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Dental Plan 9

MetLife Dental PPO Plan

ABC Company provides dental care coverage through MetLife. The plan allows you to access dental care
from any dentist you wish. You will receive the greatest level of coverage when you access care from
PPO network dentists. PPO dentists agree to discount their charges and benefit payments are based on
discounted fees.

When you obtain services from non-PPO network dentists, eligible expenses are based on Reasonable &
Customary fees, determined by MetLife for your geographical location. Since expenses are not discounted
with non-PPO dentists, your out-of-pocket costs may be greater.

Plan Features MetLife Dental PPO Plan

In-Network Out-of-Network 1
Providers When you obtain dental care services from a MetLife PPO provider,
you receive a higher level of benefits

Annual Deductible $50 per individual/$150 per family
Annual Maximum Benefits $2,000
Diagnostic/Preventive Services
(X-Rays, Cleanings, Examinations) Covered at 100%; deductible waived Covered at 100%; deductible waived
Routine/Basic Services
(Fillings, Extractions) Covered at 80%; subject to Covered at 80% of R&C fees;
deductible subject to deductible
Major Services
(Bridges, Dentures, Crowns) Covered at 50%; subject to Covered at 50% of R&C fees;
deductible subject to deductible
Orthodontia Services
(Child Only) Covered at 50%; subject to Covered at 50% of R&C fees;
deductible subject to deductible

Lifetime Maximum $2,000
1 If accessing care from a non-MetLife dentist, you may be subject to balance billing for services.