Page 11 - 360 Behavioral Health Guide 2018-2019 Final

Dental Benefits

MetLife | DHMO Dental Plan (CA only)

The HMO 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 for a printed or emailed copy at (800) 391-6812.

MetLife | DPPO Dental Plan
The PPO 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% 100%
100% for Most Services
Exams, X-Rays, Cleanings
Basic Services (Plan Pays)
Fillings, Oral Surgery, See Copay Schedule 80% 50%
Endodontics, Periodontics

Major Services (Plan Pays) See Copay Schedule 50% 50%
Crowns, Prosthetics

Orthodontia
− Child $1,695 copay 50% up to $1,500
− Adult $1,695 copay 50% up to $1,500

*For per pay period costs, please refer to page 16

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.

11