Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. * Based on MetLife data for a crown (D2740) in ZIP code 19151. The following list of services includes those services most commonly provided to covered individuals. Accessed February 1, 2021. D9933 Cleaning and inspection of removable complete denture, mandibular-1 every 6 months. D6090 Repair Implant Prosthesis -1 every 60 months, D6091 Replacement of Semi-Precision or Precision Attachment -1 every 60 months, D6095 Repair Implant Abutment - 1 every 60 months, D6096 Remove broken implant retaining screw-1 every 12 months, D6110 Implant/abutment supported removable denture for edentulous arch-maxillary- 1 every 60 months, D6111 Implant/abutment supported removable denture for edentulous arch-mandibular- 1every 60 months, D6112 Implant/abutment supported removable denture for partially edentulous arch-maxillary- 1 every 60 months, D6113 Implant/abutment supported removable denture for partially edentulous arch-mandibular- 1every 60 months, D6114 Implant/abutment supported fixed denture for edentulous arch-maxillary- 1 every 60 months, D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular- 1 every 60 months, D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary- 1 every 60 months, D6117 Implant/abutment supported fixed denture for partially edentulous arch-mandibular- 1 every 60 months, D6210 Pontic - cast high noble metal Limited to 1 every 60 months, D6211 Pontic - cast predominately base metal Limited to 1 every 60 months, D6212 Pontic - cast noble metal Limited to 1 every 60 months, D6214 Pontic titanium Limited to 1 every 60 months, D6240 Pontic - porcelain fused to high noble metal Limited to 1 every 60 months, D6241 Pontic - porcelain fused to predominately base metal Limited to 1 every 60 months, D6242 Pontic - porcelain fused to noble metal Limited to 1 every 60 months, D6245 Pontic - porcelain/ceramic Limited to 1 every 60 months, D6519 Inlay/onlay porcelain/ceramic Limited to 1 every 60 months, D6520 Inlay metallic two surfaces Limited to 1 every 60 months, D6530 Inlay metallic three or more surfaces - Limited to 1 every 60 months, D6543 Onlay metallic three surfaces - 1 every 60 months, D6544 Onlay metallic four or more surfaces -1 every 60 months, D6545 Retainer - cast metal for resin bonded fixed prosthesis -1 every 60 months, D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis -1 every 60 months, D6549 Resin retainer-for resin bonded fixed prosthesis - 1 every 60 months, D6740 Crown - porcelain/ceramic - 1 every 60 months, D6750 Crown - porcelain fused to high noble metal- 1 every 60 months, D6752 Crown - porcelain fused to noble metal- 1 every 60 months, D6780 Crown - 3/4 cast high noble metal- 1 every 60 months, D6783 Crown - 3/4 porcelain/ceramic - 1 every 60 months, D6790 Crown - full cast high noble metal- 1 every 60 months, D6791 Crown - full cast predominately base metal - 1 every 60 months, D6792 Crown - full cast noble metal - 1 every 60 months. Dental HMOs typically provide coverage for your basic care, reduce out-of-pocket costs and limit paperwork. ** Assumes the provider has no other contractual relationship regarding negotiated fees with the primary carrier. Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your providers, the MetLife Federal Dental Plan, BENEFEDS, or OPM. They may look at your Personal Health Information only when there is an appropriate reason to do so, such as to administer our products or services. D2950 Core buildup, including any pins Limited to 1 per tooth every 60 months, D2954 Prefabricated post and core, in addition to crown Limited to 1 per tooth every 60 months, D3310 Anterior root canal (excluding final restoration), D3320 Bicuspid root canal (excluding final restoration), D3330 Molar root canal (excluding final restoration), D3346 Retreatment of previous root canal therapy-anterior, D3347 Retreatment of previous root canal therapy-bicuspid, D3348 Retreatment of previous root canal therapy-molar, D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc. Removable orthodontic retainer adjustment. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves). You may have seen recent news coverage of customers of financial services companies falling victim to social engineering scams. But only if efforts have been made to tell you about the request or to obtain an order protecting the Personal Health Information requested. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. The exclusions in this section apply to all benefits. D1517 Space Maintainer- Fixed-bilateral, mandibular-Limited to children under under age 19. Open contracts andmodernized plan benefits provide coverage for services employees want and theability to adjust coverage for services that are more elective. Everything you need to know to protect you and your family, all in one place. Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time period permitted. In no instance will MetLife allow more than $1,500 in combined benefits under the Standard Option in any plan year. PDF CC0220.Optional.Benefits.for.Employers.3.21 Eff.4.1.21.FINAL - Cal Choice The decision of the independent third party is binding and is the final review of your claim. No deductibles or dollar maximums for any service. The process involves a plan participant calling AXA at (312) 935-9210 collect or(866) 384-2771 to find a local provider in their country. Contact your MetLife representative for complete details. Your Citi GEID is your MetLife member ID. The Message Relay Service enables customers who are deaf, hard of hearing, or speech impaired, and who use a Teletypewriter (TTY), to communicate with others via the telephone. When you use a participating (in-network) provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment. If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 14, through midnight EST December 12, 2022, Open Season. Kaiser NW HMOyou are covered when you receive care from a Kaiser northwest network provider. Class A, B, and C Services are subject to anunlimited maximum benefit, $5,000 Child Lifetime Maximum, $3,000 Adult Lifetime Maximum, Class A, B, and C Services are subject to a $1,500 annual maximum benefit for the In-Network benefits and $1,000 for the Out-of-Network benefits. We protect your Personal Health Information from inappropriate use or disclosure. Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity. You may enroll in FEDVIP again when you begin to receive your annuity. Relay Services is immediate assistance. You may submit questions to us there or you may write to us directly at MetLife, Americas-U.S. HIPPA Privacy Office PO Box 902, New York, NY 10159-0902. D7881 Occlusal orthotic device adjustment. When You Schedule an Appointment Let the dentist know that you participate in the MetLife PDP. The MetLife PDP offers: PDF SCHEDULE OF BENEFITS - MetLife TakeAlong Dental You may find your out-of-pocket costs by reviewing your Schedule of Benefits; ask your primary care dentist; or call MetLife at 1-800-880-1800. MetLife Preferred Dentist Program (PDP) Overview - MGM Benefits Group Federal Employees Dental and Vision Insurance Program. Frequently Asked Questions | MetLife TakeAlong Dental You must submit your claim to us within 13 months following the delivery of the services in order for them to be considered for Plan benefits. Should you experience a lapse in coverage during the calendar year, any benefits paid after reinstatement will be accrued to the maximums applicable to that same calendar year. MetLife will review your claim and notify you of its decision to approve or deny your claim. Such notification will be provided to you within a 30-day period from the date you submitted your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of the Plan. If MetLife needs such an extension, MetLife will notify you prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination. If an extension is needed because you did not provide sufficient information or filed an incomplete claim, the time from the date of MetLifes notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify you as to its claim decision. You will have 45 days to provide the requested information from the date you receive the notice requesting further information from MetLife. Care that you receive from a licensed provider that does not participate in the MetLife Preferred Dentist Program (PPO) is considered Out-of-Network. Right to Inspect and Copy Your Personal Health Information. Presenting both ID cards can ensure that you receive the maximum allowable benefit under each Program. You may also view current In-Network providers via our web website at MetLife.com/FEDVIP-Dental. In-progress treatment for dependents of retiring TDPenrollees will be covered for the2023 plan year. D6123 Implant supported retainer for metal FPD titanium and titanium alloys - 1 every 60 months. Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. We may also disclose Personal Health Information to other insurance carriers to coordinate benefits with respect to a particular claim. We would like to show you a description here but the site won't allow us. You must submit your request to us in writing to the address shown above along with any additional information you or your dentist can provide to substantiate your claim so that we can reconsider our decision. D5511 Repair broken complete denture base-mandibular, D5512 Repair broken complete denture base-maxillary, D5611 Repair resin partial denture base-mandibular, D5612 Repair resin partial denture base-maxillary, D5621 Repair cast partial framework-mandibular, D5622 Repair cast partial framework-maxillary, D5730 Reline complete maxillary denture - Limited to 1 in a 36-month period 6 months after the initial installation, D5740 Reline maxillary partial denture- Limited to 1in a 36-month period 6 months after the initial installation, D5741 Reline mandibular partial denture- Limited to 1 in a 36-month period 6 months after the initial installation, D7251 Coronectomy - intentional partial tooth removal. This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2023 plan year such as crowns and implants. The plan covers additional cleanings and periodontal maintenance, brush biopsies for oral cancer screening and adult fluoride and anesthesia benefits, including nitrous oxide and IV sedation. This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent's costs for each Covered Service. (Page numbers solely appear in the printed brochure), Opportunities to Enroll or Change Enrollment, FSAFEDS/High Deductible Health Plans and FEDVIP, Identification Cards / Enrollment Confirmation. Rates are shown at the end of this brochure. If you sign up for a dental and/or vision plan during the 2022 Open Season, your coverage will begin on January 1, 2023. Note: You cannot enroll or change