Page 11 - Impact XM 2023 Benefit Guide
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Your Dental Plan
It’s important to have regular dental exams and cleanings so problems are detected before they become
painful—and expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth decay
and periodontal disease, and is an important part of maintaining your medical health.
Can I go to any Dentist I want?
PPO Plan – Yes, the PPO plan offers the flexibility of receiving care In-Network and Out-of-Network. You will
get the most benefit by using participating providers. When using a non-participating provider, the insurance
company pays the dentist a fee that is based on Usual and Customary Charges so you may be subject to
balance billing if your dentist’s fees are higher.
Do I need to select a Primary Care Dentist? No.
How do I find a participating dentist?
You can access their website at https://www.metlife.com/insurance/dental-insurance/
to search for providers in the network.
MetLife PPO Plan
Provision In Network PPO Out-of-Network
Annual deductible
$50/$150 $50/$150
Individual/Family
Annual maximum per individual $2,000 $2,000
Diagnostic and Preventive, to include
cleanings, fluoride treatments, sealants and 100%, no deductible 100%, no deductible
x-rays
Basic Services to include fillings,
periodontics, scaling and root planning, oral 90% after deductible 90% after deductible
surgery
Major Services to include crowns, bridges,
60% after deductible 60% after deductible
full and partial dentures
Orthodontia (Adult & Child) 50%; $1,500 lifetime orthodontia maximum
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