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Tj ET BT /F3 10 Tf 1 0 0 1 0 253.36 Tm (You get benefits for a wide range of covered services both in and out of the network. The goal is to deliver) Tj ET BT /F3 10 Tf 1 0 0 1 0 240.14 Tm (affordable protection for a healthier smile and a healthier you.) Tj ET 1 1 1 RG 20.7 w 135.38 211.89 m 331.42 211.89 l S 1 w 20.7 w 331.92 211.89 m 527.97 211.89 l S 1 w BT /F4 9 Tf 1 0 0 1 -5.28 208.92 Tm (Coverage Type) Tj ET BT /F4 9 Tf 1 0 0 1 208.65 214.09 Tm (In-Network:) Tj ET BT /F3 9 Tf 1 0 0 1 193.63 203.75 Tm (% of Negotiated Fee) Tj ET BT /F4 9 Tf 1 0 0 1 395.71 214.09 Tm (Out-of-Network:) Tj ET BT /F3 9 Tf 1 0 0 1 399.69 203.75 Tm (% of R&C Fee) Tj ET BT /F3 5.4 Tf 1 0 0 1 457.21 206.45 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 -5.28 188.02 Tm (Type A) Tj ET BT /F3 10 Tf 1 0 0 1 220.59 188.02 Tm (100%) Tj ET BT /F3 10 Tf 1 0 0 1 417.14 188.02 Tm (100%) Tj ET BT /F3 10 Tf 1 0 0 1 -5.28 168.07 Tm (Type B) Tj ET BT /F3 10 Tf 1 0 0 1 223.39 168.07 Tm (80%) Tj ET BT /F3 10 Tf 1 0 0 1 419.94 168.07 Tm (80%) Tj ET BT /F3 10 Tf 1 0 0 1 -5.28 148.12 Tm (Type C) Tj ET BT /F3 10 Tf 1 0 0 1 223.39 148.12 Tm (60%) Tj ET BT /F3 10 Tf 1 0 0 1 419.94 148.12 Tm (60%) Tj ET BT /F3 10 Tf 1 0 0 1 -5.28 128.16 Tm (Orthodontia) Tj ET BT /F3 10 Tf 1 0 0 1 223.39 128.16 Tm (50%) Tj ET BT /F3 10 Tf 1 0 0 1 419.94 128.16 Tm (50%) Tj ET BT /F4 10 Tf 1 0 0 1 -5.28 112.19 Tm (Deductible:) Tj ET BT /F3 10 Tf 1 0 0 1 -5.28 100.69 Tm (Individual/Family*) Tj ET BT /F3 10 Tf 1 0 0 1 194.78 106.44 Tm ($50) Tj ET BT /F3 10 Tf 1 0 0 1 214.24 106.44 Tm (\(Type B & C\)) Tj ET BT /F3 10 Tf 1 0 0 1 391.33 106.44 Tm ($50) Tj ET BT /F3 10 Tf 1 0 0 1 410.79 106.44 Tm (\(Type B & C\)) Tj ET 2 J 0.5 w [] 0 d 0 0 0 RG -7.43 222.24 m -7.43 98.24 l S 1 w [] 0 d 0.5 w [] 0 d 135.13 222.24 m 135.13 98.24 l S 1 w [] 0 d 0.5 w [] 0 d 331.67 222.24 m 331.67 98.24 l S 1 w [] 0 d 0.5 w [] 0 d 528.22 222.24 m 528.22 98.24 l S 1 w [] 0 d 0.5 w [] 0 d -7.43 222.49 m 528.22 222.49 l S 1 w [] 0 d 0.5 w [] 0 d -6.93 201.29 m 527.72 201.29 l S 1 w [] 0 d 0.5 w [] 0 d -6.93 181.34 m 527.72 181.34 l S 1 w [] 0 d 0.5 w [] 0 d -6.93 161.39 m 527.72 161.39 l S 1 w [] 0 d 0.5 w [] 0 d -6.93 141.44 m 527.72 141.44 l S 1 w [] 0 d 0.5 w [] 0 d -6.93 121.49 m 527.72 121.49 l S 1 w [] 0 d 0.5 w [] 0 d -7.43 98 m 528.22 98 l S 1 w [] 0 d BT /F4 10 Tf 1 0 0 1 -5.48 74.39 Tm (Annual Maximum) Tj ET BT /F4 10 Tf 1 0 0 1 -5.48 62.9 Tm (Benefit:) Tj ET 0.439 w [] 0 d 0 0 1 RG 31.97 65.04 m 33.19 65.04 l S 1 w [] 0 d BT /F3 10 Tf 1 0 0 1 38.97 62.9 Tm (Per Individual) Tj ET BT /F3 10 Tf 1 0 0 1 219.4 68.64 Tm ($2000) Tj ET BT /F3 10 Tf 1 0 0 1 416.15 68.64 Tm ($2000) Tj ET 0.5 w [] 0 d 0 0 0 RG -7.63 83.44 m -7.63 60.45 l S 1 w [] 0 d 0.5 w [] 0 d 134.93 83.44 m 134.93 60.45 l S 1 w [] 0 d 0.5 w [] 0 d 331.67 83.44 m 331.67 60.45 l S 1 w [] 0 d 0.5 w [] 0 d 528.42 83.44 m 528.42 60.45 l S 1 w [] 0 d 0.5 w [] 0 d -7.63 83.69 m 528.42 83.69 l S 1 w [] 0 d 0.5 w [] 0 d -7.63 60.2 m 528.42 60.2 l S 1 w [] 0 d BT /F4 10 Tf 1 0 0 1 -5.2 28.4 Tm (Orthodontia Lifetime) Tj ET BT /F4 10 Tf 1 0 0 1 -5.2 16.9 Tm (Maximum:) Tj ET BT /F3 10 Tf 1 0 0 1 47.03 16.9 Tm (Per Individual) Tj ET BT /F3 10 Tf 1 0 0 1 219.5 32.62 Tm ($1500) Tj ET BT /F3 10 Tf 1 0 0 1 416 32.62 Tm ($1500) Tj ET BT /F3 10 Tf 1 0 0 1 199.35 12.67 Tm (Ortho applies to Adult and Child \(Up to dependent age limit\)) Tj ET 0.5 w [] 0 d -7.35 45.65 m -7.35 6.25 l S 1 w [] 0 d 0.5 w [] 0 d 135.15 45.65 m 135.15 6.25 l S 1 w [] 0 d 0.5 w [] 0 d 331.65 45.65 m 331.65 26.2 l S 1 w [] 0 d 0.5 w [] 0 d 528.15 45.65 m 528.15 6.25 l S 1 w [] 0 d 0.5 w [] 0 d -7.35 45.9 m 528.15 45.9 l S 1 w [] 0 d 0.5 w [] 0 d 135.65 25.95 m 527.65 25.95 l S 1 w [] 0 d 0.5 w [] 0 d -7.35 6 m 528.15 6 l S 1 w [] 0 d Q q Q q 1 0 0 1 47.5 184.42 cm q n -47.5 211.9 m 348.5 211.9 l 348.5 0 l -47.5 0 l h W n 2 J 0.5 w [] 0 d 0 0 0 RG -4.55 211.4 m -4.55 197.9 l S 1 w [] 0 d 0.5 w [] 0 d 346 211.4 m 346 197.9 l S 1 w [] 0 d 0.5 w [] 0 d -4.55 211.65 m 346 211.65 l S 1 w [] 0 d 0.5 w [] 0 d -4.55 197.65 m 346 197.65 l S 1 w [] 0 d 0 0 0 rg BT /F4 10 Tf 1 0 0 1 70.93 201.35 Tm (Understanding