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Benefits Summary: MetLife Freedom Choice 5K PPO Dental Plan

Plan benefits and rates are effective for group plan year January 1, 2021 through December 31, 2021, and subject to change thereafter. The service categories and plan limitations shown below represent an overview of the plan benefits. This document presents the majority of services within each category, but is not a complete description of the plan.

In-Network (PDP Plus)
% of Negotiated fee*
Out-of-Network
% of R&C fee**
COVERAGE TYPE
Type A: Preventative
(cleanings, oral exams, x-rays)
100%
(no waiting period)
90%
(no waiting period)
Type B: Basic Restorative
(fillings, extractions)
80%
(no waiting period)
70%
(no waiting period)
Type C: Major Restorative
(bridges, dentures)
50%
(after 12 month waiting period)
40%
(after 12 month waiting period)
Type D: Orthodontia
(for children up to age 19)
50%
(after 12 month waiting period)
50%
(after 12 month waiting period)
DEDUCTIBLE
Individual
(per calendar year)
$50
(waived for Type D)
$50
(waived for Type D)
Family
(per calendar year)
$150
(waived for Type D)
$150
(waived for Type D)
ANNUAL MAXIMUM BENEFIT
Per Person$5,000$5,000
ORTHODONTIA LIFETIME MAXIMUM
Per Person
(for children up to age 19)
$1,000$1,000

*Negotiated fee refers to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

**R&C fee refers to 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.

Child(ren)’s eligibility for dental coverage is from birth up to age 30.

Primary Covered Services & Limitations

TYPE A: PREVENTIVEHOW MANY / HOW OFTEN
Prophylaxis (cleanings)• One every six months
Oral Examinations• One every six months
Topical Fluoride Applications• One fluoride treatment per 12-month period for dependent children up to their 13th birthday
X-rays (bitewing)• One set per calendar year
TYPE B: BASIC RESTORATIVEHOW MANY / HOW OFTEN
X-rays (full mouth)• One every 60 months
Fillings• Initial placement of amalgam fillings;

• Replacement of existing amalgam if at least 24 months have passed since existing filling was placed, or a new surface of decay is identified on that tooth
Simple Extractions
Periodontics• Total number of periodontal maintenance treatments and prophylaxis cannot exceed two treatments in a calendar year
Crown, Denture, and Bridge Repair / Recementations• Re-cementing of Cast Restorations or Dentures (once in a 12 month period)
Sealants• One application of sealant material every 3 years for each non-restored, non-decayed 1st and 2nd molar of a dependent child up to 13th birthday
TYPE C: MAJOR RESTORATIVEHOW MANY / HOW OFTEN
Implants• Replacement: once every 10 years
Bridges and Dentures• Initial placement to replace one or more natural teeth, which are lost while covered by the plan

• Dentures and bridgework replacement: one every 10 years

• Replacement of an existing temporary full denture if the temporary denture cannot be repaired and the permanent denture is installed within 12 months after the temporary denture was installed
Crowns / Inlays / Onlays• Initial installation

• Replacement: no more than once every 10 years for the same tooth surface
Space Maintainers• For dependent children up to 13th birthday, once per lifetime per tooth area
Endodontics• Root canal treatment limited to once per tooth per lifetime
General Anesthesia• When dentally necessary in connection with oral surgery, extractions or other covered dental services
Oral Surgery• Except as mentioned elsewhere in certificate
Surgical Extractions
Periodontics• Periodontal surgery once per quadrant, every 36 months
TYPE D: ORTHODONTIAHOW MANY / HOW OFTEN
Orthodontia• Your Children, up to age 19, are covered while Dental Insurance is in effect

• All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia

• Payments are on a repetitive basis

• 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based on the plan benefit’s coinsurance level for Orthodontia as defined in the Plan Summary

• Orthodontic benefits end at cancellation of coverage

FAQs

Who is a participating dentist?

This program utilizes the MetLife PDP Plus Network of participating dentists. A participating dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for services provided to plan members. Negotiated fees typically range from 15-45% below the average fees charged in a dentist’s community for the same or substantially similar services. (Based on internal analysis by MetLife. Savings from enrolling in a dental benefits plan will depend on various factors, including how often members visit participating dentists and the cost for services rendered. Negotiated fees are subject to change. Negotiated fees for non-covered services may not apply in all states.)

How do I find a participating dentist?

There are thousands of PDP Plus Network general dentists and specialists to choose from nationwide — so you are sure to find one who meets your needs. You can search a list of these participating dentists online here or call 1-800-942-0854 to have a list faxed or mailed to you.

What services are covered by my plan?

All services defined in your group dental benefits plan certificate are covered. Please review the plan summaries for summarized information and your certificate of insurance for detailed information about your plan benefits.

How do I pay for coverage?

The choice is yours. You can make monthly payments by monthly bank draft (ACH) or pay for the entire year via credit card payment. At time of enrollment, you will choose how you want to pay.

