Page 12 - Sumitomo EE Guide 06-19 Final - English

BENEFITS

DENTAL INSURANCE

METLIFE | DENTAL PLAN
With the MetLife Preferred Dentist Program (PDP) you may visit a network dentist or visit a non‐network dentist. When you utilize
a network 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 Reasonable & Customary (R&C) amount and the actual charges and you may
be responsible for filing claims.

Employees Residing Outside Texas Texas Residents Only
METLIFE METLIFE
PLAN NAME PPO PPO
Network Name Network Non-Network Network Non-Network
Dental Benefits

Calendar Year Maximum $5,000 per individual $5,000 per individual
Calendar Year Deductible
- Individual $50 $50
- Family $150 $150
Type A
Preventive (Plan Pays) 100% 100% of R&C 100% 100% of R&C
Exams, X-Rays, Cleanings

Type B
Basic Services (Plan Pays) 90% after Deductible 80% of R&C 90% 90% of R&C
Fillings, Oral Surgery, after Deductible after Deductible after Deductible
Endodontics, Periodontics
Type C
Major Services (Plan Pays) 60% after Deductible 50% of R&C 60% 60% of R&C
Crowns, Prosthetics after Deductible after Deductible after Deductible
Orthodontia
- Covered Members Children & Adults Children & Adults
- Copay N/A N/A
- Coinsurance 60% of R&C 60% of R&C
- Lifetime Benefit Maximum $2,000 per individual $2,000 per individual

LOCATING A DENTAL PROVIDER

Go to www.metlife.com/dental or download the MetLife mobile app, available on iTunes or the Google
Play Store. Refer to the PDP Plus network when prompted

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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