| |
MetLife
Preferred Dentist Program (PDP)
All Out-of-Network services subject to a maximum reimbursement
based on the agreed PDP In-Network rates.
Please see plan documentation for limits and
exclusions. |
|
|
|
|
| Preventative
Care |
In-Network |
Out-of-Network |
| Preventative
Oral Exam/Cleaning |
$0 |
$0 |
| Flouride
Treatment (to age 19) |
$0 |
$0 |
| Sealants |
$0 |
$0 |
| Emergency
Treatment |
$0 |
20% |
| X-rays |
$0 |
$0 |
| Annual
Deductible |
$50 |
$150/member
+ excess above PDP rates |
Lifetime Maximum
|
$1,500 |
$1,500 |
|
|
|
|
| Basic
Services |
In-Network |
Out-of-Network |
| Fillings |
$0 |
20% |
| Root
Canals |
$0 |
20% |
| Stainless
Steel Crowns |
$0 |
20% |
| Extractions |
$0 |
20% |
Repair/Recement:
crown, dentures, or bridge |
$0 |
20% |
| Oral
Surgery |
$0 |
20% |
| General
Anesthesia |
$0 |
20% |
|
|
|
|
| Major
Services |
|
|
| Crowns |
40% |
50% |
| Post
& Core |
40% |
50% |
| Inlays
& Onlays |
40% |
50% |
| Periodontics
|
40% |
50% |
|
Prosthodontics |
40% |
50% |
|
|
|
| Important
Information/Web Links |
|
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Additional Information |
