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2016 Benefits Guide
8
Dental Insurance
MetLife Plan Designs
Features
High Plan
Low Plan
In-Network
Out-of-Network
In-Network Out-of-Network
Individual Deductible:
$50
$50
$50
$50
Family Deductible:
$150
$150
$150
$150
Type I
- Diagnostic/ Preventive:
Exams, Cleanings (2 in 12 months)
100%
100%
100%
100%
Type II
- Basic Procedures
80%
80%
80%
80%
Type III
- Major Services
70%
70%
50%
50%
Surgical Extractions
80%
80%
80%
80%
Endodontics
80%
80%
80%
80%
Periodontics
80%
80%
80%
80%
Other Oral Surgery
70%
70%
50%
50%
Type IV
—Orthodontia
50% to $2,000
Lifetime Max.
50% to $2,000
Lifetime Max.
Not Covered
Not Covered
Maximum Benefit/Year
$2,000
$2,000
$1,500
$1,500
Dental High Plan Costs
Coverage
Monthly
Premium
AOA
Portion
Employee
Portion
Employee Per
Paycheck Deduction
Employee Only
$46.92
$37.54
$9.38
$4.33
Employee + Spouse
$88.60
$65.46
$23.14
$10.68
Employee + Child(ren) $104.01
$75.79
$28.22
$13.03
Employee + Family
$145.97
$103.90
$42.07
$19.42
Dental Low Plan Costs
Coverage
Monthly
Premium
AOA
Portion
Employee
Portion
Employee Per
Paycheck Deduction
Employee Only
$38.46
$30.77
$7.69
$3.55
Employee + Spouse
$72.62
$53.66
$18.96
$8.75
Employee + Child(ren)
$85.25
$62.12
$23.13
$10.68
Employee + Family
$119.66
$85.17
$34.49
$15.92