Page 11 - RSD Guide
P. 11
Dental
New Benefit Effective August 1, 2015
How the Plan Works Monthly Dental
Dental insurance helps you pay for preventive, basic, major services, Contributions
and orthodontia services. Employee $39.39
Employee/spouse $77.71
Rally Sport Direct offers an active PPO Dental Plan. This means if Employee/child(ren) $77.71
you go to a dentist in the Advantage Plus network, you pay less— Family $139.62
your portion and the Company’s portion of the bill are lower due to
provider discounts. If you go to a dentist out-of-network, both you and Dental Provider Search
the Company pay a higher portion of the bill. Refer to the chart below. 1. Go to www.metlife.com/dental
2. Select “Find a participating dentist”
If your current provider is in the network, these providers have agreed
to charge within the Reasonable and Customary (R&C) limits. If you 3. Under “Select your Network Type”,
visit providers outside the network, they may charge more than what is select the “PDP” network
considered by the plan to be Reasonable and Customary—and you will 4. Enter remaining search criteria
be responsible for charges over the R&C amount.
Dental Expense Benefits
In-Network Out-of-Network Important note:
Annual Deductible Amount if you do not
Individual type A expenses $0 $0 elect dental
Individual type B and C expenses combined $50 $50 coverage at this
Type D expenses $0 $0 time and do
Family type A expenses $0 $0 not have other
Family type B expenses combined $150 $150 dental coverage
Covered Percentage currently, you
Type A expenses (preventive) 100% 100% will be subject to
Type B expenses (basic) 80% 80% waiting periods if
Type C expenses (major) 50% 50% you enroll later.
Type D expenses (orthodontics) 50% 50%
Maximums
For Orthodontic Treatment (covered for adult and dependents)
Aggregate maximum beneit (for all dental expense periods) $1,000
For Other Covered Dental Expenses
Maximum beneit (for one dental expense period) $1,000
Enrolled employees will not receive a dental ID card so you must provide the dentist
office with the policyholder’s name and SSN.
X The group number is KM5712154 X MetLife Customer Service number:
800.942.0854
11
New Benefit Effective August 1, 2015
How the Plan Works Monthly Dental
Dental insurance helps you pay for preventive, basic, major services, Contributions
and orthodontia services. Employee $39.39
Employee/spouse $77.71
Rally Sport Direct offers an active PPO Dental Plan. This means if Employee/child(ren) $77.71
you go to a dentist in the Advantage Plus network, you pay less— Family $139.62
your portion and the Company’s portion of the bill are lower due to
provider discounts. If you go to a dentist out-of-network, both you and Dental Provider Search
the Company pay a higher portion of the bill. Refer to the chart below. 1. Go to www.metlife.com/dental
2. Select “Find a participating dentist”
If your current provider is in the network, these providers have agreed
to charge within the Reasonable and Customary (R&C) limits. If you 3. Under “Select your Network Type”,
visit providers outside the network, they may charge more than what is select the “PDP” network
considered by the plan to be Reasonable and Customary—and you will 4. Enter remaining search criteria
be responsible for charges over the R&C amount.
Dental Expense Benefits
In-Network Out-of-Network Important note:
Annual Deductible Amount if you do not
Individual type A expenses $0 $0 elect dental
Individual type B and C expenses combined $50 $50 coverage at this
Type D expenses $0 $0 time and do
Family type A expenses $0 $0 not have other
Family type B expenses combined $150 $150 dental coverage
Covered Percentage currently, you
Type A expenses (preventive) 100% 100% will be subject to
Type B expenses (basic) 80% 80% waiting periods if
Type C expenses (major) 50% 50% you enroll later.
Type D expenses (orthodontics) 50% 50%
Maximums
For Orthodontic Treatment (covered for adult and dependents)
Aggregate maximum beneit (for all dental expense periods) $1,000
For Other Covered Dental Expenses
Maximum beneit (for one dental expense period) $1,000
Enrolled employees will not receive a dental ID card so you must provide the dentist
office with the policyholder’s name and SSN.
X The group number is KM5712154 X MetLife Customer Service number:
800.942.0854
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