| |
|
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 |
| |
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| |
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. |
CRA Dental Web site developed and hosted by the HDH Group, benefits consultant to the Chevron Retirees Association.