Your Dental Benefits Plan) Tj ET BT /F3 10 Tf 1 0 0 1 0 182.6 Tm (With the MetLife Preferred Dentist Program you can visit the dentist of your) Tj ET BT /F3 10 Tf 1 0 0 1 0 169.38 Tm (choice an in-network dentist \(a participating MetLife dentist\) or an out-of-) Tj ET BT /F3 10 Tf 1 0 0 1 0 156.16 Tm (network dentist.) Tj ET BT /F5 9.5 Tf 1 0 0 1 4.5 142.43 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 142.43 Tm (Plan benefits for in-network services are based on the percentage of the) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 130.93 Tm (Negotiated fee the fee that in-network dentists have agreed to accept as) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 119.44 Tm (payment in full for covered services, subject to any co-payments,) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 107.94 Tm (deductibles, cost sharing and benefit maximums. Negotiated fees are) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 96.44 Tm (subject to change.) Tj ET BT /F5 9.5 Tf 1 0 0 1 4.5 84.44 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 84.44 Tm (Plan benefits for out-of-network services are based on a percentage of) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 72.94 Tm (the Reasonable and Customary \(R&C\) charge. If you choose a dentist) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 61.44 Tm (who does not participate in the network, your out-of-pocket expenses may) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 49.94 Tm (be higher, since you will be responsible for paying any difference between) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 38.44 Tm (the dentist's fee and your plan's payment for the approved service. Please) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 26.94 Tm (refer to the Selected Covered Services and Frequency Limitations page of) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 15.45 Tm (this document for details regarding how R&C charges are defined under) Tj ET BT /F3 10 Tf 1 0 0 1 13.5 3.95 Tm (this plan.) Tj ET Q q n 348.5 211.9 m 564.5 211.9 l 564.5 48.09 l 348.5 48.09 l h W n 0.85098 0.85098 0.85098 RG 0 J 163.32 w 349.85 129.75 m 526.7 129.75 l S 1 w 0 0 0 rg BT /F4 9 Tf 1 0 0 1 355 201.26 Tm (Take advantage of online self-) Tj ET BT /F4 9 Tf 1 0 0 1 355 188.39 Tm (service capabilities with) Tj ET BT /F4 9 Tf 1 0 0 1 355 175.52 Tm (MyBenefits.) Tj ET q n 355 172.8 m 531.35 172.8 l 531.35 165.8 l 355 165.8 l h W n Q 0 0 0 rg BT /F5 9 Tf 1 0 0 1 355 154.76 Tm (x) Tj ET BT /F3 9 Tf 1 0 0 1 373 154.76 Tm (Check the status of your claims) Tj ET BT /F5 9 Tf 1 0 0 1 355 141.51 Tm (x) Tj ET BT /F3 9 Tf 1 0 0 1 373 141.51 Tm (Locate a participating dentist) Tj ET BT /F5 9 Tf 1 0 0 1 355 128.26 Tm (x) Tj ET BT /F3 9 Tf 1 0 0 1 373 128.26 Tm (Access MetLifes Oral Health Library) Tj ET BT /F5 9 Tf 1 0 0 1 355 115.01 Tm (x) Tj ET BT /F3 9 Tf 1 0 0 1 373 115.01 Tm (Elect to view your Explanation of) Tj ET BT /F3 9 Tf 1 0 0 1 373 102.66 Tm (Benefits online) Tj ET q n 355 93.94 m 531.35 93.94 l 531.35 80.94 l 355 80.94 l h W n 0 0 0 rg BT /F3 9 Tf 1 0 0 1 355 84.75 Tm (If you are not already registered, just) Tj ET Q q n 355 82.94 m 531.35 82.94 l 531.35 69.94 l 355 69.94 l h W n 0 0 0 rg BT /F3 9 Tf 1 0 0 1 355 73.75 Tm (go) Tj ET BT /F3 9 Tf 1 0 0 1 367.05 73.75 Tm (to) Tj ET BT /F4 9 Tf 1 0 0 1 379.55 73.75 Tm (www.metlife.com/mybenefits) Tj ET Q q n 355 71.94 m 531.35 71.94 l 531.35 58.94 l 355 58.94 l h W n 0 0 0 rg BT /F3 9 Tf 1 0 0 1 355 62.75 Tm (and follow the easy registration) Tj ET Q 0 0 0 rg BT /F3 9 Tf 1 0 0 1 355 50.79 Tm (instructions.) Tj ET 2 J 0.5 w [] 0 d 0 0 0 RG 349.6 211.4 m 349.6 48.59 l S 1 w [] 0 d 0.5 w [] 0 d 526.45 211.4 m 526.45 48.59 l S 1 w [] 0 d 0.5 w [] 0 d 349.6 211.65 m 526.45 211.65 l S 1 w [] 0 d 0.5 w [] 0 d 349.6 48.34 m 526.45 48.34 l S 1 w [] 0 d Q Q q Q q 1 0 0 1 47.5 60.67 cm 0 0 0 rg BT /F3 10 Tf 1 0 0 1 0 101.46 Tm (Certain plan benefits are based on a percentage of the negotiated fee. This is the amount that participating dentists) Tj ET BT /F3 10 Tf 1 0 0 1 0 88.24 Tm (have agreed to accept as payment in full. If your plan benefits are based on a percentage