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MetLife Dental Plan Primary Covered Services and Limitations

MetLife Dental plan Primary Covered Services and LimitationsPPO PlanMAC PlanType A: PreventiveHow Many/How OftenProphylaxis (cleanings)Two cleanings per calendar yearOral ExaminationsTwo exams per calendar yearTopical Fluoride ApplicationsOne fluoride treatment per calendar year for dependent children up to 14th birthdayX- r ay s Full mouth x-rays (one per 60 months) Bitewing x-rays (one set per calendar year for adults)Space MaintainersSpace maintainers for dependent children up to 16th birthdaySealantsOne application of sealant material every 60 months for each non-restored, non-decayed 1st and 2nd molar of a dependent child up to 19th birthdayType B: Basic RestorativeHow Many/How OftenFillingsOnce per 24-month replacementSimple Extraction As

Initial placement to replace one or more natural teeth, which are lost while covered by the Plan •

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Transcription of MetLife Dental Plan Primary Covered Services and Limitations

1 MetLife Dental plan Primary Covered Services and LimitationsPPO PlanMAC PlanType A: PreventiveHow Many/How OftenProphylaxis (cleanings)Two cleanings per calendar yearOral ExaminationsTwo exams per calendar yearTopical Fluoride ApplicationsOne fluoride treatment per calendar year for dependent children up to 14th birthdayX- r ay s Full mouth x-rays (one per 60 months) Bitewing x-rays (one set per calendar year for adults)Space MaintainersSpace maintainers for dependent children up to 16th birthdaySealantsOne application of sealant material every 60 months for each non-restored, non-decayed 1st and 2nd molar of a dependent child up to 19th birthdayType B: Basic RestorativeHow Many/How OftenFillingsOnce per 24-month replacementSimple Extraction As medically necessaryEndodonticsOne root canal per toothPeriodontal MaintenanceTwo times in a 12-month period following active perio therapyType C.

2 Major RestorativeHow Many/How OftenDenture and Bridge Rebase, RelineOne per 36 monthsBridges and Dentures Initial placement to replace one or more natural teeth, which are lost while Covered by the plan Dentures and bridgework replacement: one every 10 years Replacement of an existing temporary full denture if the temporary denture cannot be repaired and the permanent denture is installedwithin 12 months after the temporary denture was installedCrowns/Inlays/OnlaysReplacement : once every 10 yearsGeneral AnesthesiaWhen dentally necessary in connection with oral surgery, extractions or other Covered Dental servicesOral SurgeryAs medically necessaryPeriodontic SurgeryPeriodontal surgery once per quadrant, every 36 monthsType D.

3 OrthodontiaHow Many/How Often Your children, up to age 19, are Covered while Dental Insurance isin effect All Dental procedures performed in connection with orthodontictreatment are payable as orthodontia Payments are on a repetitive basis Orthodontic benefits end at cancellation of coverage Your children, up to age 19, are Covered while Dental Insurance isin effect All Dental procedures performed in connection with orthodontictreatment are payable as orthodontia Payments are on a repetitive basis 20% of the orthodontia lifetime maximum will be considered atinitial placement of the appliance and paid based on the planbenefit s coinsurance level for orthodontia as defined in the PlanSummary Orthodontic benefits end at cancellation of coverageThe service categories and plan Limitations shown above provide an

4 Overview of your plan benefits. This document presents the majority of Services within each category; but is not a complete description of the plan .


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