dental insurance options for the school district of …...2010/09/18 · metlife is pleased to be...

MetLife is pleased to be the dental benefits provider for The School District of Lee County employees and their covered dependents.

Our goal is to help you get the dental care you and your family need.

You have three MetLife PPO dental plans to choose from — High PPO Plan (D2000), Mid PPO Plan (D1500) and Low PPO Plan (D1000). The right dental coverage will make it easier to visit the dentist and may help you avoid more costly procedures down the road.

With the MetLife Dental PPO Plans, you can visit any licensed dentist, in or out of the network, and still receive benefits. When you choose a participating dentist, you could save even more — dentists in network accept negotiated fees that are typically 30–45% less than the average charges in the same geographical area for the same or similar services.1

To find a participating dentist near you, go to www.metlife.com/dental. Enter your zip code and select the PDP Plus Network. It’s just that simple.

Apart from a large national network, you also get 100% coverage for preventive and diagnostic procedures.2 The goal is to help you significantly lower your costs and get the care you need. Preventive and diagnostic procedures will not count toward your annual maximum — these are paid at 100% of the allowed amount.

Once you enroll, you will not have a waiting period.

And it gets better.Now checking up on your MetLife Dental PPO Plan is easy with the MetLife Mobile App.3 You can find a dentist, view your dental plan summary and dental claims, plus view your ID card.

Don’t let this happen to you.You must make an election within 30 days from your hire date in order to have dental coverage; failure to select one of the MetLife dental PPO plans will result in you not having dental insurance until the following annual open enrollment period.

If you have any questions, please call MetLife at 1-800-942-0854, Monday through Friday from 8 AM to 11 PM ET.

We look forward to serving you.MetLife

1. Based on internal analysis by MetLife. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, coinsurance and benefit maximums. Negotiated fees are subject to change.

2. Subject to frequency limitations.3. Before using the MetLife Mobile App, you must register at www.metlife.com/mybenefits

from a computer. Registration cannot be done from your mobile device.

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Dental insurance options for The School District of Lee County

Can I get an estimate of what my out-of-pocket expenses will be before receiving a service?

Yes. Your dentist can request a pre-treatment estimate prior to your procedure to help you estimate what you may need to pay.

MetLife recommends that you request a pre-treatment estimate for services that may exceed $300. Your provider can simply submit a request at www.metdental.com or call 1-877-MET-DDS9.

What should I consider when deciding which MetLife Dental PPO Plan is best for me and my family?

• You should think about the dental procedures that your dentist may need to provide to you and your family:

• Are you planning to have orthodontia work done? The High PPO Plan (D2000) covers adult orthodontia.

• Does a dependent child need braces? Child Orthodontia is covered under the High PPO Plan (D2000) and Mid PPO Plan (D1500).

• Need an Implant? The High PPO Plan (D2000) covers Implants at 50%.

• Do you typically only have two cleanings and exams? The Low PPO Plan (D1000) may be the most cost effective option for you.

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What’s important to know about these MetLife Dental PPO Plans?

• You can choose between THREE different MetLife Dental PPO Plans — High PPO Plan (D2000), Mid PPO Plan (D1500) or Low PPO Plan (D1000)

• Once you enroll, there is NO WAITING PERIOD; you can start using your dental benefits right away.

• Preventive and diagnostic procedures will NOT count towards your annual maximum

• The Missing Tooth Exclusion is WAIVED for all three MetLife Dental PPO Plans

• There are over 200,000 participating dentists to choose from in the MetLife PDP Plus Network

• Once you are enrolled in one of the MetLife Dental PPO Plans, you have access to the MyBenefits website at www.metlife.com/mybenefits.

• Use the MetLife Mobile App to find a dentist, view Dental claims or view an ID card

Things to consider

Summary of Benefits Dental insurance — dental PPO options

Under the MetLife Preferred Dentist Program, MetLife pays benefits for covered services performed by either in-network dentists or out-of-network dentists. However, you may be able to reduce out-of-pocket costs by using an in-network dentist.

