SCHEDULE OF BENEFITS Massachusetts Family High Dental Plan with Enhanced Child Orthodontia This Schedule of Benefits lists the services available under the MetLife plan, as well as the co-insurance payments associated with each procedure. There are other factors that impact how the plan works and those are included here and in the Exclusions and Limitations sections below. The Covered Person has access to Dentists through the MetLife Preferred Dentist Program. Dentists participating in the MetLife Preferred Dentist Program have agreed to limit their charges for Covered Services to the Maximum Allowed Charge for such service. Under the MetLife Preferred Dentist Program, MetLife pays benefits for Covered Services performed by either In-Network Dentists or Out-of- Network Dentists. However, the Covered Person may be able to reduce out-of-pocket costs by using an In-Network Dentist because Out-of-Network Dentists have not entered into an agreement with MetLife to limit their charges. The Covered Person s out-of-pocket annual maximum includes the Covered Person s costs for Covered Services provided by an In-Network Dentist. The out-of-pocket annual maximum does not include the Covered Person s costs for: (1) Covered Services in excess of the Maximum Allowed Charge, or (2) services that are not Covered Services. If a Covered Service is performed by an Out-of-Network Dentist, We will base the benefit on the Covered Percentage of the Reasonable and Customary Charge. Benefits for Covered Services provided by an Out-of-Network Dentist are not limited to the annual out-of-pocket annual maximum. This summary provides an overview of the plan s benefits. These benefits are subject to the terms and conditions of the MetLife policy. Specific details regarding these provisions can be found in the certificate. Like most dental insurance policies, MetLife policies contain exclusions, limitations, terms and conditions for keeping them in force. If there are additional questions regarding the Dental Insurance program underwritten by MetLife, please contact the benefits administrator or MetLife. Deductible and Annual Maximums In-Network Annual Maximum None for a Child under age 19 $1,250 for a Covered person other than a Child under age 19 In-Network Individual Out-of-Pocket Annual $350 for one Child under age 19 Maximum In-Network Family Out-of-Pocket Annual Maximum $700 for two or more Children under age 19 In-Network Individual Deductible (applies to Basic Services and Major Services) $50 Family Deductible (3 Covered Persons must each satisfy the Deductible of $50) (applies to Basic Services and Major Services) Out-of-Network Annual Maximum None for a Child under age 19 $1,000 for a Covered person other than a Child under age 19 Out-of Network Individual Out-of-Pocket Annual Maximum Out-of-Network Family Out-of-Pocket Annual Maximum $150 None None Page 1 of 12
SCHEDULE OF BENEFITS (continued) Deductible and Annual Maximums Out-of-Network Individual Deductible (applies to $50 Basic Services and Major Services) Family Deductible (3 Covered Persons must each satisfy the Deductible of $50) (applies to Basic Services and Major Services) $150 Service In-Network Covered Percentage Out-of- Network Covered Percentage Limitations Diagnostic and Preventive Care Services (Subject to applicable Maximums) Oral Examinations 100% 80% Twice every 12 months Limited oral evaluation - 100% 80% Twice every 12 months problem focused Periapical X-Rays 100% 80% Full-mouth and Panoramic X- 100% 80% Once every 36 months Rays Bitewing X-Rays 100% 80% 2 sets in 12 months Prophylaxis Cleanings 100% 80% 2 times per 12 months including minor scaling procedures, periodontal cleanings and full mouth debridement Fluoride for a Child under age 100% 80% 4 times in 12 months 19 Sealants for a Child under age 19 100% 80% One per tooth per 36 months for nonrestored teeth Space Maintainers for a Child under age 19 100% 80% Once per lifetime per tooth area Preventive resin restoration in a moderate to high caries risk patient - permanent tooth, for a Child under age 19 100% 80% One per tooth per 36 months for nonrestored teeth Basic Services (Subject to applicable Deductible and Maximums) Oral Surgery Simple 75% 55% Extractions Pulp Therapy 75% 55% Pulp Capping 75% 55% Pulpotomy 75% 55% Occlusal Adjustments 75% 55% 1 per 12 months Sedative Fillings 75% 55% Endodontics Root Canal 75% 55% 1 per tooth per lifetime (initial treatment or retreatment) Prefabricated Stainless Steel Crowns for a Child under age 19 75% 55% 1 per tooth per lifetime Page 2 of 12
