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Description: Baylor University MetLife Dental Plan Benefits Network: PDP Plus Benefits Summary Coverage Type In-Network Out-of-Network Type A - Cleanings, Oral Exams 100%...
Metlife Dental Individual Insurance Plans
Family In Network Savings* Example This hypothetical example** shows how receiving services from a participating dentist can help you save money. Your dentist says you need a crown, Type C service — Negotiated fee: $670.00 R&C fee: $1,386.00*** Regular dentist fee: $1,462.00 OUT OF NETWORK when you receive care from When you receives care from a participating dentist, a non-participating dentist dentist Regular dental fee is: $1,462.00 Regular dental fee is: $1,462.00 Negotiated fee is: $670.00 R&C fee is: $1,386.00 Your plan pays: - 0 $335. $693.00 $335.00 $769.0050% X $670 Negotiated 50% X $1,386.00 R&CFee: Fee: Your Out-of-pocket: Your Out-of-pocket: In this example, you save $434.00 ($769.00 using $769). dentist.*Savings by enrolling in the MetLife Preferred Dentist Program will depend on several factors, including how often participants visit the dentist and the cost of services provided.** Note: This is a hypothetical example revising a porcelain/ceramic crown ( D2740 ) in the Philadelphia area, zip 19151. Assumes annual deductible e is met.***Reasonable and Customary Fee (R&C) is based on -the lower of (1) the dentist's current fee, or (2) the fee of most dentists in the same geographic area for the same or similar services as determined by MetLife. The example shown reflects an R&C fee at the 80th percentile. The R&C percentile used to calculate out-of-network benefits for your plan may be different. List of primary services covered and limitations Type A - Preventive how/how often Prophylaxis (cleaning) Oral examinations One in six months. Topical fluoride applications X-rays One in six months. Sealants One treatment with fluoride for 12 months for dependent children up to 14 years Type B - Basic Restorative Simple extractions Bitewing x-ray: one set in 12 months Periodontal maintenance fillings One application of sealant every 60 months for each unrestored, uninterrupted 1stSpace Maintainers and dependent children's 2nd molars up to the 16th birthday.X-raysType C - Major Restorative How/How often Repair/replacements of crowns, prostheses and bridges One replacement per surface during 24 months. Calendar year. Placeholders for dependent children up to 14 years. Crowns/inlays/onlays Endodontics X-ray of full mouth: one every 60 months. General anesthesia Oral surgery How/how oftenPeriodonticsType D - Orthodontics Replacement: once every 60 months. Repairs: once every 12 months. Initial placement to replace one or more natural teeth, which are lost while covered by the plan. Replacement of prostheses and bridge work: once every 84 months. Replacement of an existing temporary complete prosthesis if the temporary prosthesis cannot be repaired and the permanent prosthesis is installed within 12 months after the temporary prosthesis was installed. Replacement: once every 84 months. Root canal treatment limited to once per tooth per lifetime. When dentistry is necessary in connection with oral surgery, extractions or other covered dental services. Periodontal scaling and root planing once per quadrant, every 24 months. Periodontal surgery once per quadrant, every 36 months. How much/how often You, your spouse and your children, up to the age of 26, are covered while the dental insurance is in force. All dental procedures performed in connection with orthodontic treatment are paid as orthodontics. Payments are on a recurring basis. 20% of Orthodontics Lifetime Maximum will be assessed in the first appliance placement and will be paid out based on the co-insurance level of the plan's Orthodontics benefit as defined in the Plan Summary. Orthodontic benefit ceases upon cancellation of cover. The service categories and plan limitations shown above represent an overview of your plan benefits. This document presents the majority of services in each category, but is not a complete description of the plan. Exclusions This plan does not cover the following services, treatments and supplies: Services that are not dentally necessary, those that do not meet generally accepted standards of care for the treatment of a particular dental condition, or that we consider experimental. ; Services for which you are not required to pay in the absence of dental insurance; Services or supplies received by you or your dependents before dental insurance starts for that person; Services that are primarily cosmetic (for Texas residents, see the remarks section of the certificate); Services neither performed nor prescribed by a dentist except those services of an authorized dental hygienist supervised