Bankstar Benefit Guide 2016 - NEW GRAPHICS.pub

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9
Voluntary Dental Insurance
MetLife is the dental carrier for 2016/2017. The dental plan offers coverage in a PPO network and out-of-network. It is to your
advantage to utilize a network dentist to take advantage of contracted fees. If you go out-of-network, you will be responsible for any
amount exceeding MetLife’s negotiated fees plus any deductible and coinsurance associated with your procedure. Dependent children
are eligible until the end of the month in which they turn age 26. The following is a brief summary of your MetLife benefits:
In-Network Providers:
agree to be reimbursed
from a fee schedule
and no balance billing.
Out-of-Network
Providers: benefit
payments are made up
to the 90th percentile
of Reasonable and
Customary; and
balance billing is
possible.
MetLife - Plan Design
PPO
In-Network Out-of-Network
Deductible
(Individual/Family) ■ Aggregate $50 / $150 $50 / $150
Annual
Maximum ■ Applied to Type A, B & C Services $1,500 $1,500
Type A -
Preventive
Services
■ Oral Examinations
■ Bitewing X-rays
■ Fluoride Treatments
■ Sealants
■ Prophylaxis: Cleanings
100%
(No Deductible)
80%
(No Deductible)
Type B -
Basic
Services
■ Space Maintainers
■ Full Mouth, Periapical & Other X-Rays
■ Fillings
■ Occlusal Guards / Bruxism Appliances
■ Oral Surgery - Simple Extractions
■ Labs & Other Tests
■ Emergency Palliative Treatment
80% 60%
Features
Type C -
Major
Services
■ Endodontics
■ Periodontics
■ Fixed Bridges
■ Inlays/Onlays/Crowns
■ Implants
■ Dentures
■ Occlusal Adjustments
■ General Anesthesia
■ Oral Surgery: Surgical Extractions &
Other Surgery
50% 50%
Orthodontia
Child(ren) ■ Diagnostics and Treatment 50% up to $1,000
Lifetime maximum
50% up to $1,000
Lifetime maximum
Per Paycheck Employee Cost
Type of Coverage Cost
Employee $13.87
Employee & Spouse $27.43
Employee & Child(ren) $32.35
Employee & Family $49.34
To find a MetLife provider in your area, visit
the website at .
■ Click on “Find a Dentist”
■ Enter your Zip Code
■ Select the PDP Plus network
■ Click “Submit”
A comprehensive directory of dentists will
appear.
FIND A DENTIST