of the Reasonable and) Tj ET BT /F3 10 Tf 1 0 0 1 0 75.02 Tm (Customary \(R&C\) charges, your out-of-pocket expenses may be more, since you will be responsible for paying any) Tj ET BT /F3 10 Tf 1 0 0 1 0 61.79 Tm (difference between the dentist's fee and your plan's payment for the approved service.) Tj ET BT /F3 8 Tf 1 0 0 1 0 29.68 Tm (*) Tj ET BT /F3 8 Tf 1 0 0 1 7.56 29.68 Tm (If you are enrolled for dependent coverage, a maximum family deductible may apply.) Tj ET BT /F3 8 Tf 1 0 0 1 0 11.28 Tm (Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often participants visit the dentist) Tj ET BT /F3 8 Tf 1 0 0 1 0 2.08 Tm (and the cost of services rendered.) Tj ET Q q Q Q endstream endobj 8 0 obj <>>>>> endobj 9 0 obj <>stream q 0 0 612 792 re W n q 1 0 0 1 47.5 28.8 cm 0 0 0 rg BT /F3 9 Tf 1 0 0 1 0 13.13 Tm (DN-ONECLK-LG Benefit Summary One Click) Tj ET BT /F3 9 Tf 1 0 0 1 0 2.78 Tm (2023-10-09_5957643_9999_9999 _Dental_1) Tj ET BT /F3 9 Tf 1 0 0 1 249.16 23.48 Tm (Page) Tj ET BT /F3 9 Tf 1 0 0 1 272.68 23.48 Tm (2) Tj ET BT /F3 9 Tf 1 0 0 1 277.68 23.48 Tm ( of) Tj ET BT /F3 9 Tf 1 0 0 1 290.19 23.48 Tm (8) Tj ET BT /F3 9 Tf 1 0 0 1 375.38 23.48 Tm (200 Park Ave., New York, NY 10166) Tj ET BT /F3 9 Tf 1 0 0 1 344.22 13.13 Tm ( 2023 MetLife Services and Solutions, LLC) Tj ET BT /F3 9 Tf 1 0 0 1 383.34 2.78 Tm (L0522023151[exp0524][All States]) Tj ET Q q Q Q endstream endobj 10 0 obj <>>>>> endobj 11 0 obj <>stream q 0 0 612 792 re W n q 1 0 0 1 47.5 28.8 cm 0 0 0 rg BT /F3 9 Tf 1 0 0 1 0 12.95 Tm (DN-ONECLK-LG Benefit Summary One Click) Tj ET BT /F3 9 Tf 1 0 0 1 0 2.6 Tm (2023-10-09_5957643_9999_9999 _Dental_1) Tj ET BT /F3 9 Tf 1 0 0 1 249.16 23.3 Tm (Page) Tj ET BT /F3 9 Tf 1 0 0 1 272.68 23.3 Tm (3) Tj ET BT /F3 9 Tf 1 0 0 1 277.68 23.3 Tm ( of) Tj ET BT /F3 9 Tf 1 0 0 1 290.19 23.3 Tm (8) Tj ET BT /F3 9 Tf 1 0 0 1 375.38 23.3 Tm (200 Park Ave., New York, NY 10166) Tj ET BT /F3 9 Tf 1 0 0 1 344.22 12.95 Tm ( 2023 MetLife Services and Solutions, LLC) Tj ET BT /F3 9 Tf 1 0 0 1 383.34 2.6 Tm (L0522023151[exp0524][All States]) Tj ET Q q Q q 1 0 0 1 47.5 84.25 cm 0 0 0 rg BT /F4 10 Tf 1 0 0 1 0 651.2 Tm (Selected Covered Services and Frequency Limitations*) Tj ET BT /F4 10 Tf 1 0 0 1 -1.7 631.2 Tm (Type A) Tj ET 2 J 0.5 w [] 0 d 0 0 0 RG -7.45 641.35 m -7.45 627.65 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 641.35 m 528.25 627.65 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 641.6 m 528.25 641.6 l S 1 w [] 0 d BT /F5 9 Tf 1 0 0 1 -1.7 617 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 617 Tm (Oral Examinations) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 617 Tm (2 in 1 year) Tj ET BT /F3 10 Tf 1 0 0 1 286.19 617 Tm (.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 602.8 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 602.8 Tm (Fluoride) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 602.8 Tm (Children to age 18) Tj ET BT /F3 10 Tf 1 0 0 1 321.22 602.8 Tm ( /) Tj ET BT /F3 10 Tf 1 0 0 1 329.56 602.8 Tm (2) Tj ET BT /F3 10 Tf 1 0 0 1 335.12 602.8 Tm ( in) Tj ET BT /F3 10 Tf 1 0 0 1 348.46 602.8 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 356.8 602.8 Tm (year.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 588.6 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 588.6 Tm (Bitewing X-rays) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 588.6 Tm (Adult - 2 in 1 year / Children - 2 in 1 year.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 574.4 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 574.4 Tm (Full Mouth X-rays) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 574.4 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 245.06 574.4 Tm ( in) Tj ET BT /F3 10 Tf 1 0 0 1 258.4 574.4 Tm (3 years.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 555.55 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 555.55 Tm (Space Maintainers) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 561.3 Tm (For dependent children to age 12. Limited to 1 per lifetime per) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 549.8 Tm (area.