DENTAL INSURANCE
Jagged Peak offers dental coverage through MetLife. The PPO Dental Plans allow you to use in- network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for paying the difference between MetLife’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plans.
DHMO
Low PPO
High PPO
FLORIDA EMPLOYEES ONLY
In-Network Only
In-Network
Out-of Network*
In-Network
Out-of Network*
Calendar Year Deductible
N/A
$50 / $150
$100 / $300
$25 / $75
$25 / $75
Individual / Family Annual Maximum
Unlimited
$1,250
$2,250
Diagnostic & Preventive
Covered in full after deductible
Exams, Cleanings, Fluoride, X-Rays, Sealants Regular Restorative Services
See Fee Schedule
Covered in full
Covered in full
Covered in full
Amalgam Fillings, Extractions – Single Tooth, Endodontics (Root Canal), Periodontics (Gum Disease)
Covered 80% after deductible
Covered 50% after deductible
Covered 90% after deductible
Covered 80% after deductible
See Fee Schedule
Major Services
Covered 50% after deductible
Covered 25% after deductible
Covered 60% after deductible
Covered 50% after deductible
See Fee Schedule
Crowns, Bridges, Dentures Orthodontia Services
50% $500 Lifetime Maximum
50% $2,000 Lifetime Maximum
See Fee Schedule
Children only under the age of 19
DHMO
Low PPO
High PPO
Employee Cost Per Pay Period
Employee Only
$ 5.53 $ 9.72 $ 11.58 $ 16.31
$ 10.73 $ 21.77 $ 28.41 $ 42.17
$ 6.54 $ 13.25 $ 17.41 $ 26.34
Employee + Spouse Employee + Child(ren)
Family
• Subject to balance billing. Please refer to your plan document for specific details .
Low PPO
High PPO
OHIO EMPLOYEES ONLY
In-Network
Out-of Network*
In-Network
Out-of Network*
Calendar Year Deductible
$50 / $150
$100 / $300
$25 / $75
$25 / $75
Individual / Family Annual Maximum
$1,250
$2,250
Diagnostic & Preventive
Covered in full after deductible
Covered in full
Covered in full
Covered in full
Exams, Cleanings, Fluoride, X-Rays, Sealants Regular Restorative Services
Covered 80% after deductible
Covered 50% after deductible
Covered 90% after deductible
Covered 80% after deductible
Amalgam Fillings, Extractions – Single Tooth, Endodontics (Root Canal), Periodontics (Gum Disease) Major Services
Covered 50% after deductible
Covered 25% after deductible
Covered 60% after deductible
Covered 50% after deductible
Crowns, Bridges, Dentures
Orthodontia Services
50% $500 Lifetime Maximum
50% $2,000 Lifetime Maximum
Children only under the age of 19
Employee Cost Per Pay Period
Low PPO
High PPO
Employee Only
$ 6.54 $ 13.25 $ 17.41 $ 26.34
$ 10.73 $ 21.77 $ 28.41 $ 42.17
Employee + Spouse
Employee + Child(ren)
Family
• Subject to balance billing. Please refer to your plan document for specific details .
7
Made with FlippingBook Learn more on our blog