Page 9 - OrangeTheory Benefits Guide 2018-2019 Final

Dental Benefits

MetLife | DHMO Dental Plan

The DHMO plan provides dental care through a network of contracted HMO dentists. All services must be received from
MetLife contracted HMO dentists. You must choose a Primary Care Dentist and you may self-refer to specialists within the
HMO network. There are no claim forms to file. A detailed list of all copays by procedure are available through Human
Resources or by calling the helpline at (800) 391-6812 for a printed or electronic copy.

MetLife | DPPO Dental Plan
The DPPO plan is a Preferred Provider Plan. You may visit a PPO Dentist and benefit from the negotiated rate or visit an out-
of-network dentist. When you utilize a PPO Provider, your out-of-pocket expenses will be less. When using an out-of-
network provider, the plan will cover only allowable charges and you will be responsible for any balance billed by the
provider.

MetLife MetLife
Plan Type:
DHMO Plan DPPO Dental Plan
Network Type: Network Network Non-Network
Dental Benefits

Calendar Year Maximum Unlimited $1,500 $1,500
Deductible (Annual)
- Individual $0 $50 $50
- Family $0 $150 $150
Preventive (Plan Pays) 100% for Most Services 100% 100%
Exams, X-Rays, Cleanings
Basic Services (Plan Pays)

Fillings, Oral Surgery, See Copay Schedule
80% 80%
Endodontics, Periodontics
Major Services (Plan Pays)
See Copay Schedule 50% 50%
Crowns, Prosthetics
Orthodontia
- Child $1,695 copay Not Covered
- Adult $1,695 copay Not Covered

Finding In-Network Dental Providers

Go to www.metlife.com/insurance/dental-insurance or call DHMO (800) 880-1800 / PPO (800) 942-0854

Note: We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300.
Predetermination enables you and your dentist to know in advance what the payment will be for any service that may be
in question.

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