Page 12 - 2019 Blacoh Benefit Guide Final 11/14/18

Dental Benefits

MetLife | DHMO Dental Plan
MetLife dental HMO plan, you'll have access to an extensive network of dental providers
without paying deductibles or filling out claim forms. Plus, it's easy. First, choose a dental
provider from our network during enrollment. Then, contact this dental provider for all of
your dental care, including referrals for consultation with plan specialists and emergency
services.

NOTE
MetLife | DPPO Dental Plan
We strongly The Preferred Dentist Program is designed to provide the dental coverage you need with
recommend you ask the features you want. Like the freedom to visit the dentist of your choice— in or out of
your dentist for a the network. Plan benefits for in-network services are based on the percentage of the
predetermination if negotiated fee - the fee that participating dentists have agreed to accept as payment in
total charges are full. Plan benefits for out-of-network services are based on the percentage of the
expected to exceed Reasonable and Customary (R&C) charges. If you choose a dentist who does not
$300. participate in the network, your out-of-pocket expenses may be more, since you will be
responsible for paying any difference between the dentist's fee and your plan's payment
Predetermination for the approved service.
enables you and your
dentist to know in
advance what the
payment will be for Finding In-Network Dental Providers
any service that may Go to www.metlife.com/insurance/dental-insurance/
be in question.
or call DHMO (800) 880-1800 / PPO (800) 942-0854

Plan Features MetLife Dental

DHMO DPPO DPPO
Met185 Participating Providers Non-Participating

Calendar Year
None $2,000 $2,000
Maximum
Deductible
- Individual None $50 $50
- Family None $150 $150

Preventive $5 Copay + copay per
None None
procedure
Basic Services $5 Copay + copay per
20% after deductible 20% after deductible
procedure
Major Services $5 Copay + copay per
procedure 50% after deductible 50% after deductible

Orthodontia
- Adults $1,695 copay Not covered Not covered
- Child(ren) $1,695 copay 50% up to $1,500 50% up to $1,500

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