MetLife Dental PPO Plan
Services
In-Network
Out-of-Network
Annual Deductible
$25/$75
Calendar Year
Deductible Accumulation
Annual Maximum Benefit
$3,000
Preventive Dental Services (Deductible is Waived) (cleaning, exams, x-rays)
Plan pays 100%
Plan pays 100%
Once every 6 months
Once every 6 months
Frequency
Plan pays 80% You pay 20%
Basic Dental Services (fillings, root canal)
Plan pays 100%
Full mouth X-rays:
Full mouth X-rays: 1 in
1 in 3 years
3 years
Crowns:
Crowns:
Waiting Period
1 per tooth in 5 years
1 per tooth in 5 years
Plan pays 60%
Plan pays 50% You pay 50%
Major Dental Services
You pay40%
(extractions, crowns, inlays, onlays,
bridges, dentures, repairs, root
Repairs: 1 in 12 months Bridges/Dentures: 1 in 5 years
Repairs : 1 in 12 months Bridges/Dentures: 1 in 5 years
canal)
Waiting Period
Orthodontia Services (Up to age 19)
50% Lifetime Maximum
Orthodontia Lifetime Max
$3,000
Dependent Cut Off Age (Plan)
Up to Age 26
11
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