SCHEDULE OF BENEFITS (continued) Service In-Network Covered Percentage Out-of- Network Covered Percentage Limitations Amalgam Fillings 75% 55% 1 per tooth surface per 12 months for a Child under age 19 1 per tooth surface per 24 months for a Covered Person other than a Child under age 19 Resin Composite Fillings 75% 55% 1 per tooth surface per 12 months for a Child under age 19 1 per tooth surface per 24 months for a Covered Person other than a Child under age 19 Scaling and Root Planing 75% 55% 1 per quadrant in any 24 month period Periodontal Maintenance 75% 55% 4 treatments in 12 months in combination with 2 cleanings Periodontal Surgery 75% 55% 1 per quadrant in any 36 month period Periodontal Surgery- Soft and 75% 55% 1 per unique site per 36 months Connective Tissue Grafts Other X-rays 75% 55% Labs and Other Tests 75% 55% Consultations 75% 55% 2 per 12 months Oral Surgery Surgical 75% 55% Extractions Other Oral Surgery 75% 55% Debridement 75% 55% Once per lifetime in combination with Prophylaxis Apexification & Recalcification 75% 55% Palliative (Emergency) 75% 55% Treatment of dental pain minor procedure General Anesthesia 75% 55% Intravenous Sedation, Non- Intravenous Conscious Sedation and Nitrous Oxide Biopsies 75% 55% Therapeutic Drug Injections 75% 55% Application of Desensitizing 75% 55% Agents Simple Repairs of Cast 75% 55% Restorations Repair of Dentures 75% 55% Dentures Rebases/Relines 75% 55% Office or laboratory relines or rebases are limited to one per arch in any 24 months Recementations 75% 55% Page 3 of 12
SCHEDULE OF BENEFITS (continued) Major Services (Subject to applicable Deductible and Maximums) Inlays/Onlays/Crowns (Cast 50% 30% 1 replacement per tooth per 60 months Restorations) Crown Buildups/Post & Core 50% 30% 1 replacement per tooth per 60 months Dentures Complete/Partial 50% 30% 1 replacement per 84 months Adding teeth to Dentures 50% 30% Prefabricated Stainless Steel Crowns for a Covered Person other than a Child under age 19 50% 30% 1 per tooth per lifetime Prefabricated Crowns Other 50% 30% 1 replacement per tooth per 60 months than Stainless Steel Fixed Partial Dentures 50% 30% 1 replacement per 60 months Tissue Conditioning 50% 30% 1 per 36 months Denture Adjustments 50% 30% 1 per 12 months Implant Services 50% 30% 1 per tooth per 60 months Implant Supported 50% 30% 1 per tooth per 60 months Prosthetics Implant Service Repairs 50% 30% 1 per tooth per 60 months Occlusal Guards/Bruxism 50% 30% Appliances Including Fabrication of Athletic Mouth Guards Adjunctive General Services 50% 30% Page 4 of 12
SCHEDULE OF BENEFITS (continued) Orthodontia (Subject to annual out-of-pocket maximum when medically necessary and administered by an In-Network Dentist) Service In-Network Orthodontia Lifetime Maximum Medically necessary Orthodontia... None Limitation Non-medically necessary... $1,000 Out-of-Network Orthodontia Lifetime Maximum Medically necessary Orthodontia... None Non-medically necessary... $1,000 Child Orthodontia Age Limit Up to age 19 Service In-Network and Out-of-Network Coinsurance Orthodontia Covered Percentage Limitations 50% Orthodontia services are limited to a Child under age 19. Orthodontia treatment must begin while this insurance is in force. If the insurance ends during the course of the treatment, the monthly payments will end. Dental procedures performed in connection with Orthodontia treatment are considered under the orthodontia benefit. Orthodontic treatment generally consists of initial placement of an appliance and periodic follow-up visits. The benefit payable for the initial placement will not exceed 20% of the amount charged by the Dentist. The balance of the treatment fee will be paid proportionately during the remaining course of treatment. For orthodontia services, We strongly recommend that You get a pretreatment estimate of proposed orthodontic services and then discuss that estimate with the Dentist before the services are delivered. Even though pretreatment estimates are not guarantees of benefits, obtaining a pretreatment estimate is an important part of making a well-informed decision about orthodontic services, including what Your plan may or may not cover under the Essential Health Benefit requirements. Please see the Pretreatment Estimate of Benefits section of the certificate for more details. Page 5 of 12
