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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.

**Refer to your dental benefits plan summary for your out-of-network dental coverage. Exclusions This plan does not cover the following services, treatments and supplies: Services which are not Dentally Necessary, those which do not meet generally accepted standards of

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