Dental – Low Plan (Maximum Allowable Charge ... - Midlothian ISD

Dental – Low Plan (Maximum Allowable Charge)
Plan Design for: Midlothian ISD
Choice, Service, Savings.
To help you enroll, this overview includes rate information and a List of Covered Services so you can make the most informed
decision possible.
Coverage Type:
Covered Percentage
Type A – Preventive 100%
Type B - Basic Restorative 80%
Type C - Major Restorative 50%
Type D – Orthodontia – Child 50%
Deductible 3
Individual $50
Family $150
Annual Maximum Benefit:
Per Person $1,000
Orthodontia Lifetime Max Per Person $750
Benefit Waiting Period
For employees who elect coverage during the 31-day application period, the following Dental Benefits will become effective after the satisfaction of the waiting
period(s) shown below. In the case of the transferred business, if employees elected coverage under the prior plan for which the employees were eligible, the
following waiting period(s) will not apply.
• Preventive Services, Basic Services , Major Service and Orthodontic Services ------------------------- No waiting period
Like most life insurance policies, MetLife group insurance policies contain certain exclusions, waiting periods, reductions and terms for keeping
them in force. For costs and complete details of coverage, call or write your MetLife representative. In addition, a full description of your dental
benefits will be provided in the certificate of insurance.
IMPORTANT RATE INFORMATION
Monthly (12 months)
Employee $19.17
Employee + 1 Dependent $34.91
Employee + 2 or more
Dependents
$54.95
PLEASE NOTE THAT IT IS NOT NECCESARY TO PRESENT AN INDENTIFICATION CARD
TO THE PROVIDER. YOUR SOCIAL SECURITY WILL BE USED TO VERIFY ELIGIBILITY
WITH METLIFE. If you have a claim inquiry or benefit questions, please call MetLife’s Dental Customer
Service Department at 1-800- ASK - 4 - MET after your plan’s effective date
Page 1 of 6
Metropolitan Life Insurance Company, New York, NY 10166
L050638L4(exp0606)MLIC-LD

Type A – Preventive
Oral Exams
Oral Exams-Problem Focused
Full Mouth X-Rays
Periapical X-Rays
Other X-Rays
Bitewing X-Rays
Prophylaxis / Cleanings
Fluoride Treatments
Sealants
Type B – Basic Restorative
Labs & Other Tests
Space Maintainers
List of Covered Services & Limitations*
How Many/How Often:
Oral exams (including problem focused) but not more than 1 time in 6 months.
Full mouth or Panoramic X-rays but not more than once every 5 calendar years.
Bitewing X-rays 1 time in 12 months for a child under 14; and 1 time in 12 months for everyone else.
Cleaning of teeth (oral prophylaxis) 1 time in 6 months.
Topical fluoride treatment for a child under age 13, 1 time in 1 calendar year.
Sealants for a child under age 13, which are applied to non-restored, non-decayed first and second
permanent molars once per tooth in 60 months
How Many/How Often:
Space Maintainers limited to one per lifetime per area for a child under 14 years of age.
Fillings
Amalgam or Resin Composite filling replacements if at least 24 months have passed since the existing
filling was placed; or a new surface of decay is identified on that tooth.
Adjustments of dentures if at least 6 months have passed since the installation of the denture and not
more than once in any 12 month period.
Rebases / Relines
Simple Extractions
Surgical Extractions
Oral Surgery
Emergency Palliative
Treatment
Relining and Rebasing of existing removable dentures: if at least 6 months have passed since the
installation; and not more than once in any 36 month period.
Tissue Conditioning, but not more than 1 time in 36 months.
Type C - Major Restorative
How Many/How Often:
Cone Beam Imaging
Crowns
Inlays / Onlays
Prefabricated Stainless Steel
and Resin Crowns
Recementations
Crown Build-ups / Post & Core
Repairs
Root Canal
Cone Beam Imaging but not more than once for the same tooth position in any 60 month period.
Initial installation of Cast Restorations (inlays, onlays, crowns).
- Replacement of any Cast Restorations with the same or a different type of Cast Restoration but
not more than one replacement for the same tooth surface within 10 calendar years of a prior
replacement.
Prefabricated stainless steel crowns or prefabricated resin crowns, but not more than one replacement
for the same tooth surface within any 10 calendar year period.
Recementation of Crowns, Inlays, Onlays, Dentures and Bridgework is limited to 1 time in 12 months.
Crown Buildups / Post and Core but no more than once per tooth in a period of 10 calendar years.
Repairs to Crowns, Inlays, Onlays, Dentures and Bridgework are limited to 1 time in 12 months.
Root canal treatment not more often than once per lifetime for the same tooth.
Periodontal Surgery
Periodontal Surgery - Soft and
Connective Tissue Grafts
Periodontics – Non-Surgical
Periodontal Maintenance
Dentures
Fixed Bridges
General Anesthesia
Periodontal surgery not mentioned elsewhere, including gingivectomy, gingivoplasty, gingival curettage,
and osseous surgery, but no more than one surgical procedure per quadrant in any 36 month period.
Periodontal Soft or Connective Tissue Grafts, but no more than one surgical procedure per quadrant in
any 36 month period.
Periodontal scaling and root planing but not more than once per quadrant in any 24 month period.
Periodontal Maintenance: Where periodontal treatment (including scaling, root planing and periodontal
surgery such as gingivectomy, gingivoplasty, osseous surgery) has been performed. Periodontal
maintenance is limited to 2 times in any year less the number of teeth cleanings received during such
12 month period.
Replacement of a non-serviceable removable partial denture, removable full denture or fixed bridgework
if installed more than 10 calendar years prior to replacement.
Initial installation of fixed bridgework, a partial removable denture or a full removable denture when
needed to replace congenitally missing teeth or to replace natural teeth lost while this dental insurance
coverage is in effect.
Administration of general anesthesia or intravenous sedation in connection with oral surgery,
extractions, or other covered services, when dentally necessary as determined by Metropolitan in terms
of generally accepted dental standards.
Consultations
Occlusal Adjustments
Implants
Consultations, but not more than 1 time in a 12 month period.
Occlusal Adjustments, but not more than 1 time in a 12 month period.
Type D – Orthodontia
• All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia
• Payments are on a repetitive basis.

