Page 10 - Guide
P. 10
Monthly Dental
Contributions
Monthly Dental Contributions Dental
Employee $37.42
Employee + 1 $73.82 How the Plan Works
Employee + 2+ $132.64 Dental insurance helps you pay for preventive, basic, major services, and orthodontia
services.
Dental Provider
Search RallySport Direct offers an active PPO dental plan. This means if you go to a dentist
1. Go to in the Advantage Plus network, you pay less—your portion and the Company’s
metlife.com/dental portion of the bill are lower due to provider discounts. If you go to a dentist out-of-
2. Select “Find a participating network, both you and the Company pay a higher portion of the bill. Refer to the
dentist”
3. Under “Select your chart below.
Network Type,” select the
“PDP” network If your current provider is in the network, these providers have agreed to charge
4. Enter remaining search within the Reasonable and Customary (R&C) limits. If you visit providers outside the
criteria
network, they may charge more than what is considered by the plan to be Reasonable
Important note: if and Customary—and you will be responsible for charges over the R&C amount.
you do not elect
dental coverage at Dental Expense Benefits
this time and do not In-Network Out-of-Network
have other dental Annual Deductible Amount
coverage currently, Individual Type A Expenses $0 $0
you will be subject to Individual Type B And C Expenses Combined $50 $50
$0
Type D Expenses
$0
waiting periods if you Family Type A Expenses $0 $0
enroll later. Family Type B Expenses Combined $150 $150
Covered Percentage
Type A Expenses (preventive) 100% 100%
Type B Expenses (basic) 80% 80%
Type C Expenses (major) 50% 50%
Type D Expenses (orthodontics) 50% 50%
Maximums
For Orthodontic Treatment (covered for adult and dependents)
Aggregate Maximum Benefit (for all dental expense periods) $1,000
For Other Covered Dental Expenses
Maximum Benefit (for one dental expense period) $1,000
Enrolled employees will not receive a dental ID card so you must provide the dentist
ofice with the policyholder’s name and SSN.
X The group number is KM5712154
X MetLife customer service number:
800.942.0854
10 RallySport Direct
Contributions
Monthly Dental Contributions Dental
Employee $37.42
Employee + 1 $73.82 How the Plan Works
Employee + 2+ $132.64 Dental insurance helps you pay for preventive, basic, major services, and orthodontia
services.
Dental Provider
Search RallySport Direct offers an active PPO dental plan. This means if you go to a dentist
1. Go to in the Advantage Plus network, you pay less—your portion and the Company’s
metlife.com/dental portion of the bill are lower due to provider discounts. If you go to a dentist out-of-
2. Select “Find a participating network, both you and the Company pay a higher portion of the bill. Refer to the
dentist”
3. Under “Select your chart below.
Network Type,” select the
“PDP” network If your current provider is in the network, these providers have agreed to charge
4. Enter remaining search within the Reasonable and Customary (R&C) limits. If you visit providers outside the
criteria
network, they may charge more than what is considered by the plan to be Reasonable
Important note: if and Customary—and you will be responsible for charges over the R&C amount.
you do not elect
dental coverage at Dental Expense Benefits
this time and do not In-Network Out-of-Network
have other dental Annual Deductible Amount
coverage currently, Individual Type A Expenses $0 $0
you will be subject to Individual Type B And C Expenses Combined $50 $50
$0
Type D Expenses
$0
waiting periods if you Family Type A Expenses $0 $0
enroll later. Family Type B Expenses Combined $150 $150
Covered Percentage
Type A Expenses (preventive) 100% 100%
Type B Expenses (basic) 80% 80%
Type C Expenses (major) 50% 50%
Type D Expenses (orthodontics) 50% 50%
Maximums
For Orthodontic Treatment (covered for adult and dependents)
Aggregate Maximum Benefit (for all dental expense periods) $1,000
For Other Covered Dental Expenses
Maximum Benefit (for one dental expense period) $1,000
Enrolled employees will not receive a dental ID card so you must provide the dentist
ofice with the policyholder’s name and SSN.
X The group number is KM5712154
X MetLife customer service number:
800.942.0854
10 RallySport Direct