DEFINITIONS Dentally Necessary means the services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual s dental condition due to dental disease, in order to attain or maintain the individual s achievable dental health, provided that such services are: Consistent with generally accepted standards of dental practice that are defined standards and are based on: credible scientific evidence published in peer-reviewed dental literature that is generally recognized by the relevant dental community, recommendations of a dental-specialty academy, the views of Dentists practicing in the relevant clinical areas, and any other relevant factors; Clinically appropriate in terms type, frequency, timing, site, extent and duration and considered effective for the individual s dental condition; Not primarily for the convenience of the patient or Dentist; Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual s dental condition; and Based on an assessment of the individual and his or her dental condition. DEDUCTIBLE The Individual Deductible is the amount that a Covered Person must pay for Covered Services to which such Deductible applies each Benefit Year before We will pay benefits for such Covered Services. We apply amounts used to satisfy Individual Deductibles to the Family Deductible. When three Individual Deductibles of $50 each have been satisfied, the Family Deductible will be considered satisfied and no further amount will be applied to Individual Deductibles in that Benefit Year. The amount We apply toward satisfaction of a Deductible for a Covered Service is the amount We use to determine benefits for such service. The Deductible Amount will be applied based on when Dental Insurance claims for Covered Services are processed by Us. The Deductible Amount will be applied to Covered Services in the order that Dental Insurance claims for Covered Services are processed by Us regardless of when a Covered Service is "incurred". When several Covered Services are incurred on the same date and Dental Insurance benefits are claimed as part of the same claim, the Deductible Amount is applied based on the Covered Percentage applicable to each Covered Service. The Deductible Amount will be applied in the order of highest Covered Percentage to lowest Covered Percentage. TIME PERIODS The expense periods are based on a Benefit Year. BENEFITS WE WILL PAY AFTER INSURANCE ENDS We will pay benefits for a 60 day period after your insurance ends for the completion of installation of a prosthetic device if: the Dentist prepared the abutment teeth or made impressions before your insurance ends; and the device is installed within 60 days after the date the insurance ends. Page 6 of 12
BENEFITS WE WILL PAY AFTER INSURANCE ENDS (continued) We will pay benefits for a 60 day period after your insurance ends for the completion of installation of a Cast Restoration if: the Dentist prepared the tooth for the Cast Restoration before your insurance ends; and the Cast Restoration is installed within 60 days after the date the insurance ends. We will pay benefits for a 60 day period after your insurance ends for completion of root canal therapy if: the Dentist opened into the pulp chamber before your insurance ends; and the treatment is finished within 60 days after the date the insurance ends. Page 7 of 12
DENTAL INSURANCE: EXCLUSIONS 1. Any procedures not specifically listed as a Covered Service in this SCHEDULE OF BENEFITS are not covered. 2. Services which are not Dentally Necessary and/or medically necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature. 3. Services for which you would not be required to pay in the absence of Dental Insurance. 4. Services or supplies received by a Covered Person before the Dental Insurance starts for that person. 5. Services which are primarily cosmetic, except for Orthodontia for a Child under age 19. 6. Services which are neither performed nor prescribed by a Dentist, except for those services of a licensed Dental Hygienist which are supervised and billed by a Dentist, and which are for: scaling and polishing of teeth; or fluoride treatments; 7. Services or appliances which restore or alter occlusion or vertical dimension. 8. Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease. 9. Restorations or appliances used for the purpose of periodontal splinting. 10. The prophylactic removal of third molars is not a Covered Service. Asymptomatic third molar removal or removal due to malocclusion or for orthodontic reasons is not covered. Third molar removal when there is no pathology present is not covered. 11. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. 12. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. 13. Decoration or inscription of any tooth, device, appliance, crown or other dental work. 14. Charges for missed appointments. 15. Services: covered under any workers compensation or occupational disease law; covered under any employer liability law; for which the employer of the person receiving such services is required to pay; or received at a facility maintained by your employer, labor union, mutual benefit association, or VA hospital. 16. Services covered under other coverage provided by your employer. 17. Temporary or provisional restorations. 18. Temporary or provisional appliances. 19. Prescription drugs. 20. Services for which the submitted documentation indicates a poor prognosis. Page 8 of 12
