DENTAL PLAN BENEFITS


COVERAGE TYPE


Type A

cleanings, oral exams and x-rays

Type B

fillings and x-rays

Type C

bridges and dentures

Type D

orthodontia

DEDUCTIBLE

Individual

Family

ANNUAL MAXIMUM BENEFIT††

Per Person

ORTHODONTIA LIFETIME MAXIMUM

Per Person

STANDARD PPO

IN-NETWORK


100% of Negotiated Fee*

80% of Negotiated Fee*

50% of Negotiated Fee*

Not Included


$50

$150


$1,000


Not Included

STANDARD PPO

OUT-OF-NETWORK


100% of R&C Fee**

80% of R&C Fee**

50% of R&C Fee**

Not Included



$50

$150


$1,000


Not Included

COMPREHENSIVE PPO

IN-NETWORK


100% of Negotiated Fee*

80% of Negotiated Fee*

50% of Negotiated Fee*

50% of Negotiated Fee*


$50

$150


$1,500


$1,000

COMPREHENSIVE PPO

OUT-OF--NETWORK


100% of R&C Fee**

80% of R&C Fee**

50% of R&C Fee**

50% of R&C Fee**


$50

$150


$1,500


$1,000

WAITING PERIOD

STANDARD PPO

For Type B services – 6 months from effective date of your coverage.
For Type C services – 12 months from effective date of your coverage.

COMPREHENSIVE PPO

For Type C services – 12 months from effective date of your coverage.
For Orthodontia services for children age 19 and under – 12 months from effective date of your
coverage.

Plan benefits and rates are for plan January 1, 2017 through December 31, 2017, and subject to change thereafter.
*Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.
**R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.
† Applies only to Type B & C Services.
† Applies only to Type A, B & C Services.

STANDARD & COMPREHENSIVE PPO

LIST OF PRIMARY COVERED SERVICES & LIMITATIONS

 TYPE A – PREVENTIVE


Prophylaxis (cleanings)

Oral Examinations

Topical Fluoride Applications

X-rays

HOW MANY/ HOW OFTEN

One every six months

One every six months

One fluoride treatment 12 months for dependent children up to 14th birthday

Bitewing X-rays: one set per 12 months

TYPE B – BASIC RESTORATIVE


X-rays

Fillings

Oral Surgery

Periodontics

Emergency Palliative Treatment

Space Maintainers

Sealants

HOW MANY/ HOW OFTEN

Full mouth or panoramic once every 60 months

- Amalgam and resin initial placement

- Replacement once every 24 months per tooth

Simple Extractions

- Periodontal scaling and root planing once per quadrant, every 24 months

- Total number of periodontal maintenance treatments and prophylaxis cannot exceed two treatments in a calendar year


Space Maintainers for dependent children up to 14th birthday once per lifetime per tooth area

One application of sealant material every 5 years for each non-restored, non-decayed 1st and 2nd molar of a dependent child up to 16th birthday

TYPE C – MAJOR RESTORATIVE


Crown, Denture, and Bridge

Repair/Recementations

Consultations

Implants

Bridges and Dentures

Crowns/Inlays/Onlays

Endodontics

General Anesthesia

Oral Surgery

Periodontics

HOW MANY/ HOW OFTEN

- One per tooth every 10 years

- Re-cementing of Cast Restorations or Dentures (once in a 12 month period)

Two per 12 months

1 per tooth every 60 months | Repair: one per tooth every 12 months

- Initial placement to replace one or more natural teeth, which are lost while covered by the Plan

- Dentures and bridgework replacement: one every 10 years

- Replacement of an existing temporary full denture if the temporary denture can’t be repaired and the

permanent denture is installed within 12 months after the temporary denture was installed

One per tooth every ten years | Replacement: once every 5 years

Root canal treatment limited to once per tooth in a lifetime

When dentally necessary in connection with oral surgery, extractions or other covered dental services

Surgical Extractions

Periodontal surgery once per quadrant, every 36 months

The service categories and plan limitations shown above represent an overview of your Plan Benefits. This document presents the majority of services within each category, but is not a complete description of the Plan.

COMPREHENSIVE PPO ONLY

LIST OF PRIMARY COVERED SERVICES & LIMITATIONS

 TYPE D – ORTHODONTIA



HOW MANY/ HOW OFTEN

- Your Children, up to age 19, are covered while Dental Insurance is in effect

- All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia

- Payments are on a repetitive basis

- 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based on the plan

benefit’s coinsurance level for Orthodontia as defined in the Plan Summary

- Orthodontic benefits end at cancellation of coverage

The service categories and plan limitations shown above represent an overview of your Plan Benefits. This document presents the majority of services within each category, but is not a complete description of the Plan.

This description of benefits is in effect as of 07/20/17 and is subject to change.

Who is a participating dentist?

A participating dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for services provided to plan members. Negotiated fees typically range from 15-45% below the average fees charged in a dentist’s community for the same or substantially similar services.*

* Based on internal analysis by MetLife. Savings from enrolling in a dental benefits plan will depend on various factors, including how often members visit
participating dentists and the cost for services rendered. Negotiated fees are subject to change. Negotiated fees for non-covered services may not apply in all states.

