Page 12 - 2022-23 Drug Plastics Benefit Guide

MetLife 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 is an important part of
maintaining your overall health. We offer a dental plan through MetLife.

MetLife Dental Plan
Plan Provisions Premium Standard
Annual Deductible** $50/$150 $50/$150
(Individual/Family)
Calendar Year Maximum $1,500 per individual $1,000 per individual
Orthodontia Lifetime Maximum $1,500 maximum per lifetime Not covered
Class I - Diagnostic
(exam & X-rays) Covered at 100% Covered at 100%

Class I - Preventative*** Covered at 100% Covered at 100%
(fluoride treatments, cleaning & sealants)
Class II - Basic Restorative
(fillings, extractions, root canal therapy, Plan pays 80%* Plan pays 80%*
periodontics)
Class III - Major Restorative Plan pays 50%* Not covered
(crowns, dentures, bridgework)

Orthodontics
(for children up to age 19) Plan pays 50% Not covered

*After dedutible
**For Classes II & III only
***Fluoride treatments for children up to age 19, teeth cleaning for children and adults, sealants for children up to age 14
Please note that this is only a summary of benefits. Please refer to the plan highlight sheets and your member handbook for a more detailed benefit description and a list of
standard benefit exclusions.
Using dental providers

The listed network percentages represent the portion of MetLife’s maximum allowable charges (MACs) for which the plan
will be responsible. In-Network providers agree to accept MetLife’s MAC for covered services as payment in full and also
agree to file claims for you. If you or your family members receive services from an Out-of-Network provider, MetLife will
apply the percentages shown above to the Out-of-Network reimbursement for covered services and you will be responsible
for the difference, up to the provider’s charge. MetLife standard exclusions and limitations apply.

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