DENTAL INSURANCE: EXCLUSIONS 21. Fixed and removable appliances for correction of harmful habits. 22. Local chemotherapeutic agents. 23. Replacement of an orthodontic device. 24. The following, when charged by the Dentist on a separate basis: claim form completion; infection control, such as gloves, masks, and sterilization of supplies; or local anesthesia. 25. Caries susceptibility tests. 26. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food. 27. Precision attachments associated with fixed and removable prostheses. 28. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it. 29. Relines or rebases of a Denture made within 6 months after installation by the same Dentist who installed it. 30. Duplicate prosthetic devices or appliances. 31. Intra and extraoral photographic images. 32. Diagnosis and treatment of temporomandibular joint disorders. 33. Labial veneers. 34. Modification of removable prosthodontic and other removable prosthetic services. 35. The following services are not Covered Services: a connector bar; a stress breaker; coping; pediatric partial Dentures; complete or partial overdentures. Page 9 of 12
DENTAL INSURANCE LIMITATIONS 1. Bitewing x-rays are limited to 2 sets in 12 months. Periapical films are allowed on an emergency or episodic basis. 2. Full mouth x-rays are limited to once every 36 months. Panoramic film x-rays are limited to once every 36 months. 3. Prophylaxis services are limited to 2 times per 12 months in combination with periodontal maintenance and full mouth debridement. 4. Oral examinations are limited to twice every 12 months. 5. Problem focused examinations are limited to twice every 12 months. 6. Fluoride treatments are limited to 4 times in 12 months for a Child under age 19. 7. Dental sealant treatments are limited to one per tooth per 36 months for non-restored teeth for a Child under age 19. 8. Adjustments of Dentures are limited to not more than once in a 12 month period, if at least 6 months have passed since the installation of the Denture. 9. Space maintainers are limited to once per lifetime per tooth area for a Child under age 19. 10. For a Child under age 19, amalgam fillings are limited to 1 per tooth surface per 12 months. For a Covered Person other than a Child under age 19, amalgam fillings are limited to 1 per tooth surface per 24 months. 11. For a Child under age 19, resin composite fillings are limited to 1 per tooth surface per 12 months. For a Covered Person other than a Child under age 19, resin composite fillings are limited to 1 per tooth surface per 24 months. 12. Restorations are limited as follows: Amalgam, composite resin, acrylic, synthetic or plastic restorations for treatment of caries. If the tooth can be restored with such materials, any other restoration such as a crown or jacket is not a Covered Service. Composite resin or acrylic restorations will be benefited as an alternative benefit on multi-surface restorations on posterior teeth. Micro filled resin restorations which are non-cosmetic. Replacement of a restoration is covered only when it is defective, as evidenced by conditions such as recurrent caries or fracture, and replacement is medically necessary. Preventive resin restorations are limited to one per tooth per 36 months for non-restored teeth for a Child under age 19. 13. Surgical removal of impacted teeth is a Covered Service only when evidence of pathology exists. 14. Periodontal maintenance is a Covered Service where periodontal treatment (including scaling, root planing, and periodontal surgery such as gingivectomy, gingivoplasty and osseous surgery) has been performed. Periodontal maintenance is limited to 4 times in any 12 month period less the number of teeth cleanings received during such 12 month period. 15. Periodontal scaling and root planning is limited to one per quadrant in any 24 month period. 16. Replacement of any Cast Restorations with the same or different type of Cast Restoration is limited to 1 replacement for the same tooth within 60 months. Page 10 of 12
