| MetLife and Delta Dental Options A | MetLife and Delta Dental Options B |
|---|---|
| Note: The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums, which employees pay. The Premier Network is for Delta Dental only. If you use a Premier Network provider, your dental plan benefits will generally mirror the out-of-network plan design (except as otherwise noted). | |
| Individual Annual Deductible | |
| In-Network: No annual deductible | In-Network: No annual deductible |
| Delta Dental Premier Network and Out-of-Network: $50 | Delta Dental Premier Network and Out-of-Network: $100 |
| Family Annual Deductible | |
| In-Network: No annual deductible | In-Network: No annual deductible |
| Delta Dental Premier Network and Out-of-Network: $150 | Delta Dental Premier Network and Out-of-Network: $300 |
| Diagnostic and Preventive Care | |
| In-Network: 100% | In-Network: 100% |
| Delta Dental Premier Network and Out-of-Network: 80% of R&C; deductible waived 85% of allowed amount for Delta Premier; deductible waived | Delta Dental Premier Network and Out-of-Network: 50% of R&C; deductible waived |
| Restorative Services | |
| In-Network: 80% of discounted fee | In-Network: 80% of discounted fee |
| Delta Dental Premier Network and Out-of-Network: 75% of R&C, after annual deductible | Delta Dental Premier Network and Out-of-Network: 40% of R&C, after annual deductible |
| Prosthodontics | |
| In-Network: 50% of discounted fee | In-Network: 50% of discounted fee |
| Delta Dental Premier Network and Out-of-Network: 50% of R&C, after annual deductible | Delta Dental Premier Network and Out-of-Network: 25% of R&C, after annual deductible |
| Orthodontics | |
| In-Network: 50% of discounted fee, up to a $3,000 lifetime benefit maximum per person (children to age 26 and adults) | In-Network: 50% of discounted fee, up to a $2,000 lifetime benefit maximum per person (children to age 19) |
| Delta Dental Premier Network and Out-of-Network: 50% of R&C or Allowed Amount (Delta Premier), up to a $3,000 lifetime benefit maximum per person (children to age 26 and adults) | Delta Dental Premier Network and Out-of-Network: Not covered |
| Annual Benefit Maximum per Person | |
| In-Network: $3,000 | In-Network: $2,000 |
| Delta Dental Premier Network and Out-of-Network: $2,000 | Delta Dental Premier Network and Out-of-Network: $1,000 |
Restorative Services
2024 Plan Information