Restorative Services

2020 and 2021 Plan Year Information

MetLife Option AMetLife Option BDelta Dental
Note

The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums.

Restorative Services

In-Network:
80% of discounted fee

Out-of-Network:
75% of R&C, after annual deductible

In-Network:
80% of discounted fee

Out-of-Network:
40% of R&C, after annual deductible

In-Network:
80% of discounted fee

Out-of-Network:
75% of R&C, after annual deductible

Individual Deductible

In-Network:
No annual deductible

Out-of-Network:
$50

In-Network:
No annual deductible

Out-of-Network:
$100

In-Network:
No annual deductible

Out-of-Network:
$50

Family Annual Deductible

In-Network:
No annual deductible

Out-of-Network:
$150

In-Network:
No annual deductible

Out-of-Network:
$300

In-Network:
No annual deductible

Out-of-Network:
$150

Dental Services

  • Diagnostic and preventive services: X-rays and cleanings
  • Restorative services: fillings, oral surgery, root canals and gum treatments
  • Prosthodontics: crowns, bridges, dentures and implants