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 530.55 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 530.55 Tm (Sealants \(1st & 2nd permanent molars\)) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 534.8 Tm (1 per tooth in 60 months) Tj ET BT /F3 10 Tf 1 0 0 1 350.13 534.8 Tm (of a dependent child up to) Tj ET BT /F3 10 Tf 1 0 0 1 468 534.8 Tm (18) Tj ET BT /F3 6 Tf 1 0 0 1 479.12 537.8 Tm (th) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 523.3 Tm (birthday.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 510.2 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 510.2 Tm (Cleanings) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 510.2 Tm (2 in 1) Tj ET BT /F3 10 Tf 1 0 0 1 266.74 510.2 Tm (year.) Tj ET 0.5 w [] 0 d -7.45 627.15 m -7.45 506.66 l S 1 w [] 0 d 0.5 w [] 0 d 233.75 627.15 m 233.75 506.66 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 627.15 m 528.25 506.66 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 627.4 m 528.25 627.4 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 613.2 m 527.75 613.2 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 599 m 527.75 599 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 584.8 m 527.75 584.8 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 570.6 m 527.75 570.6 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 547.1 m 527.75 547.1 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 520.61 m 527.75 520.61 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 506.41 m 528.25 506.41 l S 1 w [] 0 d BT /F4 10 Tf 1 0 0 1 -1.7 496 Tm (Type B) Tj ET 0.5 w [] 0 d -7.45 506.16 m -7.45 492.46 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 506.16 m 528.25 492.46 l S 1 w [] 0 d BT /F5 9 Tf 1 0 0 1 -1.7 481.8 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 481.8 Tm (Periodontal Maintenance) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 481.8 Tm (2) Tj ET BT /F3 10 Tf 1 0 0 1 245.06 481.8 Tm ( in) Tj ET BT /F3 10 Tf 1 0 0 1 258.4 481.8 Tm (1 year) Tj ET BT /F3 10 Tf 1 0 0 1 286.19 481.8 Tm ( less the number of teeth cleanings.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 467.2 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 467.2 Tm (Emergency Palliative Treatment) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 452.6 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 452.6 Tm (Periodontal Root Planing & Scaling) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 452.6 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 245.06 452.6 Tm ( per quadrant in any) Tj ET BT /F3 10 Tf 1 0 0 1 336.79 452.6 Tm (24 months) Tj ET BT /F3 10 Tf 1 0 0 1 383.48 452.6 Tm ( period.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 438.01 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 438.01 Tm (Periodontal Surgery) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 436.51 Tm (1 in 36 months) Tj ET BT /F3 10 Tf 1 0 0 1 305.1 436.51 Tm (.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 423.01 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 423.01 Tm (Amalgam & Composite Fillings) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 421.51 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 245.06 421.51 Tm ( per surface in) Tj ET BT /F3 10 Tf 1 0 0 1 311.2 421.51 Tm (24 months) Tj ET BT /F3 10 Tf 1 0 0 1 357.9 421.51 Tm (.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 408.01 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 408.01 Tm (Simple Extractions) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 393.01 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 393.01 Tm (Root Canal) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 391.51 Tm (One per tooth per Lifetime.