Can I enroll my dependents for dental coverage?

Yes. When enrolling you may choose to also cover your spouse, domestic partner, and/or children up to age 26. Dependent age may vary by state. Once your policy takes effect, you can still add or remove dependents to your coverage once per year on the group plan anniversary date of Jan 1 or if you have a qualifying event such as marriage, divorce, birth of a child, and spouse’s termination of employment. You simply need to provide the plan administrator with advanced written notice along with any required premium. The effective date of coverage for newly added dependent(s) will depend on when we receive notice and required premium.

Does the Preferred Dentist Program offer any discounts on non-covered services?

Negotiated fees may extend to services not covered under your plan and services received after your plan maximum has been met, where permitted by applicable state law. If permitted, you may only be responsible for the negotiated fee. (Negotiated fees are subject to change.)

May I choose a non-participating dentist?

You are always free to select any general dentist or specialist. However, you usually save more when you visit a participating dentist. Participating dentists have agreed to accept negotiated fees as payment in full for covered services. Negotiated fees typically range from 30–45% below the average fees charged in a dentist’s community for similar services.1 Non-participating dentists have not agreed to accept negotiated fees. So you may be responsible for any difference in cost between the dentist’s fee and your plan’s benefit payment.

Can I get an estimate of my out-of-pocket expenses?

Yes. We recommend that you request a pre-treatment estimate for services totaling more than $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive an estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Can my dentist apply for participation in the network?

Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application. (Due to contractual requirements, MetLife is prevented from soliciting certain providers.) This website and phone number are for use by dental professionals only.

How are claims processed?

Dentists may submit claims for you, which means you have little or no paperwork. If you need a claim form call 1-800-942-0854.

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

Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Can MetLife help me find a dentist outside of the U.S. if I am traveling?

Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be considered under your out-of-network benefits. (Refer to your dental benefits plan summary for your out-of-network dental coverage.) Please remember to hold on to all receipts to submit a dental claim.

International dental travel assistance services are administered by AXA Assistance USA, Inc. AXA Assistance is not affiliated with MetLife or any of its affiliates, and the services they provide are separate from the benefits provided by MetLife.

How does MetLife coordinate benefits with other insurance plans?

Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan.

Exclusions & Limitations

Exclusions

This plan does not cover the following services, treatments and supplies:

  • Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature;
  • Services for which covered person would not be required to pay in the absence of Dental Insurance;
  • Services or supplies received by covered person before the Dental Insurance starts for that person;
  • Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate);
  • Services which are neither performed nor 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;
  • Services or appliances which restore or alter occlusion or vertical dimension;
  • Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease;
  • Restorations or appliances used for the purpose of periodontal splinting;
  • Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
  • Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss;
  • Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work;
  • Missed appointments;
  • Services:
    • covered under any workers’ compensation or occupational disease law;
    • covered under any employer liability law;
    • for which the Policyholder of the person receiving such services is not required to pay; or
    • received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital;
  • Services covered under other coverage provided by the Policyholder;
  • Temporary or provisional restorations;
  • Temporary or provisional appliances;
  • Prescription drugs;
  • Services for which the submitted documentation indicates a poor prognosis;
  • 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;
  • 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;
  • Caries susceptibility tests;
  • Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth;
  • Other fixed Denture prosthetic services not described elsewhere in the certificate;
  • Precision attachments, except when the precision attachment is related to implant prosthetics;
  • Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth;
  • Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
  • Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth;
  • Fixed and removable appliances for correction of harmful habits;
  • Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards;
  • Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of New Mexico This exclusion does not apply to residents of Minnesota;
  • Repair or replacement of an orthodontic device;
  • Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. We will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first;
  • Duplicate prosthetic devices or appliances;
  • Replacement of a lost or stolen appliance, Cast Restoration, or Denture; and
  • Intra and extraoral photographic images

Limitations

Alternate Benefits
Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. 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 or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your 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 charge schedule for your area via fax by dialing 1-800-942-0854 and using the MetLife Dental Automated Information Service. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.

Cancellation/Termination of Benefits
Coverage is provided under a group insurance policy issued by MetLife. Coverage terminates when your membership ceases, the participating association ceases to participate in the trust, insurance ceases for your class, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. The member policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: Completion of a prosthetic device, crown or root canal therapy.

1Based on internal MetLife analysis. Negotiated fees refer to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-pays, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

This webpage is provided for summary purposes only and is not a complete description of the plan benefits, limitations, and exclusions. Read your certificate of insurance for details on plan benefits, limitations, and exclusions.

Rates are subject to change and depend on geographic area. Coverage may not be available in all states. Please contact Member Benefits at 1-800-282-8626 for more information.

A class is a group of people defined in the group policy. Benefits are subject to change upon agreement between Metropolitan Life Insurance Company and the participating organization.

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact Member Benefits at 1-800-282-8626 for costs and complete details.

Policy form GPNP99
Policy number TS 5336959-G

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