Page 7 - ABM 2021 Benefit Guide Non-Core-30
P. 7
MetLife Dental PPO DENTAL BENEFITS
ABM ofers team members two dental plans. You can Whether or not you join the medical plan, you may
ind out how a dental procedure will be covered in enroll in dental coverage administered through
advance. Ask your provider for a predetermination of
beneits to estimate plan coverage and out-of-pocket MetLife. ABM has made some modernization
costs. changes to the dental beneits. Please see
below for an overview of the plan design. The
With the MetLife plans, you can receive care from
any provider; however, you will receive a higher level percentages shown in this table are the amounts
of beneit if you stay in-network. Even though the the plan pays.
reimbursement percentages are the same for in- and
out-of-network services, out-of-network providers do Premium Dental Standard Dental
not agree to discounted fees which can make out- In-Network In-Network
of-network usage more expensive. Out-of-network Calendar Year Deductible
charges are subject to reasonable and customary Individual $25 $50
charges. Download the free apps from the App Store Family $75 $150
SM
Calendar Year Maximum
(or Google Play for Android ) by searching MetLife. $3,000 per person $1,500 per person
TM
Coinsurance
Preventive—Type A 100% no deductible 100% no deductible
Basic—Type B 70% after deductible 70% after deductible
Major—Type C 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $2,500 $1,000
Beneit Applies To Adults and children Adults and children
Visits and Exams
Limitations 2 per year 2 per year
Prophylaxis, 100% no deductible 100% no deductible
including Scaling
and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years 1 per every 3 years
to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
7 2021 Benefits Enrollment To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
ABM ofers team members two dental plans. You can Whether or not you join the medical plan, you may
ind out how a dental procedure will be covered in enroll in dental coverage administered through
advance. Ask your provider for a predetermination of
beneits to estimate plan coverage and out-of-pocket MetLife. ABM has made some modernization
costs. changes to the dental beneits. Please see
below for an overview of the plan design. The
With the MetLife plans, you can receive care from
any provider; however, you will receive a higher level percentages shown in this table are the amounts
of beneit if you stay in-network. Even though the the plan pays.
reimbursement percentages are the same for in- and
out-of-network services, out-of-network providers do Premium Dental Standard Dental
not agree to discounted fees which can make out- In-Network In-Network
of-network usage more expensive. Out-of-network Calendar Year Deductible
charges are subject to reasonable and customary Individual $25 $50
charges. Download the free apps from the App Store Family $75 $150
SM
Calendar Year Maximum
(or Google Play for Android ) by searching MetLife. $3,000 per person $1,500 per person
TM
Coinsurance
Preventive—Type A 100% no deductible 100% no deductible
Basic—Type B 70% after deductible 70% after deductible
Major—Type C 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $2,500 $1,000
Beneit Applies To Adults and children Adults and children
Visits and Exams
Limitations 2 per year 2 per year
Prophylaxis, 100% no deductible 100% no deductible
including Scaling
and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years 1 per every 3 years
to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
7 2021 Benefits Enrollment To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
