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    Metlife - Dental Ppo 12 15

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    This document summarizes a dental plan for Silicon Valley Microelectronics employees. It covers preventive, basic restorative, and major restorative services both in-network and out-of-network. In-network coverage is generally at higher rates and has lower out-of-pocket costs. The plan has a $1,500 annual maximum benefit per person and no deductible for preventive and basic services. It encourages using one of over 80,000 participating dentists through negotiated fee schedules and examples of savings when doing so.

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    © All Rights Reserved
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    Metlife - Dental Ppo 12 15

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    api-252555369
    518 views3 pages
    This document summarizes a dental plan for Silicon Valley Microelectronics employees. It covers preventive, basic restorative, and major restorative services both in-network and out-of-network. In-network coverage is generally at higher rates and has lower out-of-pocket costs. The plan has a $1,500 annual maximum benefit per person and no deductible for preventive and basic services. It encourages using one of over 80,000 participating dentists through negotiated fee schedules and examples of savings when doing so.

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    metlife - dental ppo 12 15

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    This document summarizes a dental plan for Silicon Valley Microelectronics employees. It covers preventive, basic restorative, and major restorative services both in-network and out-of-network. In-network coverage is generally at higher rates and has lower out-of-pocket costs. The plan has a $1,500 annual maximum benefit per person and no deductible for preventive and basic services. It encourages using one of over 80,000 participating dentists through negotiated fee schedules and examples of savings when doing so.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    518 views3 pages

    Metlife - Dental Ppo 12 15

    Uploaded by

    api-252555369
    This document summarizes a dental plan for Silicon Valley Microelectronics employees. It covers preventive, basic restorative, and major restorative services both in-network and out-of-network. In-network coverage is generally at higher rates and has lower out-of-pocket costs. The plan has a $1,500 annual maximum benefit per person and no deductible for preventive and basic services. It encourages using one of over 80,000 participating dentists through negotiated fee schedules and examples of savings when doing so.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    Network Comprehensive Dental

    Plan Design for: Silicon Valley Microelectronics, Inc.


    Effective Date: May 1, 2008
    Choice, Service, Savings.
    To help you enroll, the following pages outline your companys dental plan and address any questions you may have.
    Coverage Type:
    Type A Preventive
    Type B - Basic Restorative
    Type C - Major Restorative
    Deductible3
    Individual
    Family
    Annual Maximum Benefit:
    Per Person

    In-Network1
    100% of PDP Fee2
    80% of PDP Fee2
    50% of PDP Fee2

    Out-of-Network1
    100% of R&C Fee 4
    80% of R&C Fee 4
    50% of R&C Fee 4

    $0
    $0

    $50
    $50

    $1,500

    $1,500

    1
    In-Network Benefits means benefits under this plan for covered dental services that are provided by a Participating PDP Provider. Out-of-Network
    Benefits means benefits under this plan for covered dental services that are not provided by a Participating PDP Provider.
    2
    PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full.
    3
    Applies to Type B and C services only.
    4
    Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary
    Charge is based on the lesser of:
    the dentist's actual charge (the 'Actual Charge') or
    the charge of most dentists in the same geographic area for the same or similar services as determined by Metlife (the 'Customary Charge').

    An Example of Savings When You Visit a Participating PDP Dentist


    Save on out-of-pocket expenses when you receive services from one of more than 80,000 participating PDP dentists who
    generally agree to charge fees 10-35% lower than the average charges in your area.

    Your Dentist says you need a Crown, a Type C Service


    PDP Fee: $550.00 R&C Fee: $750.00
    Dentists Usual Fee: $735.00
    * Please note: this example assumes that your annual deductible has been met.

