Metlife PPO Plan Services
In-Network
Out-of-Network
$25/$75
$25/$75
Annual Deductible (per person, per calendar year)
Deductible Accumulation
Calendar Year
Calendar Year
Annual Maximum Benefit (per person, per calendar year)
$3,000
$3,000
Preventive Dental Services (cleaning, exams, x-rays)
Plan pays 100%
Plan pays 100%
Frequency
Once every 6 months
Once every 6 months
Plan pays 80% You pay 20%
Basic Dental Services (fillings, root canal)
Plan pays 100%
Full mouth X-rays: 1 in 3 years Crowns: 1 per tooth in 5 years
Full mouth X-rays: 1 in 3 years Crowns: 1 per tooth in 5 years
Waiting Period
Plan pays 60% You pay40%
Plan pays 50% You pay 50%
Major Dental Services (extractions, crowns, inlays, onlays, bridges, dentures, repairs)
Repairs : 1 in 12 months Bridges/Dentures: 1 in 5 years
Repairs: 1 in 12 months Bridges/Dentures: 1 in 5 years
Waiting Period
Plan pays 50% You pay 50%
Plan pays 50% You pay 50%
Orthodontia Services
Orthodontia Lifetime Max
$3,000
$3,000
Dependent Cut Off Age
26 years old
2024-2025 Benefit Summary
13
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