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Dental Insurance
Space Maintainers Space maintainers for dependent children up to his/her 19th birthday
One application of sealant material every 60 months for each non-restored,
Sealants
non- decayed 1st and 2nd molar of a dependent child up to his/her 19th
birthday
Type B — Basic Restorative
Fillings Replacement once every 24 months
Simple Extractions
Crown, Denture and Bridge Repair once in a 12 month period
Repair/ Recementations
Oral Surgery
Endodontics Root canal treatment limited to once per tooth per 24 month period
When dentally necessary in connection with oral surgery, extractions or
General Anesthesia
other covered dental services
Periodontal scaling and root planing once per quadrant, every 24 months
Periodontal surgery once per quadrant, every 36 months
Periodontics
Total number of periodontal maintenance treatments and prophylaxis
cannot exceed four treatments in a calendar year
Type C — Major Restorative
• Replacement once every 5 years
Implants • Repair once in a 12 month period
Dentures and bridgework replacement; one every 5 years
Bridges and Dentures 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
Crowns, Inlays and Onlays Replacement once every 5 years
Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166
L0620004683[exp1221][xNM] © 2018 MetLife Services and Solutions, LLC
DN-ANY-PPO-STAND