    (IN-NETWORK)
    When you receive care from a
    Participating PDP dentist...
    The PDP Fee is:
    Your Plan Pays:
    (50% x $550 PDP Fee)
    Your Out-of-Pocket Cost:

    (OUT-OF-NETWORK)
    When you receive care from a
    Non-Participating PDP dentist
    $550.00
    - $275.00
    $275.00

    Page 1 of 3
    Metropolitan Life Insurance Company, New York, NY 10166

    Dentist's Usual Fee is:


    Your Plan Pays:
    (50% x $750 R&C Fee)
    Your Out-of-Pocket Cost:

    $735.00
    - $375.00
    $360.00

    L0503FTPN(exp0406)MLIC-LD

    List of Covered Services & Limitations*


    Type A Preventive
    Prophylaxis (cleanings)
    Oral Examinations
    Topical Fluoride Applications
    X-rays
    Bitewing X-rays

    How Many/How Often:


    Cleaning of teeth (oral prophylaxis) but not more than once every 6 months.
    Oral exams but not more than 2 in any 12 month period.
    Topical fluoride treatment for a Dependent child under 14 years of age but not more than every 12 months.
    Full mouth X-rays: 1 per 60 months.
    Not more than once every 6 months for Dependent children under 19 years of age; every 12 months for all other Covered Persons.

    Type B Basic Restorative


    Fillings

    Amalgam and Resin-based Fillings.

    How Many/How Often:

    Extractions
    Oral Surgery
    Endodontics
    Periodontics
    Periodontal Maintenance

    Space Maintainers

    Pulp Capping, pulpal therapy, & therapeutic pulpotomy.


    Root canal treatment not more than once every 24 months for the same tooth.
    Periodontal scaling and root planing once per quadrant or area, every 24 months.
    Periodontal surgery once per quadrant or area, every 36 months.
    Periodontal maintenance where periodontal treatment has been previously performed, but the total of covered
    periodontal maintenance treatments and the number of covered oral prophylaxes will not exceed two treatments in a
    calendar year.
    Space Maintainers for dependent children to 14 years of age.

    Emergency palliative treatment


    Injections of Antibiotic Drugs
    Repairs of dentures, crowns, inlays and
    onlays
    Type C - Major Restorative

    How Many/How Often:

    Anesthesia
    Consultations
    Implantology

    When dentally necessary in connection with oral surgery, extractions or other covered dental services.
    Consultations, but not more than 2 in any 12 month period.

    Relining and Rebasing


    Bridges and Dentures

    Crowns/Inlays/Onlays

    Relining and Rebasing of existing removable dentures but not more than once in 36 months.
    Replacing an existing removable denture or fixed bridgework if: it is needed because of the loss of one or more natural
    teeth after the existing denture or bridgework was installed and the denture or bridgework cannot be made serviceable; or
    it is needed because the existing denture or bridgework can no longer be used and was installed more than 10 years
    prior to its replacement.
    Replacement of crowns, inlays or onlays but not more than once for the same tooth in a 10 year period.

    Prefabricated Stainless Steel Crown

    Prefabricated stainless steel crowns but not more than once in any 10 year period.

    Like most life insurance policies, MetLife group insurance policies contain certain exclusions, waiting periods, reductions and terms for keeping them in force. For
    costs and complete details of coverage, call or write your MetLife representative. In addition, a full description of your dental benefits will be provided in the
    certificate of insurance.

    Page 2 of 3
    Metropolitan Life Insurance Company, New York, NY 10166

    L0503FTPN(exp0406)MLIC-LD

    MetLife Preferred Dentist Program (PDP) Overview


    Frequently Asked Questions
    How does the MetLife PDP work?
    With a dental benefit plan featuring the MetLife PDP, you receive benefits
    whether or not you and/or each eligible dependent visit a participating
    dentist. But, when you visit a participating dentist, you have the
    opportunity to maximize your benefit plan with access to lower, out-ofpocket expenses. The MetLife PDP is a Preferred Provider Organization,
    wherein you choose a provider at the time of treatment. You do not have
    to pre-select a primary dentist nor do you need an ID card or referrals for
    specialty care.

    What is a participating PDP dentist?


