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Dental Plan Summary - MetLife

Metropolitan Life Insurance Company Network: PDP PlusCoverage Type In-Network % of Negotiated Fee* Out-of-Network % of Negotiated Fee* Type A: Preventive (cleanings, exams, X-rays) 100% 100% Type B: Basic Restorative (fillings, extractions) 80% 80% Type C: Major Restorative (bridges, dentures, crowns, periodontics) 50% 50% Deductible Per Individual $50 $50 Annual Maximum Benefit Per Individual ( Dental exams, bitewing x-ray, fluoride, and prophy/cleanings do not apply to individual coverage limit) $2,000 $2,000 *Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

charge schedules are subject to change each plan year. You can obtain an updated procedure charge schedule for your area via fax by calling 1-800-942-0854 and using the MetLife Dental Automated Information Service. Actual payments may vary from the pretreatment estimate depending upon annual

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