Page 15 - 2023 Mersen Benefit Guide

Dental Plan

The Dental Plan (PDP) is administered by MetLife and offers access to in and out-of-network providers for dental services such

as cleanings, preventive services as well as basic and major services. A comparison of the two plan options is noted below.
Always keep in mind that in-network services/providers will save you money and offer a large network to choose from. All plan
grids are available online on MetLife’s website www.metlife.com/insurance/dental-insurance/.

High Option Low Option
Plan Provisions In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
$50/$150 $50/$150
(Individual/Family)
Calendar Year Maximum $2,000 $1,000

Orthodontia Lifetime Maximum $1,500 per individual N/A
Diagnostic and Preventive Services
Covered at 100% Covered at 100%
(e.g., X-rays, cleanings, exams)
Basic and Restorative Services 80%* 80%*
(e.g., fillings)
Major Services
50%* N/A
(e.g., dentures, crowns, bridges)
Orthodontia (Dep. Children Only) 50%* for children under age 26 N/A
*After deductible
Reimbursement for out-of-network services is based on the lesser of the dentist’s actual fee or the Maximum Allowable Charge (MAC). The out-of-network Maximum Allowable
Charge is a scheduled amount determined by MetLife. This applies to Basic Restorative services for both plans. This also applies for Major Restorative services for the High Plan.

Vision Plan

The Vision Care Plan is administered by Highmark Blue Cross Blue Shield Davis Vision and covers a wide range of vision-

related services and products; network of access points, including both private practice and leading retail chain providers.
Highmark BCBS Davis Vision Plan
Plan Provision In-Network Out-of-Network

Covered 100%
Exam Up to $30 off
(There is a hardware copay of $10)
Frames
$120 allowance Up to $30
Fashion/Premier level frames 100%/$25 copay N/A
from “The Collection”

Lenses
Single vision lenses Up to $25 off
Bifocal lenses Covered 100% Up to $35 off
Trifocal lenses Up to $45 off

Contact Lenses
Elective Covered 100% Up to $225 off
Medically necessary N/A

Frequency
Exam 12 Months 12 Months
Lenses 12 Months 12 Months
Frames 12 Months 12 Months

For more information, please review your benefit summary on the ADP homepage.
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PLEASE NOTE: Employees covered by a collective bargaining agreement should refer to their union agreement to determine if they are eligible for these plans.