Dental

Attachment A

Deductibles, Maximums and Contract Benefit Levels

†       Reimbursement is based on PPO Contracted Fees for PPO Providers, Premier Contracted Fees for Premier Providers and Program Allowance for Non-Delta Dental Providers.

Retirees residing in California, Colorado, Arizona, Nevada, Montana, Oklahoma, Illinois, Maryland, Ohio, and Texas have the option of receiving dental benefits through a Managed Care plan provided by MetLife Dental Plan.

SafeGuard Dentists

• All services must be received from dentists contracted with MetLife. You must designate a Selected General Dentist when you enroll in the plan who will provide or manage your dental care.
• You may change your Selected General dentist up to once a month by either going online to the Safeguard website or calling MetLife customer service. Retirees and dependents do not have to designate the same MetLife General Dentist.
• Plan benefits are based on a Schedule of Benefits which lists the services available as well as the copayment you must pay for each procedure. The schedule of benefits is provided at the time of enrollment.
• There are no maximum annual benefits or deductibles that apply to your plan. All benefit payments are determined by the Schedule of Benefits.
• Your plan covers diagnostic and preventive treatment including x-rays, basic services (such as fillings, root canals, periodontics, oral surgery and extraction), crowns, prosthodontics (including bridges and dentures) as well as orthodontia.
• During the course of treatment, your MetLife selected general dentist may recommend the services of a dental specialist, and may refer you directly to a contracted MetLife specialty care provider for endodontics, oral surgery or periodontics; no referral or pre-authorization from MetLife is required for these contracted specialists. Your selected general dentist will obtain pre-authorization from MetLife for any referrals to participating orthodontists or pediatric specialists.

Non-SafeGuard Dentists

• No benefits are provided for services provided by non-Safeguard dentists.

You may visit the website or call customer service to find a participating SafeGuard dentist.

Download the Schedule of Benefits (PDF File).

Retirees residing in Hawaii receive dental benefits from Hawaii Dental Service (HDS).

As of March 1, 2008, members can choose between the original Low Option Plan or the new High Option Plan. The High Option Plan will closely match the benefits previously provided by the Direct Pay Dental Plan. Specific information was mailed to all retirees in January.

If you changed to the high option plan, any benefits paid for services received in 2008 under the low option plan will be applied to the maximum under the new plan.

HDS Dentist

• You will usually pay the lowest amount for services when you visit a HDS participating dentist, as HDS dentists have agreed to accept a reduced fee.
• You are only charged your share at the time of treatment, and Hawaii Dental Service pays its portion directly to the dentist.
• HDS dentists will complete claim forms and submit them for you.
• HDS is a member of the Delta Dental Plan Association, and about 96% of dentists in Hawaii are HDS participating dentists.
• Hawaii Dental Service has participating dentists available on the islands of Hawaii, Kauai, Lanai, Maui, Molokai, Oahu.

Non-HDS Dentists

• You are responsible for the difference between the amount HDS pays and the amount your non-HDS dentist bills. You will usually have the highest out of pocket costs when you visit a non-participating dentist.
• Non-HDS dentists may require you to pay the entire amount of the bill in advance and wait for reimbursement.
• You may have to complete and submit your own claim forms, or pay the non-participating dentist a fee to submit them for you.

You may visit the website or call customer service to find a participating HDS dentist.