Exclusions
Plan 1 does not cover the following services, treatments, and supplies:
- Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards
- Services which are not dentally necessary
- Those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature
- Services for which you would not be required to pay in the absence of dental insurance
- Services or supplies received by you or your dependent before the dental insurance starts for that person
- Services not performed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling and polishing of teeth or fluoride treatments
- Services which are primarily cosmetic unless required for the treatment or correction of a congenital defect of a newborn child
- Services or appliances which restore or alter occlusion or vertical dimension
- Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease
- Restorations or appliances used for the purpose of periodontal splinting
- Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco
- Personal supplies or devices including, but not limited to water picks, toothbrushes, or dental floss
- Decoration or inscription of any tooth, device, appliance, crown, or other dental work
- Missed appointments
- Services covered under any workers’ compensation or occupational disease law
- Services covered under any employer liability law
- Services for which the member or the person receiving such services is not required to pay
- Services received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital
- Services covered under other coverage provided by the policyholder
- Temporary or provisional restorations or appliances
- Prescription drugs
- The following when charged by the dentist on a separate basis: claim form completion; infection control such as gloves, mask, and sterilization or supplies; or local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide
- Dental service arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food
- Services for which the submitted documentation indicates a poor prognosis
- Caries susceptibility tests
- Diagnosis and treatment of temporomandibular joint (TMJ) disorders
- Initial installation of a denture to replace one or more natural teeth which were missing before such person was insured for dental insurance, except for congenitally missing natural teeth
- Precision attachments associated with fixed and removable prostheses
- Adjustment of a denture made within 6 months after installation by the same dentist who installed it
- Duplicate prosthetic devices or appliance
- Replacement of a lost or stolen appliance or crown, inlay/onlay, or denture
Plan 2 does not cover the above services plus it also excludes Type C (Major) and Type D (Orthodontia) services.
Alternate Benefits
Where two or more professionally acceptable dental treatments for a dental condition exist, the MetLife Dental 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 costlier than the treatment upon which the plan benefit is based, you will be responsible for any additional payment. 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 payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.