Page 14 - Dealer Tire 2022 Benefits Guide
P. 14
Dental
We partner with MetLife to ofer you and MetLife
your family members dental insurance. Visit Low PPO High PPO
www.metlife.com to ind in-network providers and Plan Beneits In- Out-of- In- Out-of-
access a variety of online tools and programs. Network Network Network Network
Deductible $50/$150 $75/$225 $50/$150 $50/$150
Understanding your Dental Plan’s Out Preventive 100% 90% 100% 100%
of Network Benefits Basic 80% 60% 90% 80%
Maximum Allowable Charge (MAC) Major 50% 40% 60% 50%
Orthodontia N/A N/A 60% 50%
Caps payment for services provided by an out- Annual
of-network dentist at a scheduled amount, the Maximum $1,000 $1,000 $1,500 $1,500
Maximum Allowable Charge. Ortho Limit N/A N/A $1,200 $1,200
Dealer Tire’s Low Plan features out of network This is a high-level summary of your beneit coverage. Full coverage
details are available in your summary plan description (SPD). In the event
reimbursements at the Maximum Allowable Charge. there is a discrepancy between what is relected in this guide and what is
communicated in your SPD, the terms of your SPD will prevail.
Reasonable & Customary (R&C) Charge
Plan pays out-of-network claims based on Associate Bi-Weekly Dental
Reasonable & Customary (R&C) charges determined Contributions
for your area. The R&C charge is based on the Low Plan— High Plan—
lowest of 1) the dentist’s actual charge, 2) the Bi-Weekly Bi-Weekly
dentist’s usual charge for the same or similar Associate Only $4.53 $8.51
services, or 3) the usual charge of most dentists in Associate and Spouse $8.33 $17.87
the same geographic area for the same or similar Associate and Child(ren) $11.85 $16.17
services as determined by MetLife. Family $16.92 $23.75
Dealer Tire’s High Plan features out of network Cost in excess of the MAC and R&C will be at the expense
reimbursements at the Reasonable & Customary of the member.
Charge.
Finding In-Network Orthodontia Services Examples of Services
Providers Note Preventive—exams, cleanings,
Remember to visit in-network dentists The lifetime maximum illustrated luoride, x-rays, and sealants
to receive the deepest level of discount is diferent from the calendar year Basic—illings, extractions,
on your services. maximum. For orthodontia services, periodontics, repairs, and oral
this limit does not reset each year, this
To ind a participating in- is the most your plan will cover for surgery
network dentist in your area your services for the lifetime of your Major—crowns, inlays, dentures,
go to www.metlife.com or call participation in this program. and dental impacts
800.880.1800. These plans access the
PDP Plus Network.
14
We partner with MetLife to ofer you and MetLife
your family members dental insurance. Visit Low PPO High PPO
www.metlife.com to ind in-network providers and Plan Beneits In- Out-of- In- Out-of-
access a variety of online tools and programs. Network Network Network Network
Deductible $50/$150 $75/$225 $50/$150 $50/$150
Understanding your Dental Plan’s Out Preventive 100% 90% 100% 100%
of Network Benefits Basic 80% 60% 90% 80%
Maximum Allowable Charge (MAC) Major 50% 40% 60% 50%
Orthodontia N/A N/A 60% 50%
Caps payment for services provided by an out- Annual
of-network dentist at a scheduled amount, the Maximum $1,000 $1,000 $1,500 $1,500
Maximum Allowable Charge. Ortho Limit N/A N/A $1,200 $1,200
Dealer Tire’s Low Plan features out of network This is a high-level summary of your beneit coverage. Full coverage
details are available in your summary plan description (SPD). In the event
reimbursements at the Maximum Allowable Charge. there is a discrepancy between what is relected in this guide and what is
communicated in your SPD, the terms of your SPD will prevail.
Reasonable & Customary (R&C) Charge
Plan pays out-of-network claims based on Associate Bi-Weekly Dental
Reasonable & Customary (R&C) charges determined Contributions
for your area. The R&C charge is based on the Low Plan— High Plan—
lowest of 1) the dentist’s actual charge, 2) the Bi-Weekly Bi-Weekly
dentist’s usual charge for the same or similar Associate Only $4.53 $8.51
services, or 3) the usual charge of most dentists in Associate and Spouse $8.33 $17.87
the same geographic area for the same or similar Associate and Child(ren) $11.85 $16.17
services as determined by MetLife. Family $16.92 $23.75
Dealer Tire’s High Plan features out of network Cost in excess of the MAC and R&C will be at the expense
reimbursements at the Reasonable & Customary of the member.
Charge.
Finding In-Network Orthodontia Services Examples of Services
Providers Note Preventive—exams, cleanings,
Remember to visit in-network dentists The lifetime maximum illustrated luoride, x-rays, and sealants
to receive the deepest level of discount is diferent from the calendar year Basic—illings, extractions,
on your services. maximum. For orthodontia services, periodontics, repairs, and oral
this limit does not reset each year, this
To ind a participating in- is the most your plan will cover for surgery
network dentist in your area your services for the lifetime of your Major—crowns, inlays, dentures,
go to www.metlife.com or call participation in this program. and dental impacts
800.880.1800. These plans access the
PDP Plus Network.
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