Page 18 - Lyon Benefits Guide 01-18 CA - FINAL

[EMPLOYEE BENEFITS]

DENTAL INSURANCE

METLIFE | DHMO
With the Dental Health Maintenance Organization (DHMO) plan through MetLife, you are required to select a general dentist who is
a member of the network to provide your dental care. You will contact your general dentist for all of your dental needs, such as routine
check-ups and emergency situations. If specialty care is needed, your general dentist will provide the necessary referral. For covered
procedures, you’ll pay the pre-set copay or coinsurance fee described in your DHMO plan booklet. Please keep a copy of your booklet
to refer to when utilizing your dental care. This will show the applicable copays that apply to all of the dental services that are covered
under this plan.

METLIFE | PPO

With the MetLife Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the negotiated rate
or visit a non-network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may also obtain services
using a non-network dentist; however, you will be responsible for the difference between the covered amount and the actual charges and
you may be responsible for filing claims.

METLIFE METLIFE
DHMO PPO
Network Name Dental HMO / Managed Care PDP Plus Non-Network
DENTAL BENEFITS
Calendar Year Maximum Benefit Unlimited $1,500
Annual Deductible
• Individual None $50
• Family None $150
Preventive Services 100% for Most Services No Charge No Charge (UCR)
Exams, X-Rays, Cleanings Balance Billing May Apply
Basic Services See Copay Schedule Ded, 20% Ded, 20% (UCR)
Fillings, Endodontics, Periodontics Balance Billing May Apply
Major Services See Copay Schedule Ded, 50% Ded, 50% (UCR)
Crowns, Oral Surgery, Prosthodontics Balance Billing May Apply
Orthodontia
• Covered Members Children & Adults Children & Adults
• Copay $1,450 Copay N/A
• Coinsurance N/A 50%
• Lifetime Benefit Maximum N/A $1,500

FINDING A DENTAL PROVIDER
Go to www.metlife.com/dental. Select “Find a Dentist” and enter your zip code.
• DHMO: Refer to the “Dental HMO / Managed Care” network and the “SGX85” plan when prompted.
• PPO: Refer to the “PDP Plus” network when prompted.

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