and billed by a dentist and which are for: Tooth brushing and polishing; or Fluorine treatments; Services or devices that restore or alter occlusion or vertical dimension; Restoration of tooth structure damaged by wear, tear or erosion unless caused by disease; Restorations or devices used for periodontal cutting; Advice or instructions on oral hygiene, plaque control, nutrition and tobacco; Personal supplies or equipment including but not limited to: water bottles, toothbrushes or dental floss; Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work; Lost appointments; Services: Covered by any workers' compensation or occupational disease law; Covered by any law on employers' liability; which the employer of the person receiving these services is not required to pay; or Received at a facility maintained by the employer, union, mutual benefit association, or VA hospital; Services covered by other coverage provided by the employer; Temporary or provisional restoration; Temporary or provisional equipment; Prescription drugs; Services where submitted documentation indicates poor prognosis; The following when invoicing the dentist on a separate basis: Complete the claim form; Infection control such as gloves, masks and sterilization of supplies; or Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide. Dental services resulting from accidental damage to the teeth and supporting structures, except for damage to the teeth due to chewing or biting; Tooth sensitivity tests; ; First installation of a fixed and permanent prosthesis to replace one or more natural teeth that were missing before that person was insured for dental insurance, except for congenitally missing natural teeth; Other fixed prostheses not described elsewhere in the certificate; Precision fitting, except when the precision fitting is related to the implant prosthesis; First installation of a complete or removable denture to replace one or more natural teeth that were missing before that person was insured for dental insurance, except for congenitally missing natural teeth; The addition of teeth to a removable partial denture to replace one or more natural teeth that were missing before such person was insured for dental insurance, except for congenitally missing natural teeth; Adjustment of prosthesis made within 6 months after installation by the same dentist who installed it; Implant-supported prostheses to replace one or more natural teeth that were missing before this person. was insured for dental insurance, except for congenitally missing natural teeth; Fixed and removable devices to correct harmful habits; Appliances or treatment for bruxism (teeth grinding), including but not limited to occlusal guards and night guards; Diagnosis and treatment of TMJ disorders. Duplicate prostheses or devices; Replacement of a lost or stolen device, cast restoration or prosthesis; and Intra- and extraoral photographic images. Alternative Benefits: Your dental plan states that where there are two or more professionally acceptable dental treatments for a dental condition, your plan will base reimbursement, and the associated procedure fee, on the least expensive treatment option. If you and your dentist have agreed on a treatment that costs more than the treatment on which the plan benefit is based, your actual out-of-pocket cost will be: the fee for the procedure for the treatment on which the plan is based - the plan benefit, plus the entire difference in cost between the negotiated fee or, for out-of-network care, the actual payment, for the service rendered and the negotiated fee or R&D fee (if out-of-network care) for the service on which the plan's benefit is based. To avoid misunderstandings, we suggest that you discuss treatment options with your dentist before services are provided and obtain a pre-treatment benefit estimate before receiving certain high-cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) that describes the services provided, the plan's reimbursement for those services, and the out-of-pocket cost. Procedure fee plans are subject to change each plan year. You can obtain an updated procedure fee schedule for your area by fax by calling 1-800-942-0854 and using the MetLife Dental Automated Information Service. Cancellation/termination of benefits: Coverage is provided under a group policy (Policy Form GPNP99) issued by MetLife. Coverage ends when your membership ends, when your dental benefits stop, or upon termination of the group policy by the policyholder or MetLife. The group policy ends in the event of non-payment of the premium and may end if the participation requirements are not met or if the policyholder does not fulfill any obligations under the insurance. the
Metlife Dental Insurance Senior Review
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