Taking care of your oral health is not a luxury, it is a necessity to long-term optimal health. Dental insurance can greatly reduce your costs when it comes to preventative, restorative, and emergency procedures. These plans are designed to help you keep your teeth in the best shape possible and help cover the costs. There are three plans to choose from a DHMO plan and two PPO plans by Metlife!

A range of procedures may be covered, such as comprehensive exams, cleanings, x-rays, fillings, tooth extractions, general anesthesia, crowns, or root canals.

NETWORK PLAN NAME: SG185-TX / POLICY #120998

• No claims form
• No annual maximum
• No deductibles
• Must choose from a Directory of Dentists
• No exclusion for pre-existing conditions
• Orthodontia coverage

Find an in-network provider at www.MetLife.com/dental - select PDP Plus for the PPO Network.

As our plan has always been set up, the annual deductible and maximum run calendar year; NOT plan year.

• Annual benefit maximum of $1,750 per covered person
• A $50 annual deductible to a maximum of $150 per family. The deductible does not apply to preventive services.
• Preventive Services (e.g. routine exams, bitewing x-rays, full mouth x-rays) are covered 100%
• Basic Services (e.g. simple extractions, fillings, root canals, periodontics) are covered 80%
• Major Services (e.g. crowns, dentures, bridges) are covered 50%
• Orthodontics are covered at 50% with a lifetime maximum of $1,000 - Dependent Child coverage to age 19 only
• Both plans offer Out-of-Network (OON) benefits; however, they will pay OON claims differently.

The Low PPO (PDP Plus MAC) plan pays claims the same as they would for In-Network (IN) claims. For example,
if the negotiated reimbursement for an IN cleaning is $65, if you go OON for a cleaning the plan will pay $65 and if
the OON dentist charge is $100 you will owe the $35 charge for the balance. In order to eliminate the potential for
balance billing, MAC plan members must stay in-network and seek services from a contracted Provider. Staying
with an in- network provider will lower your out-of-pocket expenses while you are at the dentist!

The High PPO (PDP Plus R&C) plan pays claims at the 90% UCR. What this means is that claims will be paid
based on what 90% of Providers, in that geographic area, bill for that specific billing code. The PPO plan allows
Members more freedom to seek services from an OON Provider as it decreases the potential for balance billing. If a
Provider’s billed charge is greater than the 90% UCR, the member will still be responsible for the difference.