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FOCUS ON BENEFITS 2022

Goodwill-Easter Seals Minnesota

DENTAL PLAN SUMMARY

This is a comprehensive plan for all dental services and covers preventive
care at 100% in-network, with no deductible. You may use any dentist for
your dental services; however, using an in-network provider will reduce
your out-of-pocket costs. We offer the dental plan through MetLife
utilizing the PDP Plus dental network. Always
Member ID cards are available on the MetLife’s member portal MyBenefits. use an in-network provider to obtain the
You can print, view or download your ID card or your dentist can verify highest level of benefits.
benefits directly with MetLife beginning 1/1/22.
When accessing care out of network, there are
Please Note: ID cards will not be mailed, visit www.metlife.com/mybenefits no provider discounts, and the member is
Features Low Plan High Plan responsible for the difference between what is
charged/billed over the usual and customary
Annual Maximum $1,250 $1,750 percentile.
Annual Deductible
Does not apply to preventive and $50/person $50/person QUESTIONS?
diagnostics
Call customer service at 800-275-4638 or visit
Diagnostic & Preventive You pay $0 You pay 0%
www.metlife.com/dental.
Basic Restorative Care You pay 20% You pay 20%
Amalgam & Resin Fillings Once you are enrolled you may take advantage
Oral Surgery You pay 20% You pay 20% of online self-service capabilities with
Simple Extractions MyBenefits:
Endodontic Therapy You pay 20% You pay 20% • Check the status of your claims
Root Canal • Locate a participating dentist
Periodontics You pay 50% You pay 50% • Access MetLife's Oral Health Library
Gum disease • Elect to view your explanation of benefits
online
Major Restoratives You pay 50% You pay 50% To register, visit www.metlife.com/mybenefits
Resins, Crowns
Prosthetics and Implants You pay 50% You pay 50% Value add benefits:

Orthodontia No coverage 50% to $1,500 A vision discount program is offered with
lifetime maximum* enrollment in the MetLife Dental plan. You can
receive the following discounts:
*Eligible dependent children only.
• 20% off eye exam

Dental Plan Premiums: The rates are shown bi-weekly and effective • 20% off lenses and lens options
Jan. 1, 2022. • 25% off frames
Per Payroll Rates • 20% off non-prescription sunglasses
Status
Low Plan High Plan • Discounts on laser vision correction.
Employee only $12.35 $15.77
Employee + 1 $25.87 $33.04 Enter program code MET2020 when making an
appointment or receiving services or materials.
Family $42.45 $54.22

Please review your plan summary document for more detailed coverage
information.
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