Page 6 - 2019 DLS Enrollment Guide
P. 6
2019 BENEFITS ENROLLMENT
Finding In-Network DENTAL
Providers We partner with MetLife to offer you and your family members dental
Remember to visit in-network insurance. Visit www.metlife.com to find in-network providers and access a
dentists to receive the deepest variety of online tools and programs.
level of discount on your services.
In-Network Out-of-Network
To find a participating in-network Calendar Year Deductible
dentist in your area go to
metlife.com or call 800.438.6388. Individual $25 $25
Family $75 $75
Orthodontia Calendar Year Maximum
Services Note $1,550 $1,550
The lifetime maximum illustrated Coinsurance 100% no deductible 100% no deductible
Preventive
is different from the calendar
year maximum. For orthodontia Basic 80% after deductible 80% after deductible
services, this limit does not Major 50% after deductible 50% after deductible
reset each year, this is the most Orthodontia
your plan will cover for your Coinsurance 50% 50%
services for the lifetime of your Lifetime Maximum $1,000 $1,000
participation in this program.
Benefit Applies to Children up to age 19 Children up to age 19
Examples of
Services This is a high level summary of your benefit coverage. Full coverage details are
available in your summary plan description (SPD). In the event there is a discrepancy
Preventive—exams, cleanings, between what is reflected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail.
fluoride, x-rays, and sealants
Basic—fillings, extractions, Employee Monthly Dental Contributions
periodontics, repairs, and oral
surgery
Employee Only $0.00
Major—crowns, inlays, Employee and Spouse $0.00
dentures, and dental impacts Employee and Child(ren) $0.00
Family $0.00
6
Finding In-Network DENTAL
Providers We partner with MetLife to offer you and your family members dental
Remember to visit in-network insurance. Visit www.metlife.com to find in-network providers and access a
dentists to receive the deepest variety of online tools and programs.
level of discount on your services.
In-Network Out-of-Network
To find a participating in-network Calendar Year Deductible
dentist in your area go to
metlife.com or call 800.438.6388. Individual $25 $25
Family $75 $75
Orthodontia Calendar Year Maximum
Services Note $1,550 $1,550
The lifetime maximum illustrated Coinsurance 100% no deductible 100% no deductible
Preventive
is different from the calendar
year maximum. For orthodontia Basic 80% after deductible 80% after deductible
services, this limit does not Major 50% after deductible 50% after deductible
reset each year, this is the most Orthodontia
your plan will cover for your Coinsurance 50% 50%
services for the lifetime of your Lifetime Maximum $1,000 $1,000
participation in this program.
Benefit Applies to Children up to age 19 Children up to age 19
Examples of
Services This is a high level summary of your benefit coverage. Full coverage details are
available in your summary plan description (SPD). In the event there is a discrepancy
Preventive—exams, cleanings, between what is reflected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail.
fluoride, x-rays, and sealants
Basic—fillings, extractions, Employee Monthly Dental Contributions
periodontics, repairs, and oral
surgery
Employee Only $0.00
Major—crowns, inlays, Employee and Spouse $0.00
dentures, and dental impacts Employee and Child(ren) $0.00
Family $0.00
6