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 378.01 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 378.01 Tm (Surgical Extractions) Tj ET 0.5 w [] 0 d -7.45 491.95 m -7.45 374.06 l S 1 w [] 0 d 0.5 w [] 0 d 233.75 491.95 m 233.75 374.06 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 491.95 m 528.25 374.06 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 492.2 m 528.25 492.2 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 478.01 m 527.75 478.01 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 463.01 m 527.75 463.01 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 448.81 m 527.75 448.81 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 433.81 m 527.75 433.81 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 418.81 m 527.75 418.81 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 403.81 m 527.75 403.81 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 388.81 m 527.75 388.81 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 373.81 m 528.25 373.81 l S 1 w [] 0 d BT /F4 10 Tf 1 0 0 1 -1.7 363.41 Tm (Type C) Tj ET 0.5 w [] 0 d -7.45 373.56 m -7.45 359.86 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 373.56 m 528.25 359.86 l S 1 w [] 0 d BT /F5 9 Tf 1 0 0 1 -1.7 349.21 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 349.21 Tm (Crowns) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 349.21 Tm (1 in 84 months.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 335.01 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 335.01 Tm (Dentures) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 335.01 Tm (1 in 84) Tj ET BT /F3 10 Tf 1 0 0 1 272.3 335.01 Tm (months.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 320.81 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 320.81 Tm (Bridges) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 320.81 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 245.06 320.81 Tm ( in) Tj ET BT /F3 10 Tf 1 0 0 1 255.62 320.81 Tm ( 84 months.) Tj ET BT /F5 9 Tf 1 0 0 1 -1.7 306.21 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 306.21 Tm (Repairs \(Crowns\)) Tj ET BT /F3 10 Tf 1 0 0 1 239.5 304.71 Tm (1 in 12 months.) Tj ET 0.5 w [] 0 d -7.45 359.36 m -7.45 302.26 l S 1 w [] 0 d 0.5 w [] 0 d 233.75 359.36 m 233.75 302.26 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 359.36 m 528.25 302.26 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 359.61 m 528.25 359.61 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 345.41 m 527.75 345.41 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 331.21 m 527.75 331.21 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 317.01 m 527.75 317.01 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 302.01 m 528.25 302.01 l S 1 w [] 0 d BT /F4 10 Tf 1 0 0 1 -2.05 291.61 Tm (Orthodontia) Tj ET BT /F5 10 Tf 1 0 0 1 -2.05 276.91 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 15.95 276.91 Tm (Dependent children are covered up to their 26th birthday.) Tj ET BT /F5 8 Tf 1 0 0 1 -1.7 261.31 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 261.31 Tm (All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.) Tj ET BT /F5 8 Tf 1 0 0 1 -1.7 246.81 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 246.81 Tm (Payments are on a repetitive basis.) Tj ET BT /F5 8 Tf 1 0 0 1 -1.7 230.59 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 230.59 Tm (20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 217.36 Tm (on the plan benefits coinsurance level for Orthodontia as defined in the Plan Summary.) Tj ET BT /F5 8 Tf 1 0 0 1 -1.7 201.14 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 16.3 201.14 Tm (Orthodontic benefits end at cancellation of coverage.) Tj ET 0.5 w [] 0 d -7.45 301.76 m -7.45 198.69 l S 1 w [] 0 d 0.5 w [] 0 d 528.25 301.76 m 528.25 198.69 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 287.81 m 527.75 287.81 l S 1 w [] 0 d 0.5 w [] 0 d -6.95 273.61 m 527.75 273.61 l S 1 w [] 0 d 0.5 w [] 0 d -7.45 198.44 m 528.25 198.44 l S 1 w [] 0 d BT /F3 10 Tf 1 0 0 1 0 174.77 Tm (The service categories and plan limitations shown in this document represent an overview of your plan benefits, but) Tj ET BT /F3 10 Tf 1 0 0 1 0 161.54 Tm (are not a complete description of the plan.) Tj ET BT /F3 10 Tf 1 0 0 1 191.78 161.54 Tm (Before making any purchase or enrollment decision you should review the) Tj ET BT /F3 10 Tf 1 0 0 1 0 148.32 Tm (certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this) Tj ET BT /F3 10 Tf 1 0 0 1 0 135.1 Tm (overview and your certificate of insurance, your certificate of insurance governs. Like most group dental insurance) Tj ET BT /F3 10 Tf 1 0 0 1 0 121.87 Tm (policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them) Tj ET BT /F3 10 Tf 1 0 0 1 0 108.65 Tm (in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations.) Tj ET BT /F4 9 Tf 1 0 0 1 0 85.98 Tm (*Alternate Benefits:) Tj ET BT /F3 9 Tf 1 0 0 1 86.02 85.98 Tm (Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives) Tj ET BT /F3 9 Tf 1 0 0 1 0 75.63 Tm (for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment) Tj ET BT /F3 9 Tf 1 0 0 1 0 65.28 Tm (alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is) Tj ET BT /F3 9 Tf 1 0 0 1 0 54.93 Tm (based, you will be responsible for any additional payment responsibility.) Tj ET BT /F3 9 Tf 1 0 0 1 290.16 54.93 Tm (To avoid any misunderstandings, we suggest you discuss) Tj ET BT /F3 9 Tf 1 0 0 1 0 44.58 Tm (treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving) Tj ET BT /F3 9 Tf 1 0 0 1 0 34.23 Tm (certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits) Tj ET BT /F3 9 Tf 1 0 0 1 0 23.89 Tm (\(EOB\) outlining the services provided, your plans reimbursement for those services, and your out-of-pocket expense. Actual) Tj ET BT /F3 9 Tf 1 0 0 1 0 13.54 Tm (payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and) Tj ET BT /F3 9 Tf 1 0 0 1 0 3.19 Tm (other limits applicable at time of payment.) Tj ET Q q Q Q endstream endobj 12 0 obj <>>>>> endobj 13 0 obj [ 12 0 R /XYZ 47.5 733 0] endobj 14 0 obj <>stream q 0 0 612 792 re W n q 1 0 0 1 47.5 28.8 cm 0 0 0 rg BT /F3 9 Tf 1 0 0 1 0 12.95 Tm (DN-ONECLK-LG Benefit Summary One Click) Tj ET BT /F3 9 Tf 1 0 0 1 0 2.6 Tm (2023-10-09_5957643_9999_9999 _Dental_1) Tj ET BT /F3 9 Tf 1 0 0 1 249.16 23.3 Tm (Page) Tj ET BT /F3 9 Tf 1 0 0 1 272.68 23.3 Tm (4) Tj ET BT /F3 9 Tf 1 0 0 1 277.68 23.3 Tm ( of) Tj ET BT /F3 9 Tf 1 0 0 1 290.19 23.3 Tm (8) Tj ET BT /F3 9 Tf 1 0 0 1 375.38 23.3 Tm (200 Park Ave., New York, NY 10166) Tj ET BT /F3 9 Tf 1 0 0 1 344.22 12.95 Tm ( 2023 MetLife Services and Solutions, LLC) Tj ET BT /F3 9 Tf 1 0 0 1 383.34 2.6 Tm (L0522023151[exp0524][All States]) Tj ET Q q Q q 1 0 0 1 47.5 84.25 cm 0 0 0 rg BT /F3 4.8 Tf 1 0 0 1 0 643.91 Tm (1.) Tj ET BT /F3 8 Tf 1 0 0 1 10.67 641.51 Tm (The Reasonable and Customary charge is based on the lowest of the: "Actual Charge" \(the dentists actual charge\); or "Usual Charge" \(the) Tj ET BT /F3 8 Tf 1 0 0 1 0 632.31 Tm (dentists usual charge for the same or similar services\); or "Customary Charge" \(the 90) Tj ET BT /F3 4.8 Tf 1 0 0 1 306.69 634.71 Tm (th) Tj ET BT /F3 8 Tf 1 0 0 1 310.69 632.31 Tm ( percentile charge of most dentists in the same geographic) Tj ET BT /F3 8 Tf 1 0 0 1 0 623.11 Tm (area for the same or similar services as determined by MetLife\).) Tj ET BT /F3 8 Tf 1 0 0 1 0 607.91 Tm (The service categories and plan limitations shown above represent an overview of your plan benefits. This document presents the majority of) Tj ET BT /F3 8 Tf 1 0 0 1 0 598.71 Tm (services within each category, but is not a complete description of the plan.) Tj ET Q q Q Q endstream endobj 15 0 obj <>>>>> endobj 16 0 obj [ 15 0 R /XYZ 47.5 275.53 0] endobj 17 0 obj [ 15 0 R /XYZ 47.5 275.53 0] endobj 18 0 obj [ 15 0 R /XYZ 47.5 275.53 0] endobj 19 0 obj <>stream q 0 0 612 792 re W n q 1 0 0 1 47.5 28.8 cm 0 0 0 rg BT /F3 9 Tf 1 0 0 1 0 12.95 Tm (DN-ONECLK-LG Benefit Summary One Click) Tj ET BT /F3 9 Tf 1 0 0 1 0 2.6 Tm (2023-10-09_5957643_9999_9999 _Dental_1) Tj ET BT /F3 9 Tf 1 0 0 1 249.16 23.3 Tm (Page) Tj ET BT /F3 9 Tf 1 0 0 1 272.68 23.3 Tm (5) Tj ET BT /F3 9 Tf 1 0 0 1 277.68 23.3 Tm ( of) Tj ET BT /F3 9 Tf 1 0 0 1 290.19 23.3 Tm (8) Tj ET BT /F3 9 Tf 1 0 0 1 375.38 23.3 Tm (200 Park Ave., New York, NY 10166) Tj ET BT /F3 9 Tf 1 0 0 1 344.22 12.95 Tm ( 2023 MetLife Services and Solutions, LLC) Tj ET BT /F3 9 Tf 1 0 0 1 383.34 2.6 Tm (L0522023151[exp0524][All States]) Tj ET Q q Q q 1 0 0 1 47.5 84.25 cm 0 0 0 rg BT /F4 10 Tf 1 0 0 1 0 651.2 Tm (Exclusions) Tj ET BT /F4 10 Tf 1 0 0 1 0 628.2 Tm (We will not pay Dental Insurance benefits for charges incurred for:) Tj ET BT /F3 10 Tf 1 0 0 1 0 616.7 Tm (1.) Tj ET BT /F3 10 Tf 1 0 0 1 18 616.7 Tm (Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for) Tj ET BT /F3 10 Tf 1 0 0 1 18 