5 / 12
4
MetLife
* Servicios dentales tienen que ser por un Dentista del Plan. Los miembros son responsables de pagar la cantidad listada
$1,500
$1,000
Deducible A
ñ
o de Plan
(Individu
o
/Famil
ia
)
deduc
Sin
ible
$50 / $150
100%
80%
100%
80%
100%
80%
80%
60%
80%
60%
80%
60%
50%
40%
O
rtodon
cia
$1,000
$1,000
50%
50%
Benefits
Copay examples are provided below, depending on procedure codes used, copays may vary. A full list can be found in the TDA Schedule of benefits.
Plan Year Maximum
No maximums
Plan Year Deductible
No deductible
Services
Exams – Once in a 6-month period
$0 copay
$0 copay *
X-rays (full mouth - once in a 3-year period, bitewings - two in a benefit year)
$0 copay *
$10 - $37 (silver) and $40 - $76 (tooth color) *
Root Canal
$175 - $395 copay *
Simple Extractions (non surgical)
$30 copay *
Cast crowns/onlay
$270 copay + lab fee *
Orthodontics
No deductible or waiting period for adults and children 8 years of age or older
See Schedule of Benefits
Description of Coverage
In-Network
Examination
$10
Lenses/Examination/Frames Frequency
12 months
Lenses
$20
Frames
$0; $130 allowance; 20% discount over $130
Up to $40
Contact Lenses - Standard
$105 allowance; 15% discount over $105
At this initial open enrollment you can purchase life and accidental death & dismemberment coverage up to
the guarantee issue amount of $150,000 with no medical questions, any amount above $150,000 will require
completion of an evidence of insurability (EOI). Maximum benefit is 10x annual salary up to $400,000.
In order to purchase for your spouse or your dependents, you will need to purchase coverage for yourself.
Your spouse is eligible for coverage up to $50,000 with no medical questions. Maximum amount is $100,000.
Child coverage is guarantee up to $10,000.
In-Nework
Out-of-Network
Benefits
$1,500
$1,000
Plan Year Deductible (Individual/Family)
No deductible
$50 / $150
Services
Rayos X (boca completa - una vez en 3 a
ñ
os, aleta - dos en a
ñ
o de prestaci
ó
n)
100
80%
100
80
100
80%
80%
60
Root Canal
80%
60%
d surgical procedures
80%
60%
50%
40%
$1,000
$1,000
Benefits for adults and children 8 years of age or older. Payable in two payments—upon initial
banding and 12 months after.
50%
50%
restaciones
Deducible A
ñ
o de Plan
$0 copa
go
$0 copa
go
*
Rayos X (boca completa - una vez en 3 a
ñ
os, aleta - dos en a
ñ
o de prestaci
ó
n)
$0 copa
go
*
$10 - $37 (
plata
) and $40 - $76 (
color diente
) *
$175 - $395 copa
go
*
$30 copa
go
*
$270 copa
go + cuota lab.
*
Description of Coverage
In-Network
Examination
$10
Lenses/Examination/Frames Frequency
12 months
Lenses
$20
Frames
$0; $130 allowance; 20% discount over $130
Contact Lenses - Fitting
Up to $40
Contact Lenses - Standard
$105 allowance; 15% discount over $105
At this initial open enrollment yo can purchase life and accidental death & dismemberment coverage up to
the guarantee issue amount of $150,000 with no medical questions, any amount above $150,000 will require
compl tion of an evidence of insurability (EOI). Maximum benefit is 10x annual salary up to $400,000.
In order to purchase for your sp use or your dependents, you will need to purchase coverage for yourself.
Your spouse is eligible for coverage up to $50,000 with no medical questions. Maximum amount is $100,000.
