Page 23 - ABM 2021 Benefit Guide MDV
P. 23
DENTAL BENEFITS
Whether or not you join the medical plan, you may MetLife Dental PPO
enroll in dental coverage administered through ABM ofers team members two dental plans. You can
MetLife. ABM has made some modernization ind out how a dental procedure will be covered in
advance. Ask your provider for a pre-determination of
changes to the dental beneits. Please see beneits to estimate plan coverage and out-of-pocket
below for an overview of the plan design. The costs.
percentages shown in this table are the amounts With the MetLife plans you can receive care from
the plan pays. any provider; however, you will receive a higher level
Premium Dental Standard Dental of beneit if you stay in-network. Even though the
reimbursement percentages are the same for in- and
In-Network
In-Network
Calendar Year Deductible out-of-network services, out-of-network providers do
Individual $25 $50 not agree to discounted fees which can make out-
Family $75 $150 of-network usage more expensive. Out-of-network
Calendar Year Maximum charges are subject to reasonable and customary
$3,000 per person $1,500 per person charges. Download the free apps from the App Store
SM
Coinsurance (or Google Play for Android ) by searching MetLife.
TM
Preventive—Type A 100% no deductible 100% no deductible
Basic—Type B 70% after deductible 70% after deductible
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 1 per every 3 years
to 14 to 14
X-rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per 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 23
Whether or not you join the medical plan, you may MetLife Dental PPO
enroll in dental coverage administered through ABM ofers team members two dental plans. You can
MetLife. ABM has made some modernization ind out how a dental procedure will be covered in
advance. Ask your provider for a pre-determination of
changes to the dental beneits. Please see beneits to estimate plan coverage and out-of-pocket
below for an overview of the plan design. The costs.
percentages shown in this table are the amounts With the MetLife plans you can receive care from
the plan pays. any provider; however, you will receive a higher level
Premium Dental Standard Dental of beneit if you stay in-network. Even though the
reimbursement percentages are the same for in- and
In-Network
In-Network
Calendar Year Deductible out-of-network services, out-of-network providers do
Individual $25 $50 not agree to discounted fees which can make out-
Family $75 $150 of-network usage more expensive. Out-of-network
Calendar Year Maximum charges are subject to reasonable and customary
$3,000 per person $1,500 per person charges. Download the free apps from the App Store
SM
Coinsurance (or Google Play for Android ) by searching MetLife.
TM
Preventive—Type A 100% no deductible 100% no deductible
Basic—Type B 70% after deductible 70% after deductible
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 1 per every 3 years
to 14 to 14
X-rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per 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 23