605.2 Tm (treating the particular dental condition, or which We deem experimental in nature.) Tj ET BT /F3 10 Tf 1 0 0 1 0 593.7 Tm (2.) Tj ET BT /F3 10 Tf 1 0 0 1 18 593.7 Tm (Services for which You would not be required to pay in the absence of Dental Insurance.) Tj ET BT /F3 10 Tf 1 0 0 1 0 582.2 Tm (3.) Tj ET BT /F3 10 Tf 1 0 0 1 18 582.2 Tm (Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person.) Tj ET BT /F3 10 Tf 1 0 0 1 0 570.71 Tm (4.) Tj ET BT /F3 10 Tf 1 0 0 1 18 570.71 Tm (Services which are primarily cosmetic \(For residents of Texas, see notice page section in your certificate\).) Tj ET BT /F3 10 Tf 1 0 0 1 0 559.21 Tm (5.) Tj ET BT /F3 10 Tf 1 0 0 1 18 559.21 Tm (Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental) Tj ET BT /F3 10 Tf 1 0 0 1 18 547.71 Tm (hygienist which are supervised and billed by a Dentist and which are for:) Tj ET BT /F5 10 Tf 1 0 0 1 18 535.21 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 535.21 Tm (scaling and polishing of teeth; or) Tj ET BT /F5 10 Tf 1 0 0 1 18 522.71 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 522.71 Tm (fluoride treatments.) Tj ET BT /F3 10 Tf 1 0 0 1 0 511.21 Tm (6.) Tj ET BT /F3 10 Tf 1 0 0 1 18 511.21 Tm (Services or appliances which restore or alter occlusion or vertical dimension.) Tj ET BT /F3 10 Tf 1 0 0 1 0 499.71 Tm (7.) Tj ET BT /F3 10 Tf 1 0 0 1 18 499.71 Tm (Restoration of tooth structure damaged by attrition, abrasion or erosion.) Tj ET BT /F3 10 Tf 1 0 0 1 0 488.21 Tm (8.) Tj ET BT /F3 10 Tf 1 0 0 1 18 488.21 Tm (Restorations or appliances used for the purpose of periodontal splinting.) Tj ET BT /F3 10 Tf 1 0 0 1 0 476.71 Tm (9.) Tj ET BT /F3 10 Tf 1 0 0 1 18 476.71 Tm (Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.) Tj ET BT /F3 10 Tf 1 0 0 1 0 465.21 Tm (10.) Tj ET BT /F3 10 Tf 1 0 0 1 18 465.21 Tm (Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.) Tj ET BT /F3 10 Tf 1 0 0 1 0 453.71 Tm (11.) Tj ET BT /F3 10 Tf 1 0 0 1 18 453.71 Tm (Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.) Tj ET BT /F3 10 Tf 1 0 0 1 0 442.21 Tm (12.) Tj ET BT /F3 10 Tf 1 0 0 1 18 442.21 Tm (Missed appointments.) Tj ET BT /F3 10 Tf 1 0 0 1 0 430.72 Tm (13.) Tj ET BT /F3 10 Tf 1 0 0 1 18 430.72 Tm (Services:) Tj ET BT /F5 10 Tf 1 0 0 1 18 418.22 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 418.22 Tm (covered under any workers compensation or occupational disease law;) Tj ET BT /F5 10 Tf 1 0 0 1 18 405.72 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 405.72 Tm (covered under any employer liability law;) Tj ET BT /F5 10 Tf 1 0 0 1 18 393.22 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 393.22 Tm (for which the employer of the person receiving such services is not required to pay; or) Tj ET BT /F5 10 Tf 1 0 0 1 18 380.72 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 380.72 Tm (received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.) Tj ET BT /F3 10 Tf 1 0 0 1 0 369.22 Tm (14.) Tj ET BT /F3 10 Tf 1 0 0 1 18 369.22 Tm (Services covered under other coverage provided by the Employer.) Tj ET BT /F3 10 Tf 1 0 0 1 0 357.72 Tm (15.) Tj ET BT /F3 10 Tf 1 0 0 1 18 357.72 Tm (Temporary or provisional restorations.) Tj ET BT /F3 10 Tf 1 0 0 1 0 346.22 Tm (16.) Tj ET BT /F3 10 Tf 1 0 0 1 18 346.22 Tm (Temporary or provisional appliances.) Tj ET BT /F3 10 Tf 1 0 0 1 0 334.72 Tm (17.) Tj ET BT /F3 10 Tf 1 0 0 1 18 334.72 Tm (Prescription drugs.) Tj ET BT /F3 10 Tf 1 0 0 1 0 323.22 Tm (18.) Tj ET BT /F3 10 Tf 1 0 0 1 18 323.22 Tm (Services for which the submitted documentation indicates a poor prognosis.) Tj ET BT /F3 10 Tf 1 0 0 1 0 311.72 Tm (19.) Tj ET BT /F3 10 Tf 1 0 0 1 18 311.72 Tm (The following when charged by the Dentist on a separate basis:) Tj ET BT /F5 10 Tf 1 0 0 1 18 299.22 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 299.22 Tm (claim form completion;) Tj ET BT /F5 10 Tf 1 0 0 1 18 286.72 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 286.72 Tm (infection control such as gloves, masks, and sterilization of supplies; or) Tj ET BT /F5 10 Tf 1 0 0 1 18 274.22 Tm (x) Tj ET BT /F3 10 Tf 1 0 0 1 36 274.22 Tm (local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.) Tj