Page 11 - Dentons 2021 Benefits Guide Retiree
P. 11
2021
Dentons Benefits Guide
DENTAL PLAN
MetLife PPO Dental Plan
This freedom-of-choice plan offers the same coverage in-network and out-of-network, although the
coverage level will be higher in-network. Maximize your dental benefits by utilizing one of MetLife’s
260,000 in-network providers. For a list of in-network providers, please visit www.metlife.com/dental .
Basic Dental Plan Enhanced Dental Plan
Out-of-Network Out-of-Network
In-Network Coverage Coverage* In-Network Coverage Coverage*
Calendar Year Maximum
$1,000 per family $500 per family member $2,000 per family $1,200 per family member
member member
Annual Deductible
(Individual/Family) (Individual/Family) (Individual/Family) (Individual/Family)
$75/$150 $75/$225 $50/$150 $75/$225
Type A Services: Preventive Care
100% 70% 100% 90%
Cleanings and oral examinations Cleanings and oral examinations
Type B Services: Basic Care
60% 40% 80% 60%
Fillings Fillings
Type C Services: Major Care
50% 25% 50% 40%
Bridges and dentures Bridges and dentures
Type D Services: Orthodontia
50% 25% 50% 50%
$750/person lifetime $500/person lifetime $2,000/person lifetime $1,000/person lifetime
maximum maximum maximum maximum
* OON benefit will vary for Texas employees due to state law mandates
11
Dentons Benefits Guide
DENTAL PLAN
MetLife PPO Dental Plan
This freedom-of-choice plan offers the same coverage in-network and out-of-network, although the
coverage level will be higher in-network. Maximize your dental benefits by utilizing one of MetLife’s
260,000 in-network providers. For a list of in-network providers, please visit www.metlife.com/dental .
Basic Dental Plan Enhanced Dental Plan
Out-of-Network Out-of-Network
In-Network Coverage Coverage* In-Network Coverage Coverage*
Calendar Year Maximum
$1,000 per family $500 per family member $2,000 per family $1,200 per family member
member member
Annual Deductible
(Individual/Family) (Individual/Family) (Individual/Family) (Individual/Family)
$75/$150 $75/$225 $50/$150 $75/$225
Type A Services: Preventive Care
100% 70% 100% 90%
Cleanings and oral examinations Cleanings and oral examinations
Type B Services: Basic Care
60% 40% 80% 60%
Fillings Fillings
Type C Services: Major Care
50% 25% 50% 40%
Bridges and dentures Bridges and dentures
Type D Services: Orthodontia
50% 25% 50% 50%
$750/person lifetime $500/person lifetime $2,000/person lifetime $1,000/person lifetime
maximum maximum maximum maximum
* OON benefit will vary for Texas employees due to state law mandates
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