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Dental Comparison Chart
Previous
Chart
This chart is a summary. There may be additional restrictions or limitations.
You must meet your annual deductible of $25 per person before benefits
are paid for restorative, oral surgery, endodontic, periodontic and prosthetic services.
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Preferred Choice
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Quality Dental
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Network
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Non-Network
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Periodontics (surgical and non-surgical)
Scaling and root planing, subgingival curettage, hemisection, or gingivoplasty |
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Prosthetics
Installation of full or partial dentures, crowns (caps), post and core, bridge abutments/pontics, implants |
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Maintenance of full or partial dentures, crowns (caps), crown or bridge repair, denture reline
or rebasing (full or partial), post and core, bridge abutments/pontics |
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Orthodontic services
Teeth straightening for eligible dependent children. One course of treatment per person. |
50% or $1,500 per person, whichever is less (lifetime
maximum)
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50% or $1,000 per person, whichever is less (lifetime maximum)
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50% or $1,500 per person, whichever is less
(lifetime maximum)
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The
network fee, a discounted fee negotiated by MetLife for service from network providers, applies to these
benefits.
R&C - Reasonable and Customary: the prevailing and usual fee for services charged by dentists in
your area.
Plan year - July 1 through June 30.
If you are married and your spouse has coverage through
his or her employer, coordinated benefits may apply. Contact the Trust for the non-duplication coordination
of benefits policy.
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Percentages in the chart reflect the amount that the plan pays for your treatment
or service. This chart is just a summary, and there are additional restrictions or limitations (in the plan booklets).
Updated April 2007
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