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

[EMPLOYEE BENEFITS]

DENTAL INSURANCE

METLIFE | PPO
With the MetLife Preferred Provider Organization (PPO) dental plans, 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
LOW PPO HIGH PPO
Network Name PDP Plus Non-Network PDP Plus Non-Network
DENTAL BENEFITS

Calendar Year Maximum Benefit $1,500 $1,000 $1,500
Annual Deductible
• Individual $0 $100 $50
• Family $0 $300 $150
Preventive Services No Charge Ded, 30% (UCR) No Charge No Charge (UCR)
Exams, X-Rays, Cleanings Balance Billing Balance Billing
May Apply May Apply
Basic Services 10% Ded, 40% (UCR) Ded, 20% Ded, 20% (UCR)
Fillings, Endodontics, Periodontics Balance Billing Balance Billing
May Apply May Apply
Major Services 40% Ded, 70% (UCR) Ded, 50% Ded, 50% (UCR)
Crowns, Oral Surgery, Balance Billing Balance Billing
Prosthodontics May Apply May Apply
Orthodontia
• Covered Members Children & Adults Children & Adults Children & Adults
• Copay N/A N/A N/A
• Coinsurance 50% 60% 50%
• Lifetime Benefit Maximum $1,500 $1,000 $1,500

FINDING A DENTAL PROVIDER
Go to www.metlife.com/dental. Select “Find a Dentist” and enter your zip code. Refer to the “PDP Plus” network
when prompted.

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