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Benefits High PPO Plan (D2000) Mid PPO Plan (D1500) Low PPO Plan (D1000)

Coverage typeIn-network1/out-of- network2

In-network1/out-of- network2

In-network1/out-of- network2

Preventive100%No deductible

100%No deductible

100%/50%No deductible

Basic80%After deductible

80%After deductible

80%/30%After deductible

Major50%After deductible

50%After deductible

50%/0%After deductible

Orthodontia 50% 50% Not covered

Implants 50% Not covered Not covered

Prophylaxis cleanings Covered under preventive Covered under preventive Covered under preventive

Periodontal maintenance/Periodontal cleanings

Covered under preventive Covered under basic Covered under basic

Individual/Family Deductible $25/$75 both in- and out-of-network $50/$150 both in- and out-of-network$100/$300 in-network$250/$750 out-of-network

Annual Maximum $2,000 both in- and out-of-network $1,500 both in- and out-of-network$1,000 in-network$250 out-of-network

Orthodontia In-network/out-of-network In-network/out-of-network In-network/out-of-network

Adult orthodontia Covered Not covered Not covered

Child orthodontia Covered up to age 26 Covered up to age 26 Not covered

Lifetime orthodontia maximum $2,000 $1,500 N/A

1 In-network pays as % of negotiated fees. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, coinsurance and benefit maximums. Negotiated fees are subject to change.2 Out-of-network pays as % of the reasonable and customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.

Rates per pay period High PPO Plan (D2000) Mid PPO Plan (D1500) Low PPO Plan (D1000)

Employee $22.30 $18.00 $13.85

Employee/spouse $45.55 $36.85 $28.30

Employee/child(ren) $45.70 $37.00 $28.45

Employee/family $72.25 $58.80 $45.25

Preventive Basic Major

Examinations: 2 in 1 plan year Amalgam fillings:1 replacement per surface in 24 months

Crown buildups/ post core

1 per tooth in 5 plan years

Examinations —Problem focused:

Combined withexaminations limit

Root canal: 1 in 2 plan years Repairs 1 in 12 months

Cleanings:Prophylaxis:2 in 1 plan year

Periodontalsurgery:

1 per quadrant in any 3 plan years

Dentures 1 in 5 plan years

Periodontalmaintenance:

Periodontal cleanings:2 in 1 plan year

Scaling &root planing:


Dentures —rebases/relines

1 in 36 months

Sealants:Child under age 14:1 per molar in lifetime

Prefabricated crowns: 1 per tooth in 24 months Denture adjustments 1 in 6 months

Space maintainers:Child under age 14:1 per lifetime

Recementations Fixed bridges 1 in 5 plan years

Fluoride:Child under age 14:1 in 1 plan year

Emergency palliative treatmentInlays/onlays/ crowns

1 replacement per tooth in 5 plan years

Full mouth x-rays: 1 in 5 plan years General anesthesia Implant services1 per tooth position in 5 plan years

Bitewing x-rays:Child under age 19:1 in 1 plan yearAdult: 1 in 1 plan year

Resin composite fillings (excludes composite fillings on molars)

Implant repairs1 per tooth in24 months

Labs & other tests PulpotomyImplant supported prosthetic


Periapical x-rays Pulp therapy Tissue conditioning 1 in 36 months

Other x-rays Apexification & recalcification Occlusal adjustments 1 in 36 months

Periodontal surgery —Soft & connective tissue grafts Orthodontic

(Adult & Children up to age 26)Periodontics — non-surgical

Oral surgery — simple extractions Orthodontic diagnostics

Oral surgery — surgical extractions Orthodontic treatment

Other oral surgery

General services

Harmful habit appliances

Covered services & frequency limitations

High PPO Plan (D2000) Benefits are available immediately from the start date of an individual’s benefits (no waiting period).

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Exclusions for High PPO Plan (D2000)

We will not pay dental insurance benefits for charges incurred for:1. services which are not dentally necessary or those which do

not meet generally accepted standards of care for treating the particular dental condition;

2. services for which you would not be required to pay in the absence of dental insurance;

3. services or supplies received by you or your dependent before dental insurance starts for that person;

4. services which are neither performed or prescribed by a dentist, except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for:• scaling and polishing of teeth; or• fluoride treatments;

5. services which are primarily cosmetic unless such service is:• required for reconstructive surgery which is incidental to or

follows surgery which results from trauma, an infection or other disease of the involved part; or

• required for reconstructive surgery because of a congenital disease or anomaly of a child which has resulted in a functional defect;

For residents of Texas see notice page section of the Dental Certificate;

6. services or appliances which restore or alter occlusion or vertical dimension;

7. restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease;

8. restorations or appliances used for the purpose of periodontal splinting;

9. counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;

10. personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss;

11. decoration or inscription of any tooth, device, appliance, crown or other dental work;

12. missed appointments;

13. services:• paid under any workers’ compensation or occupational

disease law;• paid under any employer liability law;• for which you are not required to pay; or• received at a facility maintained by the policyholder, labor

union, mutual benefit association, or VA hospital;

14. services covered under other coverage provided by the policyholder;

15. biopsies of hard or soft oral tissues;

16. temporary or provisional restorations;

17. temporary or provisional appliances;

18. prescription drugs;

19. services for which the submitted documentation indicates a poor prognosis;

20. the following when charged by the dentist on a separate basis:• claim form completion;• infection control such as gloves, masks, and sterilization of

supplies; or• local anesthesia, non-intravenous conscious sedation or

analgesia such as nitrous oxide;

21. dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food;

22. caries susceptibility tests;

23. appliances or treatment for bruxism (grinding teeth);

24. precision attachments associated with fixed and removable prostheses, except when the precision attachment is related to implant prosthetics;

25. adjustment of a denture made within 6 months after installation by the same dentist who installed it;

26. duplicate prosthetic devices or appliances;

27. replacement of a lost or stolen appliance, cast restoration or denture;

28. replacement of an orthodontic device;

29. diagnosis and treatment of temporomandibular joint (TMJ) disorders and cone beam imaging associated with the treatment of temporomandibular joint disorders;

30. intra and extraoral photographic images.

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Mid PPO Plan (D1500) Benefits are available immediately from the start date of an individual’s benefits (no waiting period).










Periodontal cleanings: 2 in 1 plan year



Periodontalsurgery:



1 in 36 months




Denture adjustments 1 in 6 months


Prefabricated crowns: 1 per tooth in 24 months Fixed bridges 1 in 5 plan years

Full mouth x-rays: 1 in 5 plan years RecementationsInlays/onlays/ crowns



Emergency palliative treatment Tissue conditioning 1 in 36 months

Labs & other tests General anesthesia Occlusal adjustments 1 in 36 months

Periapical x-raysResin composite fillings (excludes composite fillings on molars) Orthodontic

(Children up to age 26)Other x-rays Pulpotomy

Pulp therapy Orthodontic diagnostics

Apexification & recalcification Orthodontic treatment

Periodontal surgery —Soft & connective tissue grafts

Periodontics — non-surgical

Oral surgery — simple extractions

Oral surgery — surgical extractions

Other oral surgery

General services


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Exclusions for Mid PPO Plan (D1500)




3. services or supplies received by you or your dependent before dental Insurance starts for that person;



























23. implant supported cast restorations;

24. implants including, but not limited to any related surgery, placement, maintenance, and removal;

25. implant supported dentures;

26. repair of implants;


28. precision attachments associated with fixed and removable prostheses;




32. replacement of an orthodontic device;



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Low PPO Plan (D1000) Benefits are available immediately from the start date of an individual’s benefits (no waiting period).




1 per tooth in 5plan years






Periodontal cleanings: 2 in 1 plan year



Periodontalsurgery:



1 in 36 months




Denture adjustments 1 in 6 months


Prefabricated crowns: 1 per tooth in 24 months Fixed bridges 1 in 5 plan years

Full mouth x-rays: 1 in 5 plan years RecementationsInlays/onlays/ crowns



Emergency palliative treatment Tissue conditioning 1 in 36 months

Labs & other tests General anesthesia Occlusal adjustments 1 in 36 months

Periapical x-raysResin composite fillings (excludes composite fillings on molars)

Other x-rays Pulpotomy

Pulp therapy

Apexification & recalcification

Periodontal surgery —Soft & connective tissue grafts

Periodontics — non-surgical

Oral surgery — simple extractions

Oral surgery — surgical extractions

Other oral surgery

General services


Dental

Exclusions for Low PPO Plan (D1000)

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 101661712 948614 L0318503256[exp0319][FL] © 2018 MSS




3. services or supplies received by you or your dependent before dental insurance starts for that person;



























23. implant supported cast restorations;

24. implants including, but not limited to any related surgery, placement, maintenance, and removal;

25. implant supported dentures;

26. repair of implants;


28. precision attachments associated with fixed and removable prostheses;




32. orthodontic services or appliances;

33. repair or replacement of an orthodontic device;



dental insurance options for the school district of …...2010/09/18 · metlife is pleased to be...

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