    A general dentist or specialist who meets MetLifes strict credentialing
    standards and accepts negotiated fees as payment-in-full for services
    rendered. There are more than 76,000 participating PDP dentists
    nationwide, including over 15,000 specialists. So you should have no
    problem finding a participating PDP dentist near your home or workplace,
    while youre away on vacation, or while your covered dependents are
    away at college.

    How do I find a Participating PDP dentist?


    You can call the PDP automated Computer Voice Response line to obtain
    an up-to-date directory of participating dentists in your area. The system
    prompts you to enter your Social Security Number and a home or work
    ZIP code. A list of up to 205 participating dentists in the requested ZIP
    code is then mailed to your home the next business day. To receive your
    personalized directory, call 1-800-474-PDP1 (7371) Mon.-Fri. 6:00am to
    11:00 pm ET or Saturday 7 am to 4:00 pm ET. You can also conduct
    online provider searches (with direction and mapping capabilities) via
    MetLifes Dental Internet site at www.metlife.com/dental.
    Please Note: Be sure to verify provider participation when you make your
    appointment.

    What is a negotiated fee?


    A negotiated fee refers to the PDP fee schedule which participating
    dentists agree to accept as payment in full. The fee is typically 10% to
    35% below average fees of dentists in your area. Your plan may
    reimburse you for all or part of the PDP fee. When you use a participating
    PDP dentist, you are responsible only for the difference between MetLifes
    benefit payment amount and the PDP fee.

    Do I need an ID card?
    No, you do not need to present an ID card to confirm that youre eligible.
    You should notify your dentist that you participate in MetLifes PDP. Your
    dentist can easily verify information about your coverage through a tollfree automated Computer Voice Response system

    Do my dependents have to visit the same dentist


    that I select?
    No, you and your dependents each have the freedom to choose any
    dentist.

    Page 3 of 3
    Metropolitan Life Insurance Company, New York, NY 10166

    My dentist does not participate in the PDP. Is there


    anything I can do to encourage my dentist to
    participate?
    The MetLife PDP Network is continually expanding, and new providers
    may be added if they meet MetLifes credentialing standards. You may
    ask your dentist to complete a MetLife PDP nomination card or visit the
    dentist directory online at www.metlife.com/dental, and MetLife will send
    him or her information on how to apply for participation. The timing
    depends on how quickly MetLife receives the necessary information.
    Please note that there may be instances where a dentist chooses not to
    participate and others where MetLife does not accept the application
    under their stringent credentialing requirements.

    Can I find out how much services will cost and


    obtain an estimate of what will be covered prior to
    treatment?
    Yes, MetLife recommends that you have your dentist submit a request for
    a pre-treatment estimate for services in excess of $300.00. This often
    applies to services such as: crowns, bridges, inlays, and periodontics.
    When your dentist suggests treatment, have him or her send an undated
    claim form, along with the proposed treatment plan, to MetLife. A pretreatment estimate will be sent to you and the dentist detailing an estimate
    of what services your plan will cover and at what payment level.

    How do I file a claim?


    Claim forms are available from your human resources department or can
    be downloaded and printed out from MetLifes dental website at
    www.metlife.com/dental. Remember to bring one with you to your
    appointment. Complete the employee portion, and your dentist will assist
    you with the rest. You can use the same claim form whether or not your
    dentist is a participating PDP dentist. MetLife will mail you a concise
    explanation of benefits (EOB) statement after each claim submission. If
    you have a claim inquiry or benefit questions, please call MetLifes Dental
    Customer Service Department at 1-800- ASK - 4 - MET after your plans
    effective date.
    Dental Claims Address: MetLife Dental Claims, P.O. BOX 981282,
    El Paso, TX 79998-1282

    If I do not enroll during my initial enrollment period


    can I still purchase Dental Insurance at a later
    date?
    Yes, employees who do not elect coverage during their 31-day application
    period may still elect coverage later. Dental coverage would be subject to
    the following waiting periods.

    6 months on Basic Restorative (Fillings)


    12 months on all other Basic Services
    24 months on Major Services
    24 months on Orthodontia Services (if applicable)

    L0503FTPN(exp0406)MLIC-LD

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