DENTAL INSURANCE LIMITATIONS 17. Crown Buildups/Post & Core are limited to 1 replacement for the same tooth surface within 60 months. 18. General anesthesia or intravenous sedation, non-intravenous conscious sedation and nitrous oxide in connection with oral surgery, extractions or other Covered Services, are only a Covered Services when such anesthesia is determined to be medically necessary or Dentally Necessary. 1. 19. Periodontal surgery including gingivectomy, gingivoplasty and osseous surgery, is limited to 1 surgical procedure per quadrant in any 36 month period. 20. Periodontal surgery- soft and connective tissue grafts is limited to 1 per unique site per 36 months. 21. Prefabricated stainless steel crowns are limited to no more than 1 per tooth per lifetime. 22. Prefabricated crowns other than stainless steel crowns - are limited to no more than one replacement for the same tooth per 60 months. 23. Root canal is limited to once per tooth per lifetime. 24. Full mouth debridements are limited to once per lifetime. 25. Fixed partial dentures will be used only when a partial cannot satisfactorily restore the case. If fixed partial dentures are used when a partial could satisfactorily restore the case, the benefit determination will be based upon the partial which is the less costly service. Fixed partial dentures are only available if Dentally Necessary. 26. Dentures, full maxillary, full mandibular, partial upper, partial lower, teeth, clasps and stress breakers are only available if Dentally Necessary. 27. Replacement of a non-serviceable fixed Denture is covered if such Denture was installed more than 60 months prior to replacement. 28. Replacement of a non-serviceable removable Denture is covered if such Denture was installed more than 84 months prior to replacement. 29. Replacement of an immediate temporary, full Denture with a permanent full Denture, if the immediate, temporary, full Denture cannot be made permanent and such replacement is done within 12 months of the installation of the immediate, temporary, full Denture. 30. Office or laboratory relines or rebases are limited to one per arch in any 24 months. 31. Tissue conditioning is limited to once in a 36 month period. 32. Fixed partial Dentures are limited to 1 replacement per 60 months. 33. Occlusal adjustments are limited to 1 per 12 months. 34. Orthodontic services must begin while this insurance is in force. If the insurance ends during the course of the treatment plan, the monthly benefits will end. 35. Consultations are limited to 2 per 12 months. 36. Implant services (including sinus augmentation and bone replacement and graft for ridge preservation) are limited to no more than once per tooth every 60 months. Page 11 of 12
DENTAL INSURANCE LIMITATIONS 37. Implant supported prosthetics are limited to no more than once for the same tooth position in a 60 month period. 38. Repair of implants is limited to not more than one every 60 months. 39. When multiple dental services of similar types are provided, the frequency limit under the plan will combine all the similar types of services under the stated frequency limit in combination. 40. Have your Dentist submit a complete pretreatment estimate with pretreatment dated x-rays for all third molar extractions to determine if they will be covered. Please see the Pretreatment Estimate of Benefits section of the certificate for more details. Prophylactic removal of third molars is not a Covered Service. Removal because of malocclusion or orthodontic reasons is not covered. Full bony impactions with no evidence of pathology are not covered. The removal of third molars due to active dental disease may be covered with prior approval. Partial bony impactions and soft tissue impactions may be covered with prior approval if the tooth and/or supporting structures are involved with active disease such as an acute periodontal infection. If emergency removal of a third molar is needed, radiographs and/or documentation of the pathological condition causing the emergent situation may be required prior to payment. 41. Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes under this plan, these separate steps of one service are considered to be part of the more comprehensive service. Even if the Dentist submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the pulp chamber, additional x-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, We will only pay benefits for the root canal therapy. MA FEEOP PPO 2016 Page 12 of 12