Page 9 - ABM 2021 Benefit Guide DV
P. 9
DENTAL BENEFITS
Whether or not you join the medical plan, you may enroll
in dental coverage administered through MetLife. ABM MetLife Dental PPO
has made some modernization changes to the dental ABM ofers team members two dental plans.
You can ind out how a dental procedure will
beneits. Please see below for an overview of the plan be covered in advance. Ask your provider for
design. The percentages shown in this table are the a pre-determination of beneits to estimate
amounts the plan pays. plan coverage and out-of-pocket costs.
Premium Dental Standard Dental With the MetLife plans you can receive
care from any provider; however, you will
In-Network
In-Network
Calendar Year Deductible receive a higher level of beneit if you stay
Individual $25 $50 in-network. Even though the reimbursement
Family $75 $150 percentages are the same for in- and
Calendar Year Maximum out-of-network services, out-of-network
$3,000 per person $1,500 per person providers do not agree to discounted fees
Coinsurance which can make out-of-network usage
more expensive. Out-of-network charges
Preventive—Type A 100% no deductible 100% no deductible are subject to reasonable and customary
Basic—Type B 70% after deductible 70% after deductible charges. Download the free apps from the
Major—Type C 50% after deductible 50% after deductible App Store (or Google Play for Android )
SM
TM
Orthodontia by searching MetLife.
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, Including 100% no deductible 100% no deductible
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 Crowns 70% after deductible 70% after deductible
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 9
Whether or not you join the medical plan, you may enroll
in dental coverage administered through MetLife. ABM MetLife Dental PPO
has made some modernization changes to the dental ABM ofers team members two dental plans.
You can ind out how a dental procedure will
beneits. Please see below for an overview of the plan be covered in advance. Ask your provider for
design. The percentages shown in this table are the a pre-determination of beneits to estimate
amounts the plan pays. plan coverage and out-of-pocket costs.
Premium Dental Standard Dental With the MetLife plans you can receive
care from any provider; however, you will
In-Network
In-Network
Calendar Year Deductible receive a higher level of beneit if you stay
Individual $25 $50 in-network. Even though the reimbursement
Family $75 $150 percentages are the same for in- and
Calendar Year Maximum out-of-network services, out-of-network
$3,000 per person $1,500 per person providers do not agree to discounted fees
Coinsurance which can make out-of-network usage
more expensive. Out-of-network charges
Preventive—Type A 100% no deductible 100% no deductible are subject to reasonable and customary
Basic—Type B 70% after deductible 70% after deductible charges. Download the free apps from the
Major—Type C 50% after deductible 50% after deductible App Store (or Google Play for Android )
SM
TM
Orthodontia by searching MetLife.
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, Including 100% no deductible 100% no deductible
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 Crowns 70% after deductible 70% after deductible
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 9
