Page 10 - MGM 2020 Benefits
P. 10
Find an In-Network Dental Coverage
Provider We partner with MetLife to offer you and your family members dental
Remember to visit in-network insurance. Visit www.metlife.com to ind in-network providers and access
dentists to receive the deepest a variety of online tools and programs.
level of discount on your
services. Gold Plan Silver Plan
Out-of-
Out-of-
To find a participating in- In-Network Network In-Network Network
network dentist in your area, Calendar Year Deductible
go to Metlife.com or call one to Individual $50 $50 $75 $75
have a list faxed to you.
Family $150 $150 $225 $225
Orthodontia Services Calendar Year Maximum
Note Coinsurance $1,000 $1,000
The lifetime maximum Preventive 100% 100% 80%
illustrated is different from the Basic 80% 80% 60%
calendar year maximum. For Major 50% 50% 40%
orthodontia services, this limit
does not reset each year. This Orthodontia
is the most your plan will cover Coinsurance 50%
for your services for the lifetime Lifetime $1,000
of your participation in this Maximum
program. Beneit Applies Children to age 19*
to
Examples of Services
dependents up to age 26.
X Preventive—exams, * Orthodontia services apply to children up to age 19. All other dental services apply to
cleanings, fluoride, x-rays, This is a high level summary of your beneit coverage. Full coverage details are available in your
and space maintainers summary plan description (SPD). In the event 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.
X Basic—fillings, extractions,
periodontics, and sealants Employee Contributions—Semi-Monthly
X Major—crowns, inlays, and Gold Plan Silver Plan
dentures Employee $10.55 $6.96
Employee + Spouse $19.87 $13.11
Employee + Child(ren) $28.24 $18.63
Family $37.57 $24.78
10 2019 Benefits Guide
Provider We partner with MetLife to offer you and your family members dental
Remember to visit in-network insurance. Visit www.metlife.com to ind in-network providers and access
dentists to receive the deepest a variety of online tools and programs.
level of discount on your
services. Gold Plan Silver Plan
Out-of-
Out-of-
To find a participating in- In-Network Network In-Network Network
network dentist in your area, Calendar Year Deductible
go to Metlife.com or call one to Individual $50 $50 $75 $75
have a list faxed to you.
Family $150 $150 $225 $225
Orthodontia Services Calendar Year Maximum
Note Coinsurance $1,000 $1,000
The lifetime maximum Preventive 100% 100% 80%
illustrated is different from the Basic 80% 80% 60%
calendar year maximum. For Major 50% 50% 40%
orthodontia services, this limit
does not reset each year. This Orthodontia
is the most your plan will cover Coinsurance 50%
for your services for the lifetime Lifetime $1,000
of your participation in this Maximum
program. Beneit Applies Children to age 19*
to
Examples of Services
dependents up to age 26.
X Preventive—exams, * Orthodontia services apply to children up to age 19. All other dental services apply to
cleanings, fluoride, x-rays, This is a high level summary of your beneit coverage. Full coverage details are available in your
and space maintainers summary plan description (SPD). In the event 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.
X Basic—fillings, extractions,
periodontics, and sealants Employee Contributions—Semi-Monthly
X Major—crowns, inlays, and Gold Plan Silver Plan
dentures Employee $10.55 $6.96
Employee + Spouse $19.87 $13.11
Employee + Child(ren) $28.24 $18.63
Family $37.57 $24.78
10 2019 Benefits Guide
