Page 14 - ABM 2021 Benefit Guide SVC HI
P. 14
Dental PPO DENTAL BENEFITS
ABM ofers team members three dental plans. You Whether or not you join the medical plan, you may
can ind out how a dental procedure will be covered in enroll in dental coverage administered through
advance. Ask your provider for a predetermination of
beneits to estimate plan coverage and out-of-pocket MetLife or Hawaii Dental Service. In order to
costs. modernize the dental beneits, ABM has made
some changes to the MetLife plan. Please see
With the MetLife dental plans you can receive care
from any provider; however, you will receive a higher below for an overview of the plan designs. The
level of beneit if you stay in-network. Even though the percentages shown in this table are the amounts
reimbursement percentages are the same for in- and the plan pays.
out-of-network services, out-of-network providers do
not agree to discounted fees which can make out- Premium Dental Standard Dental
of-network usage more expensive. Out-of-network In-Network In-Network
charges are subject to reasonable and customary Calendar Year Deductible
charges. Individual $25 $50
Family $75 $150
Calendar Year Maximum
Hawaii Dental Service $3,000 per person $1,500 per person
In-Network Coinsurance
100% no deductible
100% no deductible
Calendar Year Deductible Preventive—Type A 70% after deductible 70% after deductible
Basic—Type B
Individual $25 Major—Type C 50% after deductible 50% after deductible
Family $75 Orthodontia
Calendar year maximum Coinsurance 50% after deductible 50% after deductible
$1,200 Lifetime Maximum $2,500 $1,000
Coinsurance Beneit Applies to Adults and children Adults and children
Preventive 0% no deductible Visits and Exams 2 per year 2 per year
Limitations
Basic You pay approximately 30% Prophylaxis, 100% no deductible 100% no deductible
Major You pay approximately 50% including Scaling
Orthodontia Not covered and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years 1 per every 3 years
to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
14 2021 Benefits Enrollment To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
ABM ofers team members three dental plans. You Whether or not you join the medical plan, you may
can ind out how a dental procedure will be covered in enroll in dental coverage administered through
advance. Ask your provider for a predetermination of
beneits to estimate plan coverage and out-of-pocket MetLife or Hawaii Dental Service. In order to
costs. modernize the dental beneits, ABM has made
some changes to the MetLife plan. Please see
With the MetLife dental plans you can receive care
from any provider; however, you will receive a higher below for an overview of the plan designs. The
level of beneit if you stay in-network. Even though the percentages shown in this table are the amounts
reimbursement percentages are the same for in- and the plan pays.
out-of-network services, out-of-network providers do
not agree to discounted fees which can make out- Premium Dental Standard Dental
of-network usage more expensive. Out-of-network In-Network In-Network
charges are subject to reasonable and customary Calendar Year Deductible
charges. Individual $25 $50
Family $75 $150
Calendar Year Maximum
Hawaii Dental Service $3,000 per person $1,500 per person
In-Network Coinsurance
100% no deductible
100% no deductible
Calendar Year Deductible Preventive—Type A 70% after deductible 70% after deductible
Basic—Type B
Individual $25 Major—Type C 50% after deductible 50% after deductible
Family $75 Orthodontia
Calendar year maximum Coinsurance 50% after deductible 50% after deductible
$1,200 Lifetime Maximum $2,500 $1,000
Coinsurance Beneit Applies to Adults and children Adults and children
Preventive 0% no deductible Visits and Exams 2 per year 2 per year
Limitations
Basic You pay approximately 30% Prophylaxis, 100% no deductible 100% no deductible
Major You pay approximately 50% including Scaling
Orthodontia Not covered and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years 1 per every 3 years
to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
14 2021 Benefits Enrollment To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
