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Annual Maximum $2,000 Elective Orthodontic Lifetime Maximum $1,000 Maximum Lifetime Cap Unlimited Carry Over Max: $400 In Network Bonus: $200 Carry Over Limit: $1500 In-Network Deductible Individual $50 Family $150 Out-of-Network Deductible Individual $50 Family $150 Dependent Coverage Dependent children are covered under these benefits up until the end of the month that they turn 26. CITY OF SALEM Group Number: 2932-0001 Altus Dental Preferred Point of Service Option - Includes Connection Dental and DenteMax Networks In Network: Plan pays 100%; Member Coinsurance 0% Out of Network: Plan pays 100%; Member Coinsurance 0% In Network: Plan pays 100%; Member Coinsurance 0% - (Deductible Applies) Out of Network: Plan pays 80%; Member Coinsurance 20% - (Deductible Applies) In Network: Plan pays 60%; Member Coinsurance 40% - (Deductible Applies) Out of Network: Plan pays 50%; Member Coinsurance 50% - (Deductible Applies) In Network: Plan pays 50%; Member Coinsurance 50% Out of Network: Plan pays 50%; Member Coinsurance 50% Benefits Summary Pre-treatment Estimate Recommended P Prior Authorization Required A See back page for additional information Oral exam twice per calendar year • Cleaning twice per calendar year • Fluoride treatment for children under age 19 twice per calendar year • Bitewing x-rays one set per calendar year • Complete x-ray series or panoramic film once every 36 months. • Single x-rays as required • Sealants for children under age 16, once every 36 months on unrestored permanent molars • Space maintainers unilateral space maintainers once per lifetime for lost deciduous (baby) teeth. Bilateral space maintainers once every 60 months for lost deciduous (baby) teeth • Palliative treatment (minor procedures necessary to relieve acute pain) twice per calendar year • Amalgam (silver) fillings and composite (white) fillings • Extractions and other routine oral surgery when not covered by a patient's medical plan • General anesthesia or intravenous sedation for certain complex surgical procedures • Repairs to existing partial or complete dentures once per calendar year • Recementing crowns or bridges once every 60 months • Rebasing or relining of partial or complete dentures once every 60 months • Root canal therapy on permanent teeth one procedure per tooth per lifetime. • Crowns over natural teeth, build ups, posts and cores replacement limited to once every 60 months • P Bridges and crowns over implants replacement limited to once every 60 months • P Partial and complete dentures replacement limited to once every 60 months • P Root planing and scaling once per quadrant every 24 months • P Osseous (bone) surgery once per quadrant every 24 months (bone grafts are not covered) • P Gingivectomies once per site every 24 months • P Soft tissue grafts once per site every 60 months • P Crown lengthening once per site every 60 months • P Surgical placement of endosteal implant and abutment replacement limited to once every 60 months • P Periodontal maintenance following active therapy two per year • Elective braces and related services for dependent children under the age of 19. Subject to a lifetime maximum. No pre-approval required. • P Altus Dental • P.O. Box 1557 • Providence, RI 02901-1557 • 1.[PHONE REDACTED] • altusdental.com ---PAGE BREAK--- This is a summary of benefits. The information shown here is not a guarantee of payment. Refer to the Certificate of Coverage for the full plan terms. The Certificate includes any limitations or exclusions not seen here. For a complete listing of frequencies and limitations go to www.altusdental.com/el. To be covered, services must be dentally necessary and appropriate as per our review guidelines. Note: This plan does not include a missing tooth clause. In addition, if covered, crowns, bridges, partials and complete dentures are paid when the permanent structure is inserted (seated) by the dentist. Member coverage must be active on the date that the permanent structure is inserted and payment is based on benefits available on that day — for example, if the member’s annual maximum has been paid prior to the insertion of the permanent structure, the service will not be paid. * 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. Out-of-Network Coverage You have the freedom to choose any dentist, but it is important to know that your out-of-pocket costs may be higher when you visit a dentist who does not participate in our network. Non-participating dentists have not agreed to accept the Altus Dental allowance as payment in full, so services from an out-of-network dentist may cost you more. You may also have to pay the dentist at the time of service and file a claim yourself. To be eligible, all claims must be filed within one year of the date of service. To find a participating dentist near you, use our Find A Dentist tool at www.altusdental.com. How to Find a Dentist Choose from Altus Dental’s extensive network of dentists, you’re sure to find one that’s right for you. Visit www.altusdental.com to use our online Find A Dentist tool. You can see if your current dentist participates with us or look for a new dentist by searching by name, location or specialty. Enter your address or other criteria important to you (extended hours, languages spoken, etc.), and our tool will return a list of dentists that meet your needs – as well as maps and driving directions. Beyond Benefits When you visit us at www.altusdental.com, you can access a wealth of important dental health information and manage your plan by: Notice of Nondiscrimination and Accessibility Policy Altus Dental does not discriminate on the basis of race, color, national origin, age, disability, or sex. Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-223- 0588. Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-877-223- 0588. Checking your benefits and claims • Reviewing your deductibles and maximums • Using our Find A dentist tool to find a dentist in your area • Altus Dental • P.O. Box 1557 • Providence, RI 02901-1557 • 1.[PHONE REDACTED] • altusdental.com