Page 10 - 2013 Salus Group Benefits and Notices

Benefits Partner, LLC dba Salus Group 2013

Voluntary Dental Coverage

Voluntary dental benefits are offered through Met Life. As one of the country’s largest dental providers,
Met Life’s dental network is extensive no matter what part of the country you reside.

To find a Met Life provider dentist call 1.800.638.5000 or visit www.metlife.com .

Salus Group Met Life Voluntary Dental Plan
Member’s Responsibility (copays and dollar maximums)
Annual Deductible
None
Copays
- Type A services None
- Type B services 20% of approved amount
- Type C services 50% of approved amount
- Type D services (Orthodontia) 50% of approved amount
Dollar Maximums
- Annual Maximum (for Type I, II and III services) $1,500 per member
- Lifetime Maximum (for Type IV services) $1,000 per member
Benefit Waiting Periods for Late Entrants
Type A Services No Waiting Period
Type B Service (Fillings) 6 month waiting period
All other Type B Services 12 month waiting period
Type C Services 24 month waiting period
Type D Services (Orthodontic) 24 month waiting period
Type A Services – Covered at 100%
Oral Exams 100% of approved amount, one every 6 months
Bitewing x-rays 100% of approved amount, one set every 12 months
Panoramic or full-mouth x-rays 100% of approved amount, one every 84 months

Dental prophylaxis (teeth cleaning) 100% of approved amount, twice a calendar year
100% of approved amount, one per tooth every 60 months when applied
Pit and fissure sealants – for members age 14 and younger
to the first and second permanent molars
Fluoride treatment – for members age 14 and younger 100% of approved amount, once a calendar year
Space maintainers – missing posterior (back) primary teeth – 100% of approved amount, once per quadrant per lifetime
for members age 14 and younger
Type B Services – Covered at 80%
Fillings – permanent teeth - 80% of approved amount, Root canal treatment – permanent tooth - 80% of approved amount, 24
replacement fillings covered after 24 months or more after month limitation
initial filling
Diagnostic Casts – 80% of approved amount Pulp Capping/Pulp Therapy - 80% of approved amount
Oral surgery including extractions – 80% of approved amount Apexification/re-calcification - 80% of approved amount
Palliative (emergency) treatment - 80% of approved amount Scaling and root planing – 80% of approved amount
Panoramic or full-mouth x-rays - 80% of approved amount Periapical x-rays and other x-rays – 80% of approved amount
Injection of Antibiotic drugs – 80% of approved amount Therapeutic Pulpotomy - 80% of approved amount
Periodontic maintenance – 80% of approved amount  (Four cleanings per year, combined)
Type C Services – Covered at 50%
Onlays, crowns and veneer restorations – permanent teeth 50% of approved amount, 10 year replacement
Dentures 50% of approved amount, 10 year replacement
Relines/Rebases 50% of approved amount, once every 36 months
General Anesthesia 50% of approved amount
Pre-Fabricated Stainless Steel Crowns 50% of approved amount, 10 year replacement
Bridges (fixed partial dentures) 50% of approved amount
Implants (dental coverage must be in effect with same employer at time natural teeth are lost) 50% of approved amount, 1 tooth in 60 months
Type IV Services – Covered at 50% (Orthodontic services for dependents under age 19)
Minor treatment of tooth guidance appliances 50% of approved amount
Minor treatment to control harmful habits 50% of approved amount
Interceptive and comprehensive orthodontic treatment 50% of approved amount
Post-treatment stabilization 50% of approved amount
This is only a summary for informational purposes. For complete benefit details, please refer to certificate of coverage
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