Page 21 - ABM 2021 Benefit Guide EDU
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DENTAL BENEFITS MetLife Dental PPO
Whether or not you join the medical plan, you may enroll ABM ofers team members two dental plans.
in dental coverage administered through MetLife. ABM You can ind out how a dental procedure will
be covered in advance. Ask your provider for
has made some modernization changes to the dental a pre-determination of beneits to estimate
beneits. Please see below for an overview of the plan plan coverage and out-of-pocket costs.
design. The percentages shown in this table are the With the MetLife plans you can receive
amounts the plan pays. care from any provider; however, you will
receive a higher level of beneit if you stay
Premium Dental Standard Dental in-network. Even though the reimbursement
In-Network
In-Network
Calendar Year Deductible percentages are the same for in- and
out-of-network services, out-of-network
Individual $25 $50 providers do not agree to discounted fees
Family $75 $150 which can make out-of-network usage
Calendar Year Maximum more expensive. Out-of-network charges
$3,000 per person $1,500 per person are subject to reasonable and customary
Coinsurance charges. Download the free apps from the
Preventive—Type A 100% no deductible 100% no deductible App Store (or Google Play for Android )
SM
TM
Basic—Type B 70% after deductible 70% after deductible by searching MetLife.
Major—Type C 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $2,500 $1,000
Beneit Applies to Adults and children Adults and children
Visits and Exams
Limitations 2 per year 2 per year
Prophylaxis, 100% no deductible 100% no deductible
Including Scaling
and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years to 14 1 per every 3 years to 14
X-rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 per 2 per year to 19, 1 per
year thereafter year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
To look for a provider to learn more about this coverage; visit: metlife.com/mybeneits.
ABM 21
Whether or not you join the medical plan, you may enroll ABM ofers team members two dental plans.
in dental coverage administered through MetLife. ABM You can ind out how a dental procedure will
be covered in advance. Ask your provider for
has made some modernization changes to the dental a pre-determination of beneits to estimate
beneits. Please see below for an overview of the plan plan coverage and out-of-pocket costs.
design. The percentages shown in this table are the With the MetLife plans you can receive
amounts the plan pays. care from any provider; however, you will
receive a higher level of beneit if you stay
Premium Dental Standard Dental in-network. Even though the reimbursement
In-Network
In-Network
Calendar Year Deductible percentages are the same for in- and
out-of-network services, out-of-network
Individual $25 $50 providers do not agree to discounted fees
Family $75 $150 which can make out-of-network usage
Calendar Year Maximum more expensive. Out-of-network charges
$3,000 per person $1,500 per person are subject to reasonable and customary
Coinsurance charges. Download the free apps from the
Preventive—Type A 100% no deductible 100% no deductible App Store (or Google Play for Android )
SM
TM
Basic—Type B 70% after deductible 70% after deductible by searching MetLife.
Major—Type C 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $2,500 $1,000
Beneit Applies to Adults and children Adults and children
Visits and Exams
Limitations 2 per year 2 per year
Prophylaxis, 100% no deductible 100% no deductible
Including Scaling
and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years to 14 1 per every 3 years to 14
X-rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 per 2 per year to 19, 1 per
year thereafter year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
To look for a provider to learn more about this coverage; visit: metlife.com/mybeneits.
ABM 21
