Page 13 - Dent Wizard 2021 Annual Benefits Enrollment
P. 13
2021
Dent Wizard Benefits Enrollment
Dental Finding In-Network Providers
We partner with MetLife to offer you and your family Remember to visit in-network dentists to receive the
members dental insurance. Visit www.metlife.com to deepest level of discount on your services.
ind in-network providers and access a variety of To ind a participating in-network dentist in your area, go
online tools and programs. to www.metlife.com or call 800.942.0854 .
MetLife Your dental plans access the MetLife PDP Plus Dental
Low PPO High PPO Network .
In-
Out-of-
Out-of-
In-
Plan Beneits Network Network Network Network Orthodontia Services Note
Deductible $50/$150 $75/$225 $50/$150 $50/$150 The lifetime maximum illustrated is diferent from the
Preventive 100% 90% 100% 100% calendar year maximum. For orthodontia services, this
Basic 80% 60% 90% 80% limit does not reset each year, this is the most your
plan will cover for your services for the lifetime of your
Major 50% 40% 60% 50% participation in this program.
Orthodontia N/A N/A 60% 50%
Annual $1,000 $1,000 $1,500 $1,500 Examples of Services
Maximum Preventive—exams, cleanings, luoride, x-rays, and
Ortho Limit N/A N/A $1,200 $1,200 sealants
This is a high-level summary of your beneit coverage. Full coverage Basic—illings, extractions, periodontics, repairs, and
details are available in your summary plan description (SPD). In the oral surgery
event there is a discrepancy between what is relected in this guide and Major—crowns, inlays, dentures, and dental impacts
what is communicated in your SPD, the terms of your SPD will prevail.
Associate Bi-Weekly Dental
Contributions
Low Plan— High Plan—
Bi-Weekly Bi-Weekly
Associate Only $4 .53 $8 .51
Associate and Spouse $8 .33 $17 .87
Associate and Child(ren) $11 .85 $16 .17
Family $16 .92 $23 .75
13
Dent Wizard Benefits Enrollment
Dental Finding In-Network Providers
We partner with MetLife to offer you and your family Remember to visit in-network dentists to receive the
members dental insurance. Visit www.metlife.com to deepest level of discount on your services.
ind in-network providers and access a variety of To ind a participating in-network dentist in your area, go
online tools and programs. to www.metlife.com or call 800.942.0854 .
MetLife Your dental plans access the MetLife PDP Plus Dental
Low PPO High PPO Network .
In-
Out-of-
Out-of-
In-
Plan Beneits Network Network Network Network Orthodontia Services Note
Deductible $50/$150 $75/$225 $50/$150 $50/$150 The lifetime maximum illustrated is diferent from the
Preventive 100% 90% 100% 100% calendar year maximum. For orthodontia services, this
Basic 80% 60% 90% 80% limit does not reset each year, this is the most your
plan will cover for your services for the lifetime of your
Major 50% 40% 60% 50% participation in this program.
Orthodontia N/A N/A 60% 50%
Annual $1,000 $1,000 $1,500 $1,500 Examples of Services
Maximum Preventive—exams, cleanings, luoride, x-rays, and
Ortho Limit N/A N/A $1,200 $1,200 sealants
This is a high-level summary of your beneit coverage. Full coverage Basic—illings, extractions, periodontics, repairs, and
details are available in your summary plan description (SPD). In the oral surgery
event there is a discrepancy between what is relected in this guide and Major—crowns, inlays, dentures, and dental impacts
what is communicated in your SPD, the terms of your SPD will prevail.
Associate Bi-Weekly Dental
Contributions
Low Plan— High Plan—
Bi-Weekly Bi-Weekly
Associate Only $4 .53 $8 .51
Associate and Spouse $8 .33 $17 .87
Associate and Child(ren) $11 .85 $16 .17
Family $16 .92 $23 .75
13
