Page 5 - Hanover Medical Management Sevices - 2022 Benefit Guide
P. 5
Dental Option:
MetLife
Rate Information Dependent Information
Per Pay Period Hanover Medical Management Services, LLC offers
employees the opportunity to cover their spouse or
Employee Only $ 18.80
dependent children. Children can join or remain on
Employee + Spouse $ 37.20 a parent’s dental plan until age 26. When a child
turns 26, they will lose dental coverage on the last
Employee + Child(ren) $ 43.90 day of their birth month. This is an automated pro-
cess.
Employee + Family $ 67.00
Amount You Pay
BRIEF OVERVIEW / Service
Non-Network Dentists Reimbursed at 90% of U&C
Annual Deductible (CYD) $50 Individual / $150 Family
Preventive Services Covered at 100%; CYD Waived
Basic Services Covered at 80% after CYD
Major Services Covered at 50% after CYD
Annual Maximum $5,000
Annual Maximum Preventive Services Does Not Apply
Orthodontia (Child Only) Covered at 50% - CYD Waived (Lifetime Max of 1,500)
Type of Service Benefit Description
See Summary of Benefits and Policy for the age and frequency limitations of benefits.
Routine cleanings, exams, x-rays, oral cancer screenings.
Preventive Services
(Fluoride, sealants, space maintainers under age 16)
Restorations (Amalgam or Composite) fillings, simple extractions,
Basic Services oral surgery, endodontics (root canals), periodontics. Emergency
Treatment/General Services
Crowns, implants, inlays, onlays, fixed partial denture (bridges)
Major Services dentures & removable prosthetics
Annual Maximum Applies January 1 to December 31
Orthodontia Children under age 19
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