Sample Benefit Enrollment Guide

2019 Benefit Guide

MetLife Dental Plan Summary

Basic Plan

Buy Up Plan

Benefit Summary

In-Network Non-Network * In-Network Non-Network *

Calendar Yr. Deductible (Types B-C)

$100 ind/$300 fam

$50 ind/$150 fam

Calendar Yr. Maximum Benefit (per person)

$1,000

$1,500

Type A: Diagnostic & Preventive

Cleanings (2 per 12 months)

Oral Exams (2 per 12 months) Fluoride (2 per year children under 19)

100%

100%

100%

100%

X-rays (frequency variations) Sealants (for children under 19)

Type B: Basic Restorative

Fillings, Simple Extractions

Space Maintainers Periodontal Scaling Non-Surgical Endo and Perio

80%

50%

100%

80%

Type C: Major Restorative

Oral surgery, Anesthesia

50%

50%

60%

50%

Access MetLife online or via mobile app to: „ „ View your claims „ „ View your ID Card „ „ Look up providers

Surgical Endo and Perio Root Canal Therapy Dentures, Crowns, Bridges Bridge Repairs, Implants

Type D: Orthodontia (for children under 19)

50%

50%

50%

50%

Orthodontia lifetime max

$1,000

$1,000

* Services with Non MetLife dentists are paid at the rate of reasonable and customary.

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