Brandywine Benefits -- Dental

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Dental
Plan C: Basic Option

Plan C provides you and your family with a basic level of dental coverage. Like the other two plans, Plan C covers ongoing preventive and basic care, as well as benefits for major services such as dentures and crowns. However, Plan C pays only 50% of the covered cost (reasonable and customary charges) for preventative, basic and major services after a deductible has been met. There is no orthodontia benefit in this plan.

A deductible of $25 per person and $50 per family must be met before the plan pays any benefits. If your actual charges exceed the amount payable under the plan, you pay the difference. The maximum benefit you can receive each year under this plan is $1,500 per person. Orthodontia carries a separate $1,500 lifetime maximum.

Here's an Example
Let's assume you need a major procedure that's covered at 50%:

	Participating Dentist	Non-participating Dentist
Provider's Regular Fee	$600	$600
Negotiated Fee	$375	N/A
Reasonable & Customary Limit	N/A	$500
Plan Pays	50% of $375 = $187.50	50% of $500= $250
You Pay	50% of $375 = $187.50	$350 ($600-$250 = $350)
Savings obtained by using a participating provider: $162.50

NOTE: This chart is for illustrative purposes only.

To locate a participating provider in your area, visit www.metlife.com/dental or call 1-800-942-0854 to request a provider directory.

Plan Option C Benefit Summary:

Coverage Type:	In-Network	Out-of-Network
Type A - Preventive	50% of PDP Fee*	50% of R&C Fee**
Type B - Basic Restorative	50% of PDP Fee*	50% of R&C Fee**
Type C - Major Restorative	50% of PDP Fee*	50% of R&C Fee**

Deductible***	In-Network	Out-of-Network
Individual	$25	$25
Family	$50	$50

Annual Maximum Benefit:	In-Network	Out-of-Network
Per Person	$1,500	$1,500


*	PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full.
**	Reasonable & Customary charges are based on the research of a dentist's usual, actual & community average charge as determined by MetLife.
***	Applies only to Type B & C Services.


Dental
	Plan A: High Option
	Plan B: Moderate Option
	Plan C: Basic Option
	What Is Covered
	What Is Not Covered
	Orthodontia
	When Coverage Ends
	Glossary
	MetLife Customer Service Call Instructions

Related Forms
	MetLife Claim Form
	MetLife Enrollment Form

Related Links
	MetLife
	MetLife MyBenefits

Disclaimer: Brandywine Benefits Online provides only an overview of your benefits from Brandywine School District and The State of Delaware. Brandywine School District and The State of Delaware reserve the right to amend or to terminate any benefit plan at any time, with or without notice. Review more important legal information about your benefits plans.