Page 6 - 2024 Hanover Medical Management Sevices Benefit Guide - EN Revised
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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 $ 20.12
dependent children. Children can join or remain on a
Employee + Spouse $ 39.80 parent’s dental plan until age 26. When a child turns
26, they will lose dental coverage on the last day of
Employee + Child(ren) $ 46.97 their birth month. This is an automated process.
Employee + Family $ 71.69
Amount You Pay
BRIEF OVERVIEW / Service Non-Network Dentists Reimbursed
at 90% of Usual & Customary (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
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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