General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures	80%	None

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

To review exclusions & limitations click here.