In-Nework
Out-of-Network
Benefits
Plan Year Maximum
$1,500
$1,000
Plan Year Deductible (Individual/Family)
No deductible
$50 / $150
Services
Exams ,
100%
80%
Extracciones y Procedimientos de Cirug
í
a
aning
(
two
in a benefit year
100%
80%
X-rays (full mouth - once in a
, bitewings - two in a benefit year)
100%
80%
per surface every
years)
80%
60%
Root Canal
80%
60%
80%
60%
Crowns, Bridges, Partial Dentures
50%
40%
Orthodontics
Lifetime Ortho Benefit Maximum
$1,000
$1,000
Benefits for adults and children 8 years of age or older. Payable in two payments—upon initial
banding and 12 months after.
50%
50%
Benefits
Copay examples are provided below, depending on procedure codes used, copays may vary. A full list can be found in the TDA Schedule of benefits.
Plan Year Maximum
N i
Plan Year Deductible
No e uct e
Serv i ces
Exams – Once in a 6-month period
$0 copay
Cleaning (two in a benefit year period)
$0 copay *
X-rays (full mouth - once in a 3-year period, bitewings - two in a benefit year)
$0 copay *
Fillings (varies based on number of surfaces and whether front or back teeth)
$10 - $37 (silver) and $40 - $76 (tooth color) *
Ortodoncia
l
$175 - $395 copay *
Simple Extractions (non surgical)
$30 copay *
Cast crowns/ nlay
$270 copay + lab fee
*
Orthodontics
No d ductible or waiting p riod for adults and children 8 years of age or older
See Schedule of Benefits
$10
12 m
eses
Len
t
es
$20
Aro
s
$0; $130
asignados
; 20%
descuento arriba de
$130
Hasta
$40
Contact Lenses - Standard
$105
asignados
; 15%
descuento arriba de
$105
At this initial open enrollment you can purchase life and accidental death & dismemberment coverage up to
the guarantee issue amount of $150,000 with no medical questions, any amount above $150,000 will require
completion of an evidence of insurability (EOI). Maximum benefit is 10x annual salary up to $400,000.
PRESTACIONES DENTAL Y VISI
Ó
N
Puede ver el resumen de prestaciones completas en l
í
nea para m
á
s detalles, o contactar a MetLife o TDA.
Prestaciones
M
á
ximo A
ñ
o de Plan
Servicios
Ex
á
menes, evaluaciones o consultas (dos en a
ñ
o de prestaci
ó
n)
Limpieza (dos en a
ñ
o de prestaci
ó
n)
Rellenos (uno por superficie cada dos a
ñ
os)
Tratamiento de Canal
Coro as, Pu n es, Dentadura Parcial
M
á
ximo Beneficio Ortodoncia de por Vida
Prestaciones para adultos y ni
ñ
os de 8 a
ñ
os de edad y m
á
s. A pagar en dos pagos
—
con
bandas iniciales y 12 meses despu
é
s.
Se recomienda predeterminaci
ó
n para servicios arri a de $250.
Prepagado Total Dental Administrators (TDA)
Se dan ejemplos de copago, dependiendo de códigos de procedimiento usados, copagos pueden variar. Ver lista completa en Programa de prestaciones TDA.
M
á
ximo A
ñ
o de Plan
Sin m
á
ximos
Sin deducible
Servicios
Ex
á
menes
–
Una vez en per
í
odo de 6 meses
Limpieza (dos en a
ñ
o de prestaci
ó
n)
Rellenos (var
í
a por cantidad de superficies y si son dientes delanteros o muelas)
Tratamiento de Canal
Extracciones Simples (sin cirug
í
a)
Coronas met
á
licas/recubrimientos
Sin deducible ni per
í
odo de espera - adultos y ni
ñ
os de 8 a
ñ
os de edad y m
á
s
Ver Programa de Prestaciones
m
á
s toda cuota aplicable de lab., al recibir el servicio, o conforme a procedimientos de cobro del Dentista seleccionado.
Visi
ó
n EyeMed
Descripción de Cobertura
En la Red
Ex
á
menes
Lentes/Ex
á
menes/Aros Frecuencia
Lentes de Contactos - Ajustes
En la Red
Fuera de la Red