Dental
Metropolitan Life Insurance Company
Plan Design for: Hughston Medical Management Group Original Plan Effective Date: January 1, 2023 Network: PDP Plus
The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver cost-effective protection for a healthier smile and a healthier you.
In-Network 1
Out-of-Network 1
High Plan
In-Network % of Negotiated Fee 2
Out-of-Network 1 % of R&C Fee 4
Coverage Type:
Type A - Preventive
100%
100%
Type B - Basic Restorative Type C - Major Restorative
80%
80%
50%
50%
Type D – Orthodontia
50%
50%
Deductible 3 Individual
$50
$50
Family
3 Individual Deductibles
3 Individual Deductibles
Annual Maximum Benefit: Per Individual
$3000
$3000
Ortho applies to Child Only Up to dependent age limit
Orthodontia Lifetime Maximum
$1500 per Person
$1500 per Person
Dependent Age:
Eligible for benefits until the end of the month that he or she turns 26. Low Plan
In-Network % of Negotiated Fee 2
Out-of-Network 1 % of R&C Fee 4
Coverage Type:
Type A - Preventive
100%
100%
Type B - Basic Restorative Type C - Major Restorative
80%
80%
0%
0%
Type D – Orthodontia
NA
NA
Deductible 3 Individual
$50
$50
Family
3 Individual Deductibles
3 Individual Deductibles
Annual Maximum Benefit: Per Individual
$1500
$1500
Dependent Age: Eligible for benefits until the day that he or she turns 26. 1 . "In-Network Benefits" means benefits provided under this plan for covered dental services that are provided by a MetLife PDP dentist. "Out-of-Network Benefits" means benefits provided under this plan for covered dental services that are not provided by a MetLife PDP dentist. Utilizing an out-of-network dentist for care may cost you more than using an in-network dentist. 2 . Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.
High Plan 3. Applies to Type B and C services only. 4. Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary
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DN-GCERT-GOLD Multioption Dental Benefit Summary
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