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 ALTUS DENTAL UNDER AGE 19 PLAN BENEFITS SUMMARY (HMO ADVANTAGE SAVER RI) In-­‐Network Coverage Only This is a summary of benefits. Refer to the Evidence of Coverage for a full description of the plan provisions. To be covered, services must be dentally
necessary and appropriate as per our review guidelines.
MAXIMUMS
Annual Maximum None Medically Necessary Orthodontic Lifetime
None Maximum
Maximum Lifetime Cap
Unlimited Please refer to your Tufts Health Plan Summary of Benefits and Coverage for
information about you out-of-pocket maximum and deductible
Apply to certain services DEDUCTIBLES
Indicates Pre-treatment
Estimate recommended. Prior authorization as required.
Indicates Deductible applies to
this procedure.
Procedure
In Network
Frequency/Limitations†
Diagnostic
Oral exam
Bitewing x-rays
Complete x-ray series and panoramic film
100%
100% 100%
100%
100%
100%
100%
100%
Single x-rays
Preventive
Cleaning
Fluoride treatment
Sealants
Space maintainers
100%
100%
100%
100%
100%
100%
100%
100%
Minor Restorative
Twice per calendar year
Two sets per calendar year
Once every 60 months
As required
Twice per calendar year
Twice per calendar year
Once every 36 months on unrestored permanent molars
Once every 60 months for lost deciduous (baby) teeth
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.
Once per calendar year
Once every 60 months
Once every 36 months
Amalgam (silver) fillings
75%
Repairs to existing partial or complete dentures
Recementing crowns or bridges
Rebasing or relining of partial or complete dentures
75%
75%
75%
75%
50%
Root planning and scaling
75%
75%
50%
50%
Osseous (bone) surgery
50%
Gingivectomies
50%
50%
50%
50%
50%
Once per site every 60 months
50%
50%
Replacement limited to once every 60 months
50%
50%
Once per tooth site per lifetime
75%
Major Restorative
Crowns, build ups, posts and cores
Covered over natural teeth when teeth cannot be restored with
regular fillings. Replacement limited to once every 60 months.
Endodontics
Root canal therapy
Periodontics
Periodontal maintenance following active therapy
Soft tissue grafts
Crown lengthening
Prosthodontics
Bridges and crowns over implants
Partial and complete dentures
Surgical placement of endosteal implant and abutment
Extractions and Oral Surgery
Extractions and other routine oral surgery when not covered
by a patient’s medical plan
Orthodontics
Medically necessary braces and related services
Twice per calendar year
Once per quadrant every 24 months
Once per quadrant every 36 months (bone grafts are not
covered)
Once per site every 24 months
Once per site every 60 months
Replacement limited to once every 60 months
50%
Requires prior authorization. No payment will be made if not
obtained. Covered only when medically. Patient must have
severe and handicapping malocclusion as defined by our
guidelines. Once per lifetime.
50%
15_Altus_Tufts_HMOSaver-­‐6450-­‐EHB Altus Dental Insurance Company, Inc. | 10 Charles Street | Providence, RI 02904 | www.altusdental.com A-­‐HMOAdvSaverRI-­‐1115 1/2016 Procedure
In Network
Frequency/Limitations†
Other Services
Palliative treatment (minor procedures necessary to
relieve acute pain)
75%
General anesthesia or intravenous (I.V.) sedation for certain
complex surgical procedures
75%
Twice per calendar year
Dependent children are covered under these benefits up until the end of the month that they turn age 19.
*
Out-of-network care: This is the amount Altus Dental pays. For services received out-of-network, your costs will be greater. Non-participating dentists are paid
at a reduced level. Please refer to your Certificate of Coverage for further details.
† Time limits on services (e.g. 6, 12, 24, 36, or 60 months) are figured to the exact day. Services are then covered the following day. For example, when a service
is covered once every 12 months, if the service was done on July 1, it will not be covered again until the following year on July 2 or after.
15_Altus_Tufts_HMOSaver-­‐6450-­‐EHB Altus Dental Insurance Company, Inc. | 10 Charles Street | Providence, RI 02904 | www.altusdental.com A-­‐HMOAdvSaverRI-­‐1115 1/2016