Page 14 - 2022 Penn Engineering Guide

Your Dental Coverage

MetLife - High PPO Plan MetLife - Low PPO Plan AETNA – (DHMO) PA/NJ

Deductible Deductible Deductible
$50 individual $50 individual None
$150 family $150 family None
Annual Maximum Annual Maximum Annual Maximum
$1,000 per person $1,000 per person See DHMO booklet

Preventive Care Preventive Care Preventive Care
100% of reasonable and 100% of covered charges; no deductible;
customary charges; no deductible; up to 2 routine exams per year 100%, no deductible
See DHMO booklet for limitations
up to 2 routine exams per year
Basic Care Basic Care Basic Care
80% of reasonable and 80% of covered charges after
See DHMO booklet
customary charges after deductible
deductible

Major/Restorative Major/Restorative Major/Restorative
50% of reasonable and 50% of covered charges after
See DHMO booklet
customary charges after deductible
deductible
Orthodontia
Orthodontia Orthodontia
See DHMO booklet
50% of reasonable and 50% of covered charges after
customary charges after deductible; up to $1,000 lifetime
deductible; up to maximum
$1,000 lifetime maximum

You must visit a Metlife network provider to receive discounted services.
High PPO Plan – MetLife Dental
If you participate in the High PPO, you have the flexibility of seeing the dentist of your choice.
Under the High PPO, you pay for part of basic, restorative and orthodontia care, after meeting
an annual plan year $50 individual or $150 family deductible.

Reimbursements under the Plan are based on reasonable and customary charges. “Reasonable
and customary” refers to what providers in the same geographic area usually charge for dental
services. The High Option Plan covers 100% of the reasonable and customary charges for
preventive care treatment for up to two routine exams per plan year. There is no deductible for
preventive care treatment. The chart on page 12 summarizes the levels of coverage under the
High PPO Plan.

Low PPO Plan - MetLife Dental
The Low PPO Plan covers a percentage of the cost of preventive, basic, restorative, major and
orthodontic services after you meet an annual deductible. Dental care can be received from
network providers at pre-negotiated discounted rates. When you use out-of-network providers,
reimbursement for care is subject to reasonable and customary limits.

AETNA Dental Health Maintenance Organization (DHMO) PA/NJ only
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Participants in the DHMO receive coverage at 100% for preventive and diagnostic care and are
charged reduced fees for additional covered services performed by Network providers.
Complete coverage details can be found in the DHMO booklet.