MetLife High Dental Plan

MetLife High Dental

	Covered Percentage		Member's Minimum Payment ⁴
	In-network¹	Out-of-network²	In-network¹	Out-of-network^₂
Periodic Oral Evaluations³	100% of PDP Fee	100% of R&C Fee	0% of PDP Fee	0% of R&C Fee
Cleanings (prophylaxis)³	100% of PDP Fee	100% of R&C Fee	0% of PDP Fee	0% of R&C Fee
Bitewings³	100% of PDP Fee	100% of R&C Fee	0% of PDP Fee	0% of R&C Fee
Sealants (age 14 & under)	80% of PDP Fee	80% of R&C Fee	20% of PDP Fee	20% of R&C Fee
Topical Fluoride (age 14 & under)	80% of PDP Fee	80% of R&C Fee	20% of PDP Fee	20% of R&C Fee
Fillings	80% of PDP Fee	80% of R&C Fee	20% of PDP Fee	20% of R&C Fee
Root canals	80% of PDP Fee	80% of R&C Fee	20% of PDP Fee	20% of R&C Fee
Extractions	80% of PDP Fee	80% of R&C Fee	20% of PDP Fee	20% of R&C Fee
Crowns	70% of PDP Fee	70% of R&C Fee	30% of PDP Fee	30% of R&C Fee
Partials & Dentures-Procedures & Services	70% of PDP Fee	70% of R&C Fee	30% of PDP Fee	30% of R&C Fee
Bridge Work	70% of PDP Fee	70% of R&C Fee	30% of PDP Fee	30% of R&C Fee
Space Maintainers	70% of PDP Fee	70% of R&C Fee	30% of PDP Fee	30% of R&C Fee

$1000 Annual Maximum
$500 Lifetime Maximum for Orthodontia (Ortho coverage up to age 19).

PDP Fee refers to the PDP Table of Maximum Allowed Charges (PDP Schedule). Participating PDP dentists have agreed to accept the PDP fee schedule as payment in full for services rendered.
R&C (Reasonable and Customary) charges are based on the lowest of: 1) the dentist’s actual charge, 2) the dentist’s usual charge for the same or similar services, or 3) the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.

“In-Network Benefits” means benefits provided under this plan for covered dental services that are provided by a participating PDP provider. Back to top
“Out-of-Network Benefits” means benefits provided under this plan for covered dental services that are not provided by a participating PDP provider. Back to top
Limited to two per year. Back to top
If the actual charge is greater than the R&C fee, the employee’s out-of-pocket expense is the amount remaining after the covered percentage of the R&C fee is reimbursed plus the difference between the R&C fee and the actual charge. Back to top

How might the PDP save you money?

Example: Crown
Dentist's Usual Fee Reasonable and Customary PDP Fee	$700.00 $600.00 $500.00

In-Network Dental Expenses

PDP Fee

Plan Payment
70% x $500 PDP Fee:

Your out-of-pocket cost:

$500.00

-$350.00

$150.00

Out-of-Network Dental Expenses

Dentist's Usual Fee:

Plan Payment
70% x $600 R&C Fee:

Your out-of-pocket cost:

$700.00

-$420.00

$280.00

In this example, by utilizing MetLife’s PDP network, you save: $130.00 ($280-$150)

Dental Claims Address:
MetLife Dental Claims
P.O. Box 981282
El Paso, TX 79998-1282
1-800-ASK-4MET (1-800-275-4638)
Hours of Operation: 8 a.m. – 7 p.m. (CST)

Please refer to your Certificate booklet for a complete list and description of covered services, limitations and exclusions.

Metropolitan Life Insurance Company, New York, NY 10010 L04057WQZ(exp0505)MLIC-LD

Scott & White Health Plan