Dental Plan Summary
This table illustrates the benefits provided under each dental plan option. The percentages listed below represent the approximate amount of cost covered. Please be aware that out-of-network providers are reimbursed up to the reasonable and customary limit for covered dental services. These providers may bill you the difference between their actual charge and the amount they are reimbursed by MetLife. For more specific planinformation, pleaserefer toyourSummaryPlanDescription(SPD).
MetLife Core Dental Plan
MetLife Buy-Up Dental Plan
Benefit Description
In-Network
Out-of-Network
In-Network
Out-of-Network
Annual Deductible Individual Family
$50* $150*
$50* $150*
$50* $150*
$50* $150*
Annual Maximum
$2,000 per person
$2,000 per person
$4,000 per person
$4,000 per person
80% of PDP Fee** deductible waived
80% of R&C Charges*** deductible waived
100% of PDP Fee** deductible waived
100% of R&C Charges*** deductible waived
Type A – Preventive Services
80% of PDP Fee** after deductible
80% of R&C Charges*** after deductible
90% of PDP Fee** after deductible
90% of R&C Charges*** after deductible
Type B – Basic Restorative Services
50% of PDP Fee** after deductible
50% of R&C Charges*** after deductible
60% of PDP Fee** after deductible
60% of R&C Charges*** after deductible
Type C – Major Restorative Services
50% of PDP Fee** after deductible
50% of R&C Charges*** after deductible
TypeD – Orthodontia
Not Covered
Not Covered
Orthodontia Lifetime Maximum
Not Applicable
Not Applicable
$1,500 per person
$1,500 per person
*Applies only to Type B and C services. **PDP Fee refers to the negotiated fees that participating providers charge for covered dental services. ***Reasonable& Customary(R&C)chargesarebasedon the researchof a dentist's usual, actual, and communityaverage chargeas determinedby MetLife.
Pre-Treatment Estimates It is highly recommended that you obtain pre-treatment estimates for all dental services in excess of $300. To obtain a pre-treatment estimate, a claim form must be submitted to MetLifethat outlines 1) the dental work to be done and 2) what the cost will be.
Alternate Benefits Your dental plan provides that where two or more professionally accepted dental treatments for a dental condition exist, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment upon which the plan benefit is based, your actual out-of-pocket expense will be: the procedure charge for the treatment upon which the plan benefit is based, plus the full difference in cost between the scheduled PDP fee or, if non PDP, the actual charge for the service actually rendered and the scheduled PDP fee or R&C fee (if non PDP) for the service upon which the plan benefit is based. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pre-treatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges, and dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, the plan's reimbursement for those services, and your out-of-pocket expense. Procedure charge schedules are subject to change each plan year. You can obtain an updated procedure chargeschedule for yourarea via fax by calling 1-800-942-0854 and using the MetLife DentalAutomated Information Service.
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