MetLife Mid Dental Plan - Scott & White Health Plan

MetLife Mid Dental

> Benefit Highlights PDF document

Covered Percentage

Member's Minimum Payment⁴

	In-network ¹	Out-of-network²	In-network¹	Out-of-network²
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	50% of PDP Fee	50% of R&C Fee	50% of PDP Fee	50% of R&C Fee
Partials & Dentures-Procedures & Services	50% of PDP Fee	50% of R&C Fee	50% of PDP Fee	50% of R&C Fee
Bridge Work	50% of PDP Fee	50% of R&C Fee	50% of PDP Fee	50% of R&C Fee
Space Maintainers	50% of PDP Fee	50% of R&C Fee	50% of PDP Fee	50% of R&C Fee

$750 Annual Maximum

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 & Customary PDP Fee	$700.00 $600.00 $500.00

In-Network Dental Expenses
PDP Fee Plan Payment 50% x $500 PDP Fee: Your out-of-pocket cost:	$500.00 -$250.00 $250.00

Out-of-Network Dental Expenses
Dentist's Usual Fee: Plan Payment 50% x $600 R&C Fee: Your out-of-pocket cost:	$700.00 -$300.00 $400.00

In this example, by utilizing MetLife’s PDP network, you save: $150.00 ($400-$250)
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