Page 106 - 2021 Miami Marlins Front Office Benefits Guide

Dental Insurance

Space Maintainers Space maintainers for dependent children up to his/her 19th birthday

One application of sealant material every 5 years for each non-restored, non-
Sealants
decayed 1st and 2nd molar of a dependent child up to his/her 19th birthday
Type B — Basic Restorative
Fillings Replacement once every 24 months
Simple Extractions
Crown, Denture and Bridge Repair/ Repair once every 12 months
Recementations Recementations once every 12 months
Oral Surgery

Endodontics Root canal treatment limited to once per tooth per 24 months

When dentally necessary in connection with oral surgery, extractions or other
General Anesthesia
covered dental services

 Periodontal scaling and root planing once per quadrant, every 24 months
 Periodontal surgery once per quadrant, every 36 months
Periodontics
 Total number of periodontal maintenance treatments and prophylaxis cannot
exceed four treatments in a calendar year

Type C — Major Restorative

Implants Replacement once every 5 years

 Dentures and bridgework replacement; one every 5 years
Bridges and Dentures  Replacement of an existing temporary full denture if the temporary denture
cannot be repaired and the permanent denture is installed within 12 months
after the temporary denture was installed

Crowns, Inlays and Onlays Replacement once every 5 years

Type D — Orthodontia

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166
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