Midlothian ISD - MAC Fees
PROCEDURE
GENERALIST
CODE DESCRIPTION PDP FEE
00120 PERIODIC ORAL EXAMINATION $25
00140 LTD ORAL EVALUATION - PROBLEM FOCUS $37
00150 COMP ORAL EVALUATION - NEW/EST PT $35
00180 COMP PERIODONTAL EVAL - NEW/EST PT $39
00210 INTRAORAL-COMPLETE SERIES $73
00220 INTRAORAL PERIAPICAL FIRST FILM $14
00230 INTRAORL PERIAPICAL EA ADD FILM $6
00240 OCCLUSAL XRAY $23
00270 BITEWING - SINGLE FILM $14
00272 BITEWINGS - TWO FILMS $22
00274 BITEWINGS - FOUR FILMS $29
00330 PANORAMIC FILM $61
01110 PROPHYLAXIS - ADULT $53
01120 PROPHYLAXIS - CHILD $43
01203 TOP FLUORIDE - CHILD $27
01204 TOP FLUORIDE - ADULT $27
01206 TOP FLUORIDE VARNISH $41
01351 SEALANT - PER TOOTH $25
02140 AMALGAM-ONE SURFACE PRIMARY/PERM $66
02150 AMALGAM-TWO SURFACES PRIMARY/PERM $81
02160 AMALGAM-3 SURFACES PRIMARY/PERM $103
02330 RESIN COMPOS - ONE SURFACE ANTERIOR $75
02331 RESIN COMPOS - 2 SURFACES ANTERIOR $97
02332 RESIN COMPOS - 3 SURFACES ANTERIOR $117
02335 RSN COMPOS-4/> SURF/W/INCISAL ANG $141
02391 RESIN COMPOS - 1 SURFACE POSTERIOR $81
02392 RESIN COMPOS - 2 SURFACES POSTERIOR $110
02393 RESIN COMPOS - 3 SURFACES POSTERIOR $136
02740 CROWN - PORCELAIN/CERAMIC SUBSTRATE $688
02750 CROWN - PORCELN FUSED HI NOBLE METL $683
02751 CROWN PORCELAIN-BASE METAL $625
02752 CROWN - PORCELAIN FUSED NOBLE METAL $653
02790 CROWN - FULL CAST HIGH NOBLE METAL $642
02792 CROWN - FULL CAST NOBLE METAL $586
02920 RECEMENT CROWN $41
02930 STAINLESS STEEL CROWN - CHILD $125
02950 CORE BUILDUP INCLUDING ANY PINS $103
02954 PREFABR POST&CORE ADDITION CROWN $158
03120 PULP CAP - INDIRECT $36
03310 ANTERIOR $397
03320 BICUSPID $474
03330 MOLAR $654
04341 PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUAD $116
04342 PRDONTAL SCAL&ROOT PLAN 1-3 TEETH $73
04355 FULL MOUTH DEBRID COMP EVAL&DX $57
04381 LOC DEL ANTIMICROBIAL AGT TOOTH BR $60
04910 PERIODONTAL MAINTENANCE $71

06010 ENDOSTEAL IMPLANT $1,339
06240 PONTIC - PORCELAIN - HIGH NOBLE $659
06750 CRWN PORCLN FUSD HI NOBL MTL-DENTUR $683
07140 EXTRAC ERUPTED TOOTH/EXPOSED ROOT $68
07210 SURG REMOVAL ERUPTED TOOTH $128
07220 SURG REMOVAL IMPACTED TOOTH $166
07230 REMOVAL IMPACT TOOTH - PARTLY BONY $204
07240 REMOVAL IMPACTED TOOTH - CMPL BONY $269
09110 PALLIATVE TX DENTAL PAIN-MINOR PROC $43
09220 DP SEDATION/GEN ANES-1ST 30 MIN $226
09221 DP SEDAT/GEN ANES-EA ADD 15 MIN $73
09310 CONSULTATION $54
09940 OCCLUSAL GUARD BY REPORT $352