Page 13 - Kate Somerville Benefits Guide 2020 NonCA FINAL

Dental Plan Choices

METLIFE | PPO PLAN
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and
reduce your out-of-pocket costs if you choose a dentist who participates in the MetLife network. When you utilize a network den-
tist, your out-of-pocket expenses will be less, however, you will usually pay the lowest amount for services when you visit a PPO
dentist. If you obtain services using a non-network dentist, you will be responsible for the difference between the covered
amount and the actual charges and you may be responsible for filing claims. The chart below provides a high-level overview of
your dental plan.

MetLife
Plan Name DPPO
Network Name In-Network Non-Network
Dental Benefits
Calendar Year Maximum Benefit $2,500
Annual Deductible
- Individual $50
- Family $150
Preventive Services No Charge 10%*

Basic Services Deductible, 20% Deductible, 20%*
Major Services Deductible, 50% Deductible, 50%*
Orthodontia
- Child 50% / $1,500 Lifetime Benefit Maximum
- Adult 50% / $1,500 Lifetime Benefit Maximum
*Dentists who are out-of-network have not agreed to pricing, and may bill you for the difference between what MetLife pays them
and what the dentist usually charges.
Cost Per Pay Period (24 per year)
- Employee $4.67
- Employee + spouse $18.00
- Employee + child(ren) $20.58
- Employee + family $38.05

NOTE:
We strongly recommend you ask your dentist
for a predetermination if total charges are ex-
pected to exceed $300. Predetermination ena-
bles you and your dentist to know in advance
what the payment will be for any service that
may be in question.

FINDING A DENTAL PROVIDER:

Visit www.metlife.com, click "Dentist" in middle of page.
Enter zip code, city or state.

Then, select the following network: PDP Plus

KATE SOMERVILLE EMPLOYEE BENEFITS 13