Page 10 - Sonsio 2021 Annual Benefits Enrollment
P. 10
Finding In-Network Providers Dental
Remember to visit in-network dentists to receive the We partner with MetLife to offer you and your family
deepest level of discount on your services. members dental insurance. Visit www.metlife.com to
To ind a participating in-network dentist in your area go ind in-network providers and access a variety of
to www.metlife.com or call 800.942.0854 . These online tools and programs.
plans access the PDP Plus Network.
Low PPO High PPO
Orthodontia Services Note In- Out-of- In- Out-of-
The lifetime maximum illustrated is diferent from the Network Network Network Network
calendar year maximum. For orthodontia services, this Calendar Year Deductible
limit does not reset each year, this is the most your Individual $50 $75 $50 $50
plan will cover for your services for the lifetime of your Family
participation in this program. $150 $225 $150 $150
Calendar Year Maximum
Examples of Services $1,000 $1,000 $1,500 $1,500
Preventive—exams, cleanings, luoride, x-rays, and Coinsurance
sealants Preventive 100% 90% 100% 100%
Basic—illings, extractions, periodontics, repairs, and Basic 80% 60% 90% 80%
oral surgery Major 50% 40% 60% 50%
Major—crowns, inlays, dentures, and dental impacts Orthodontia—Child(ren) eligible only
Coinsurance N/A N/A 60% 50%
Lifetime N/A N/A $1,200 $1,200
Maximum
This is a high level summary of your beneit coverage. Full coverage
details are available in your summary plan description (SPD). In the
event there is a discrepancy between what is relected in this guide and
what is communicated in your SPD, the terms of your SPD will prevail.
Associate Bi-Weekly Dental
Contributions
Low Plan- High Plan-
Biweekly Biweekly
Associate Only $4 .53 $8 .51
Associate and Spouse $8 .33 $17 .87
Associate and Child(ren) $11 .85 $16 .17
Family $16 .92 $23 .75
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Remember to visit in-network dentists to receive the We partner with MetLife to offer you and your family
deepest level of discount on your services. members dental insurance. Visit www.metlife.com to
To ind a participating in-network dentist in your area go ind in-network providers and access a variety of
to www.metlife.com or call 800.942.0854 . These online tools and programs.
plans access the PDP Plus Network.
Low PPO High PPO
Orthodontia Services Note In- Out-of- In- Out-of-
The lifetime maximum illustrated is diferent from the Network Network Network Network
calendar year maximum. For orthodontia services, this Calendar Year Deductible
limit does not reset each year, this is the most your Individual $50 $75 $50 $50
plan will cover for your services for the lifetime of your Family
participation in this program. $150 $225 $150 $150
Calendar Year Maximum
Examples of Services $1,000 $1,000 $1,500 $1,500
Preventive—exams, cleanings, luoride, x-rays, and Coinsurance
sealants Preventive 100% 90% 100% 100%
Basic—illings, extractions, periodontics, repairs, and Basic 80% 60% 90% 80%
oral surgery Major 50% 40% 60% 50%
Major—crowns, inlays, dentures, and dental impacts Orthodontia—Child(ren) eligible only
Coinsurance N/A N/A 60% 50%
Lifetime N/A N/A $1,200 $1,200
Maximum
This is a high level summary of your beneit coverage. Full coverage
details are available in your summary plan description (SPD). In the
event there is a discrepancy between what is relected in this guide and
what is communicated in your SPD, the terms of your SPD will prevail.
Associate Bi-Weekly Dental
Contributions
Low Plan- High Plan-
Biweekly Biweekly
Associate Only $4 .53 $8 .51
Associate and Spouse $8 .33 $17 .87
Associate and Child(ren) $11 .85 $16 .17
Family $16 .92 $23 .75
10
