Page 14 - 2015 Enrollment Guide
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Dental
MetLife Network MetLife Traditional Dental Plan
Dental Plan
The MetLife Network The MetLife Traditional Dental Plan features a network of dentists who have
agreed to a discount payment schedule. You are not required to designate a
Dental Plan features a primary care dentist, and you have the choice to select any participating MetLife
network of dental providers dentist. You may choose to obtain services from a non-preferred provider;
who manage dental care for however, your out-of-pocket costs will be higher and your annual maximum
its members. There are no beneit will be lower.
deductibles or coinsurance
under the Network Dental MetLife Network Dental Plan MetLife Traditional
Plan and you pay a lat Dental Plan
Out-of-
fee for services based on In-Network Out-of-Network In-Network Network
the plan’s patient charge Deductible (Plan Year) None None $50 $50
Individual
schedule. Family $100 $100
Coinsurance—Percent You Pay
Preventive services: exams, No charge 15% of R&C No charge
x-rays, prophylaxis
Basic services: illings, oral Copay schedule 50% of R&C 20% after 20% after
surgery, root canals deductible deductible
Major services: bridges, Copay schedule 70% of R&C 50% after 50% after
crowns, dentures deductible deductible
Calendar Year Maximum
$1,000 $1,000 $1,000
Orthodontist Services
Dependent children Copay schedule 50% of R&C 50%
Adults Copay schedule 50% of R&C
Orthodontist lifetime $1,900 $1,900 $1,500
maximum
Dental Contribution Rates
This chart illustrates your weekly and bi-weekly pre-tax contributions or each of
the Optimas Dental plans:
Network Dental Plan Traditional Dental Plan
All Employees Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly
Employee only $3.05 $6.09 $13.20 $7.36 $14.72 $31.90
Employee + spouse $5.84 $11.68 $25.30 $14.22 $28.43 $61.60
Employee + child(ren) $6.35 $12.69 $27.50 $15.74 $31.48 $68.20
Family $8.88 $17.77 $38.50 $21.32 $42.65 $92.40
Optimas OE Solutions Holdings, LLC
Dental
MetLife Network MetLife Traditional Dental Plan
Dental Plan
The MetLife Network The MetLife Traditional Dental Plan features a network of dentists who have
agreed to a discount payment schedule. You are not required to designate a
Dental Plan features a primary care dentist, and you have the choice to select any participating MetLife
network of dental providers dentist. You may choose to obtain services from a non-preferred provider;
who manage dental care for however, your out-of-pocket costs will be higher and your annual maximum
its members. There are no beneit will be lower.
deductibles or coinsurance
under the Network Dental MetLife Network Dental Plan MetLife Traditional
Plan and you pay a lat Dental Plan
Out-of-
fee for services based on In-Network Out-of-Network In-Network Network
the plan’s patient charge Deductible (Plan Year) None None $50 $50
Individual
schedule. Family $100 $100
Coinsurance—Percent You Pay
Preventive services: exams, No charge 15% of R&C No charge
x-rays, prophylaxis
Basic services: illings, oral Copay schedule 50% of R&C 20% after 20% after
surgery, root canals deductible deductible
Major services: bridges, Copay schedule 70% of R&C 50% after 50% after
crowns, dentures deductible deductible
Calendar Year Maximum
$1,000 $1,000 $1,000
Orthodontist Services
Dependent children Copay schedule 50% of R&C 50%
Adults Copay schedule 50% of R&C
Orthodontist lifetime $1,900 $1,900 $1,500
maximum
Dental Contribution Rates
This chart illustrates your weekly and bi-weekly pre-tax contributions or each of
the Optimas Dental plans:
Network Dental Plan Traditional Dental Plan
All Employees Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly
Employee only $3.05 $6.09 $13.20 $7.36 $14.72 $31.90
Employee + spouse $5.84 $11.68 $25.30 $14.22 $28.43 $61.60
Employee + child(ren) $6.35 $12.69 $27.50 $15.74 $31.48 $68.20
Family $8.88 $17.77 $38.50 $21.32 $42.65 $92.40
Optimas OE Solutions Holdings, LLC
