MetLife Dental Options

BNY Mellon Benefits Guide

The two MetLife options are Preferred Dental Program (PDP) organizations. As with the health plans, you may visit any provider you choose, but the plan will pay a greater benefit when you stay within the network. Network providers will also file your claims for you. If you use an out-of-network provider, you will have to pay out-of-pocket at the time services are received, then submit your claim for reimbursement.

Out-of-network reimbursement is based on usual, reasonable and customary (URC) charges instead of the negotiated rate used for in-network claims. If you receive care from an out-of-network dentist, you pay your share of the URC charge, plus the difference between the URC charge and your dentist's actual fee. Out-of-network usual, reasonable and customary ("URC") charges are charged at the 80th percentile which means that 80 percent of dentists in your geographic area charge that fee or less.

MetLife's negotiated fees with in-network dentists may extend to services not covered under your plan and services received after your plan maximum has been met, where permitted under state law. If you receive services from an in-network dentist that are a) not covered under the plan, or b) after you have reached the annual maximum, then you may be responsible for the in-network fee (where permitted by law). Using out-of-network dentists may result in higher out-of-pocket costs.

During Open Enrollment, if you change your MetLife option from the MetLife PDP Option 2 (with orthodontia benefits) to the MetLife PDP Option 1, any orthodontia benefits previously approved but not yet received will be forfeited, that is, not paid.


	METLIFE PDP OPTION 1		METLIFE PDP OPTION 2
	In-Network	Out-of-Network	In-Network	Out-of-Network
Annual Deductible	$75 per individual $150 per family¹		$50 per individual $100 per family¹
Choice of Any Provider	Yes²		Yes²
Plan Payments
Diagnostic and Preventive Services Routine cleanings, routine exams (2 per calendar year) Bitewing X-rays (1 per calendar year) Full mouth or panoramic X-rays (once every 60 months) Topical fluoride application (to age 19; 2 in a calendar year) Sealants (to age 19; first and second permanent molars, once per tooth every 5 years)	100% of PDP fee²	80% of URC²	100% of PDP fee²	90% of URC²
Basic Services Fillings (silver) Resin (white) fillings Endodontics Non-surgical periodontics Simple extractions Oral surgery Consultations (1 per calendar year) Space maintainers	80% of PDP fee²,³ after deductible	60% of URC² after deductible	90% of PDP fee²,³ after deductible	80% of URC² after deductible
Major Services Bridges Inlays Onlays Crowns Dentures Dental implants and preparation for the installation of implants Surgical periodontics Extraction of impacted 3rd molars (wisdom teeth) General anesthesia Bruxism	50% of PDP fee²,³ after deductible	30% of URC² after deductible	60% of PDP fee²,³ after deductible	50% of URC² after deductible
Orthodontia Services⁴ (covered for dependents under age 19; lifetime maximum $1,500 per child)	Not covered		50% up to $1,500² (for children under age 19)
Annual Maximum	$1,500 per individual		$1,500 per individual
Lifetime Orthodontia Maximum	Not applicable		Up to $1,500 per child under age 19

¹ Family applies to the Employee + Child(ren), Employee + Spouse/Qualified Domestic Partner, and Employee + Family levels of coverage.

² If you use an out-of-network dentist, plan payments are based on usual, reasonable and customary (URC) charges.

³ The plan pays this percentage after you meet the annual deductible.

⁴ Orthodontia is eligible on a monthly basis only. So if treatment continues into the next plan year, you must elect the plan with the orthodontia coverage to continue to be reimbursed. Charges for services not yet rendered are not allowed. Upfront reimbursement for the entire procedure is prohibited unless treatment is complete and braces have been removed. You must remain covered under this plan to receive continued reimbursement for orthodontic services.

Age, frequency limitations or exclusions may apply to certain services. For specific details, please contact MetLife directly.