In-Network
Plan Year Deductible (Individual / Family)
$50 / $150
Plan Year Maximum
$5,000 per Person
Preventive & Diagnostic Services
Covered 100% No Deductible
Basic Restorative Services
Plan Pays 90% After Deductible
Major Restorative Services
Plan Pays 60% After Deductible
Orthodontia (children up to age 19)
Plan Pays 50% No Deductible
Lifetime max of $1,500 per Person
Out-of-Network1
Plan Year Deductible (Individual / Family)
$50 / $150
Plan Year Maximum
$5,000 per Person
Preventive & Diagnostic Services
Covered 100% No Deductible
Basic Restorative Services
Plan Pays 80% After Deductible
Major Restorative Services
Plan Pays 50% After Deductible
Orthodontia (children up to age 19)
Plan Pays 50% No Deductible
Lifetime max of $1,500 per Person
- If you receive services from an out-of-network provider, you may be required to submit the claim yourself. Reimbursement will be based on the insurance carrier’s allowed amount, and you may be responsible for any difference between the provider’s charges and the allowed amount (balance billing).
- The orthodontia lifetime maximum is a one-time limit that does not reset each year. Once the maximum is reached, no additional orthodontia benefits will be paid.
Preventive
Procedures that dentists use to diagnose, monitor, and maintain a patient's oral health:
- Cleaning and oral exam
- Fluoride treatment
- Sealants
- X-rays
Basic
Treatments that are relatively straightforward and don’t involve a significant laboratory expense:
- Filling
- Tooth removal
- Root canal
- Anesthesia
Major
Procedures that are more complex and often involve a dental laboratory expense:
- Bridges and dentures
- Inlays, onlays, and veneers
- Crowns, bridges, and dentures (repair & maintenance)
Orthodontia
Specialist care and corrective action to align bite and/or straighten teeth:
- Appliances, including braces and retainers
Contribution Rates
Semi-Monthly Pre-Tax Contributions (24 Pay Periods)
Payroll Rates
Semi-Monthly Pre-Tax Contributions (24 Pay Periods)
Employee Only
$0.00
Employee + Spouse
$22.69
Employee + Child(ren)
$25.23
Employee + Family
$38.14
Contact the provider of these benefits by calling this phone number or visiting this website: 800-942-0854, www.metlife.com