Page 41 - Touching All the Bases- Power point 2023 Umpires_Neat

Dental Insurance

 Full mouth X-rays; one per 36 months
X-rays  Bitewings X-rays; one set per calendar year for adults; two sets every six
months for children

Space Maintainers Space maintainers for dependent children up to his/her 19th birthday

Type B — Basic Restorative
Fillings
Simple Extractions
Crown, Denture and Bridge Repair/ No more than one replacement within 60 months.
Recementations
Oral Surgery

Endodontics

When dentally necessary in connection with oral surgery, extractions or other
General Anesthesia
covered dental services

 Periodontal scaling and root planing once per quadrant
Periodontics  Periodontal surgery once per quadrant, every 36 months
 Total number of periodontal maintenance treatments and prophylaxis

Space Maintainers Space maintainers for dependent children up to his/her 19th birthday.

One application of sealant material every 5 years for each non-restored, non-
Sealants
decayed 1st and 2nd molar of a dependent child up to his/her 19th birthday

Implants Replacement once every 60 months

 Initial placement to replace one or more natural teeth, which are lost while
covered by the Plan
Bridges and Dentures  Dentures and bridgework replacement; one every 60 months
Replacement of an existing temporary full denture if the temporary denture cannot
be repaired and the permanent denture is installed within 12 months after the
temporary denture was installed
Type C — Major Restorative

Crowns, Inlays and Onlays Replacement once every 60 months

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166
L0620004683[exp1221][xNM] © 2018 MetLife Services and Solutions, LLC
DN-ANY-PPO-STAND