enrollmentin a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page. This scamming can happen via text, email or websites set up to look like the trusted company. All exams,oral evaluations and treatments such as fluorides and some images are combined under one limitation under the plan. Benefits are payable at 50% of the Plan Allowance. If MetLife Dental is not listed as an enrollment option in SAP, please call SDPEBA at phone number provided below. If you have questions as how to file a complaint please contact us at (212) 578-0299 or at HIPPAprivacyAmericasUS@metlife.com. The lifetime maximum benefit for a child receiving orthodontia services depends on the option in which you enroll and if services are received from a network provider. The following describe these and other uses and disclosures, together with some examples. The lifetime maximum benefit is $2,000 under the Standard Option. $2,000 Child Lifetime Maximum,$2,000 Adult Lifetime Maximum. The Plan Allowance for Out-of-Network services will be equal to the In-Network Plan Allowance for the covered service (see page 52 for further details). D9944 Occlusal guard-hard appliance, full arch - 1 in 12 months for patients 13 and older. D1556 Removal of fixed unilateral space maintainer per quadrant. 2022 MetLife Services and Solutions, LLC, L0218503064[exp0219][CA,FL,TX] 02/28/2019, Summary of Dental Benefits and Coverage Disclosure Matrix. Coverage is effective January 1, 2023. Certain administrative services are provided through Careington Benefit Solutions, Frisco, TX (Careington). D9934 Cleaning and inspection of removablepartial denture, maxillary-1 every 6 months. Health MaintenanceOrganization. interim abutment: provisional implant crown) originally placed for a specific clinical purpose and period of time determined by the dentist. The plan allowance may vary by geographic location and/or a participating providers contracted fee schedule. When you make your appointment pleaseinform the dental office you are enrolled in the FEDVIP plan and that you wish to use your In-Network benefits. MetLifes PPO network consists of independently credentialed and contracted providers. 1. These plans are designed to help you and your family save big on care and maintain your oral health. It is not an all-inclusive list of covered services. Dental Insurance Plans: Healthy Smiles Ahead | MetLife D6753 Retainer crown porcelain fused to titanium and titanium alloys - 1 every 60 months. We may recover such overpayment in accordance with that agreement. If the overpayment results from MetLife having made a payment to you that should have been made under another group plan, we may recover such overpayment from one or more of the following: This section describes how medical information about you may be used and disclosed and how you can get information. NOTE: There are no waiting periods under this plan. The State offers two dental benefits plans through SafeGuard. Qualifying Life EventA qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an open season. Orthodontic care for dependent children age 22 and over for Federal civilian employees. The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility or receipt of an annuity or portion of an annuity: You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. Our network attorneys have an overall average of 25 years of experience and offer a broad range of legal services like: Legal coverage is needed for both planned and unplanned events. D9110 Palliative treatment of dental pain minor procedure, D9310 Consultation(diagnostic service provided by dentist or physician other than practitioner providing treatment), D9311 Consultation With Medical Professional, D9440 Office Visit- after regularly scheduled hours, D0387 Intraoral tomosynthesis comprehensive series of radiographic images, D0388 Intraoral tomosynthesis bitewing radiographic image image capture only, D0389 Intraoral tomosynthesis periapical radiographic image image capture only. The following list of services includes those services most commonly provided to covered individuals. The calendar year deductible may apply to Type A expenses provided by an Out-of-Network provider. Title: CC0220.Optional.Benefits.for.Employers.3.21_Eff.4.1.21.FINAL.pdf Author: KASHY Created Date: 3/26/2021 3:00:20 PM Your enrollment or your eligibility to enroll may continue after retirement. You do not need to be enrolled in FEDVIP for any length of time to continue enrollment into retirement. Your family members may also be able to continue enrollment after your death. Please see Section 1, Eligibility,for more information. D0210 Intraoral complete set of radiographic images including bitewings -1 every 60 (sixty) months, D0220 Intraoral - periapical radiographic image, D0230 Intraoral - additional periapical image, D0270 Bitewing - single image Adult - 1 set every calendar year/Children - 1 set every 6 months, D0272 Bitewings - two images - Adult - 1 set every calendar year/Children - 1 set every 6 months, D0274 Bitewings - four images -Adult - 1 set every calendar year/Children - 1 set every 6 months, D0277 Vertical bitewings 7 to 8 images Adult - 1 set every calendar year/Children - 1 set every 6 months, D0330 Panoramic radiographic image 1 image every 60 (sixty)months, D03502D Oral / Facial Photographic Images-obtained intraorally and extraorally.

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