DN-ONECLK-LG Benefit Summary One Click 2024-10-15_5655036_0001_0001 _Dental_31 Selected Covered Services and Frequency Limitations* Type A · Oral Examinations 1 in 6 months. · Fluoride Children to age 14 / 1 in 12 months. · Bitewing X-rays Adult - 1 in 12 months / Children - 1 in 12 months. · Full Mouth X-rays 1 in 60 months. · Cleanings 1 in 6 months. Type B · Periodontal Maintenance 2 in 1 year less the number of teeth cleanings. · Space Maintainers · Emergency Palliative Treatment · Periodontal Root Planing & Scaling 1 per quadrant in any 36 months period. · Periodontal Surgery 1 in 36 months. · Sealants (1st & 2nd permanent molars) 1 per tooth in 60 months of a dependent child up to 16th birthday. · Amalgam & Composite Fillings 1 per surface in 24 months. · Simple Extractions · Root Canal 1 in 24 months. · Surgical Extractions Type C · Crowns 1 in 60 months. · Dentures 1 in 10 years. · Bridges 1 in 10 years. · Repairs (Crowns) 1 in 12 months. · Implants 1 in 60 months. Orthodontia · Dependent children are covered up to their 19th birthday. · All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia. · Payments are on a repetitive basis. · 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based on the plan benefit’s coinsurance level for Orthodontia as defined in the Plan Summary. · Orthodontic benefits end at cancellation of coverage. The service categories and plan limitations shown in this document represent an overview of your plan benefits, but are not a complete description of the plan. Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this overview and your certificate of insurance, your certificate of insurance governs. Like most group dental insurance policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations. *Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual Page 2 of 3 200 Park Ave., New York, NY 10166 © 2023 MetLife Services and Solutions, LLC L0522023151[exp0525][All States]