D E N TA L Select A Dental Plan That Meets Your Needs Plateau is pleased to offer MetLife dental this year. This dental plan provides In-Network and Out-of-Network benefits. Benefits provide access to coverage for dental care ranging from routine cleanings to major services and repairs. Through MetLife you have access to thousands of unique providers. Out-of-network benefits are available, however, using In-Network dentists will provide the best rates for services. Below is a summary of the benefits offered. Service Waiting Period for Late Enrollees? Employees who enroll themselves and/or their dependents 31 or more days after the initial eligibility period will be subject to a 12-month waiting period before the plan elected will pay for Basic or Major services. The waiting periods may be decreased or eliminated based on the number of months the member had dental insurance immediately before their effective date. To find a dentist, log on to www.metlife.com. Your dental network is “PDP/PDP PLUS”.
MetLife Dental Plan Highlights
In-Network (Plan Pays)
Out-of-Network (Plan Pays)
Your Deductible
$50 individual / $150 Family
$50 individual / $150 Family
Calendar Year Maximum Applies to preventive, basic, and major services
$1,000 combined In-network and Out-of-Network
$1,000 combined In-network and Out-of-Network
Preventive & Diagnostic Services – Type A Exams: 2 times in 1 calendar year Cleanings: 2 times in 1 calendar year Fluoride: 1 time in 12 months for child under age of 19 Sealants: 1 per molar in 36 months for child under the age of 16 Full Mouth X-Rays: Once in 60 months Bitewing W-Rays: 1 time in 12 months for child under the age of 19; 1 time in 12 months for adults
100% (Deductible waived)
100% (Deductible waived)
Basic Services – Type B Space Maintainers: 1 per lifetime for child under the age of 17 Amalgam Filings: 1 replacement per surface in 24 months Labs & Other Tests Emergency Palliative Treatment Resin Composite Fillings (includes coverage for composite fillings on molars) Oral Surgery: Simple Extractions
80% After deductible
80% After deductible
Major Services – Type C Consultations: 2 in 12 months Root Canal: 1 per tooth per lifetime Periodontal Maintenance: 2 perio Treatments in 1 calendar year, includes 2 cleanings Periodontal Surgery: 1 per quadrant in any 36 month period Scaling & Root Planning: 1 per quadrant in any 36 month period Dentures: 1 in 84 months Denture Adjustments: 1 in 6 months Inlays/Onlays/Crowns: 1 replacement per tooth in 84 months Implant Services: 1 per tooth position in 84 months Implant Supported Prosthetic: 1 per tooth in 84 months Implant Repairs: 1 per tooth in 12 months Tissue Conditioning: 1 in 24 months General Anesthesia Pulpotomy Periodontal Surgery – soft & connective tissue grafts Other Oral Surgery TMJ
50% Coinsurance
50% Coinsurance
Plateau Excavation Benefit Guide | 13
