| LOW PLAN | HIGH PLAN | ||
| In-Network/Outside-Network | In-Network/Outside-Network | ||
| Eligibility | |||
| CRA Member | Must Be Dues Paying Member | Must Be Dues Paying Member | |
| Dependents | Spouse, Children to Age 25 | Spouse, Children to Age 25 | |
| Coverage | |||
| Type A – Preventive (See Below) | 100%, No Deductible | 100%, No Deductible | |
| Type B – Basic (See Below) | 70% | 70% | |
| Type C – Major (See Below) | Not Applicable | 50% | |
| Deductibles & Maximum Benefit (Per Calendar Year) | |||
| Individual Deductible – Coverage Types B & C Only | $75 | $75 | |
| Family Deductible – Coverage Types B & C Only | $225 | $225 | |
| Maximum Benefit Per Person | $750 | $1,500 | |
| Maximum Allowable Charge | |||
| Negotiated Fee* | Negotiated Fee* | ||
| * Negotiated Fee applies In-Network and 80th Percentile R&C applies Outside-Network. | |||
| Type A – Preventive | Type B – Basic | Type C – Major | |
| ———————————— | ———————————— | ———————————— | |
| Oral Exams Full-Mouth or Panoramic x-Rays Bitewing x-Rays Prophylaxis/Cleanings Fluoride Treatmentsv |
Intraoral, periapical, and extraoral x-rays Pulp vitality tests Diagnostic Casts Diagnostics Photographics Bacteriological Studies Sealants Space Maintainers Palliative Care Sedative Fillings Fillings Periodontal Maintenance Pulp Capping Therapeutic Pulpotomy |
Recementations and Repairs Rebases/Relines Implants General Anesthesia Simple Extractions Surgical Extractions/Oral Surgery Consultations Inlays/Onlays Crowns Crown Build-ups Veneers Dentures Bridges Endodontics/Root Canal Periodontics |
|
Although orthodontia and cosmetic services are not covered under the plan design, MetLife members still receive the 10-15% in-network discounts on services.