How do I find a participating dentist?

There are thousands of general dentists and specialists to choose from nationwide — so you are sure to find one who meets your needs. You can receive a list of these participating dentists online at www.metlife.com or call 1-800-942-0854 to have a list faxed or mailed to you.

What services are covered by my plan?

All services defined under your group dental benefits plan are covered. Please review the enclosed plan benefits to learn more.

Does the Preferred Dentist Program offer any discounts on non-covered services?

Negotiated fees may extend to services not covered under your plan and services received after your plan maximum has been met, where permitted by applicable state law. If permitted, you may only be responsible for the negotiated fee.

* Negotiated fees are subject to change.

May I choose a non-participating dentist?

Yes. You are always free to select the dentist of your choice. However, if you choose a non-participating dentist, your
out-of-pocket costs may be higher. He or she hasn’t agreed to accept negotiated fees. So you may be responsible for any difference in cost between the dentist’s fee and your plan’s benefit payment.

Can my dentist apply for participation in the network?

Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application.* The website and phone number are for use by dental professionals only.

* Due to contractual requirements, MetLife is prevented from soliciting certain providers.

How are claims processed?

Dentists may submit your claims for you which means little or no paperwork for you. You can track your claims online and even receive e-mail alerts when a claim has been processed. If you need a claim form, visit https://www.metlife.com/individual/service/forms-library/metlife/index.htmlor request one by calling 1-800-942-0854.

Can I find out what my out-of-pocket expenses will be before receiving a service?

Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency
limits and other conditions at the time of payment.

Can MetLife help me find a dentist outside of the U.S. if I am traveling?

Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be considered under your out-of-network benefits.** Please remember to hold on to all receipts to submit a dental claim.

*International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife.
** Refer to your dental benefits plan summary for your out-of-network dental coverage.

How does MetLife coordinate benefits with other insurance plans?

Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan.

This plan does not cover the following services, treatments and supplies:
• Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the
particular dental condition, or which we deem experimental in nature;
• Services for which you would not be required to pay in the absence of Dental Insurance;
• Services or supplies received by you or your Dependent before the Dental Insurance starts for that person;
• Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate);
• Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which
are supervised and billed by a Dentist and which are for:
– Scaling and polishing of teeth; or
– Fluoride treatments;
• Services or appliances which restore or alter occlusion or vertical dimension;
• Restoration of tooth structure damaged by attrition, abrasion or erosion;
• Restorations or appliances used for the purpose of periodontal splinting;
• Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
• Personal supplies or devices including, but not limited to: water picks, toothbrushes, or dental floss;
• Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work;
• Missed appointments;
• Services:
– Covered under any workers’ compensation or occupational disease law;
– Covered under any employer liability law;
– For which the employer of the person receiving such services is not required to pay; or
– Received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital;
• Services covered under other coverage provided by the Employer;
• Temporary or provisional restorations;
• Temporary or provisional appliances;
• Prescription drugs;
• Services for which the submitted documentation indicates a poor prognosis;
• The following when charged by the Dentist on a separate basis:
– Claim form completion;
– Infection control such as gloves, masks, and sterilization of supplies; or
– Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.
• Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to
chewing or biting of food;
• Caries susceptibility tests;
• Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person
was insured for Dental Insurance, except for congenitally missing natural teeth;
• Other fixed Denture prosthetic services not described elsewhere in the certificate;
• Precision attachments, except when the precision attachment is related to implant prosthetics;
• Initial installation of a full or removable Denture to replace one or more natural teeth which were missing before such person was
insured for Dental Insurance, except for congenitally missing natural teeth;
• Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was
insured for Dental Insurance, except for congenitally missing natural teeth;
• Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
• Implants including, but not limited to any related surgery, placement, restorations, maintenance, and removal;
• Fixed and removable appliances for correction of harmful habits;
• Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards;
• Diagnosis and treatment of temporomandibular joint (TMJ) disorders.
• Orthodontic services or appliances.
• Duplicate prosthetic devices or appliances;
• Replacement of a lost or stolen appliance, Cast Restoration, or Denture; and
• Intra and extraoral photographic images.

Alternate Benefits
Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Procedure charge schedules are subject to change each plan year. You can obtain an updated procedure charge schedule for your area via fax by calling 1-800-942-0854 and using the MetLife Dental Automated Information Service. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.

Cancellation/Termination of Benefits
Coverage is provided under a group insurance policy (Policy form GPNP99 / G.2130-S) issued by MetLife to the American Association of Business Networking (ABN). ABN membership is required to participate in this group plan. Coverage terminates when your membership ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. The group policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: Completion of a prosthetic device, crown or root canal therapy. All premium payments, coverage changes, and cancellation requests must be submitted in writing or through the appropriate web form, directly to the plan administrator, Member Benefits. Change or cancellation requests submitted directly to MetLife will not be honored.

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.

 

Metropolitan Life Insurance Company, New York, NY

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