Page 8 - OrangeTheory Benefits Guide 07-2019_FINAL - NonCA

Dental Benefits

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
Plan Type:
DPPO Dental Plan
Network Type: Network Non-Network

Dental Benefits
Calendar Year Maximum $1,500 $1,500
Deductible (Annual)
- Individual $50 $50
- Family $150 $150

Preventive (Plan Pays)
100% 100%
Exams, X-Rays, Cleanings
Basic Services (Plan Pays)
Fillings, Oral Surgery,
80% 80%
Endodontics, Periodontics
Major Services (Plan Pays) 50% 50%
Crowns, Prosthetics

Orthodontia
- Child Not Covered
- Adult Not Covered

Finding In-Network Dental Providers

Go to www.metlife.com/insurance/dental-insurance or call 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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