ET BT /F3 10 Tf 1 0 0 1 0 262.72 Tm (20.) Tj ET BT /F3 10 Tf 1 0 0 1 18 262.72 Tm (Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the) Tj ET BT /F3 10 Tf 1 0 0 1 18 251.22 Tm (teeth due to chewing or biting of food.) Tj ET BT /F3 10 Tf 1 0 0 1 0 239.72 Tm (21.) Tj ET BT /F3 10 Tf 1 0 0 1 18 239.72 Tm (Caries susceptibility tests.) Tj ET BT /F3 10 Tf 1 0 0 1 0 228.23 Tm (22.) Tj ET BT /F3 10 Tf 1 0 0 1 18 228.23 Tm (Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing) Tj ET BT /F3 10 Tf 1 0 0 1 18 216.73 Tm (before such person was insured for Dental Insurance, except for congenitally missing natural teeth.) Tj ET BT /F3 10 Tf 1 0 0 1 0 205.23 Tm (23.) Tj ET BT /F3 10 Tf 1 0 0 1 18 205.23 Tm (Other fixed Denture prosthetic services not described elsewhere in this certificate.) Tj ET BT /F3 10 Tf 1 0 0 1 0 193.73 Tm (24.) Tj ET BT /F3 10 Tf 1 0 0 1 18 193.73 Tm (Precision attachments.) Tj ET BT /F3 10 Tf 1 0 0 1 0 182.23 Tm (25.) Tj ET BT /F3 10 Tf 1 0 0 1 18 182.23 Tm (Adjustment of a Denture) Tj ET BT /F3 10 Tf 1 0 0 1 0 170.73 Tm (26) Tj ET BT /F3 10 Tf 1 0 0 1 18 170.73 Tm (Diagnosis and treatment of temporomandibular joint \(TMJ\) disorders. This exclusion does not apply to residents) Tj ET BT /F3 10 Tf 1 0 0 1 18 159.23 Tm (of Minnesota.) Tj ET BT /F3 6 Tf 1 0 0 1 78.03 162.23 Tm ( 1) Tj ET BT /F3 10 Tf 1 0 0 1 0 147.73 Tm (27.) Tj ET BT /F3 10 Tf 1 0 0 1 18 147.73 Tm (Repair or replacement of an orthodontic device.) Tj ET BT /F3 6 Tf 1 0 0 1 228.67 150.73 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 0 136.23 Tm (28.) Tj ET BT /F3 10 Tf 1 0 0 1 18 136.23 Tm (Duplicate prosthetic devices or appliances.) Tj ET BT /F3 10 Tf 1 0 0 1 0 124.73 Tm (29.) Tj ET BT /F3 10 Tf 1 0 0 1 18 124.73 Tm (Replacement of a lost or stolen appliance, Cast Restoration, or Denture.) Tj ET BT /F3 10 Tf 1 0 0 1 0 113.23 Tm (30.) Tj ET BT /F3 10 Tf 1 0 0 1 18 113.23 Tm (Intra and extraoral photographic images.) Tj ET BT /F3 5.4 Tf 1 0 0 1 0 94.99 Tm (1) Tj ET BT /F3 9 Tf 1 0 0 1 4.5 92.29 Tm (Some of these exclusions may not apply.) Tj ET BT /F3 9 Tf 1 0 0 1 173.09 92.29 Tm (Please see your plan design and certificate for details.) Tj ET Q q Q Q endstream endobj 20 0 obj <>>>>> endobj 21 0 obj <>stream q 0 0 612 792 re W n q 1 0 0 1 47.5 28.8 cm 0 0 0 rg BT /F3 9 Tf 1 0 0 1 0 12.95 Tm (DN-ONECLK-LG Benefit Summary One Click) Tj ET BT /F3 9 Tf 1 0 0 1 0 2.6 Tm (2023-10-09_5957643_9999_9999 _Dental_1) Tj ET BT /F3 9 Tf 1 0 0 1 249.16 23.3 Tm (Page) Tj ET BT /F3 9 Tf 1 0 0 1 272.68 23.3 Tm (6) Tj ET BT /F3 9 Tf 1 0 0 1 277.68 23.3 Tm ( of) Tj ET BT /F3 9 Tf 1 0 0 1 290.19 23.3 Tm (8) Tj ET BT /F3 9 Tf 1 0 0 1 375.38 23.3 Tm (200 Park Ave., New York, NY 10166) Tj ET BT /F3 9 Tf 1 0 0 1 344.22 12.95 Tm ( 2023 MetLife Services and Solutions, LLC) Tj ET BT /F3 9 Tf 1 0 0 1 383.34 2.6 Tm (L0522023151[exp0524][All States]) Tj ET Q q Q q 1 0 0 1 47.5 84.25 cm 0 0 0 rg BT /F4 10 Tf 1 0 0 1 0 639.7 Tm (COMMON QUESTIONS IMPORTANT ANSWERS) Tj ET BT /F4 10 Tf 1 0 0 1 0 616.87 Tm (Who is a participating dentist?) Tj ET BT /F3 10 Tf 1 0 0 1 0 605.37 Tm (A participating dentist is a general dentist or specialist who has agreed to accept MetLife's negotiated fees as) Tj ET BT /F3 10 Tf 1 0 0 1 0 593.87 Tm (payment in full for services provided to plan participants. Based on internal analysis by MetLife, negotiated fees) Tj ET BT /F3 10 Tf 1 0 0 1 0 582.38 Tm (typically range from 15-45% below the average fees charged for the same services by dentists in the same) Tj ET BT /F3 10 Tf 1 0 0 1 0 570.88 Tm (geographic area.) Tj ET BT /F3 8 Tf 1 0 0 1 0 549.69 Tm (*Negotiated Fees refers to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-) Tj ET BT /F3 8 Tf 1 0 0 1 0 540.49 Tm (payments, deductibles, cost sharing and benefits maximums.) Tj ET BT /F3 8 Tf 1 0 0 1 220.55 540.49 Tm (Negotiated fees are subject to change.) Tj ET BT /F4 10 Tf 1 0 0 1 0 517.98 Tm (How do I find a participating dentist?) Tj ET BT /F3 10 Tf 1 0 0 1 0 506.48 Tm (You can access a list of participating dentists with directions and mapping capabilities online at) Tj ET BT /F3 10 Tf 1 0 0 1 0 494.98 Tm (www.metlife.com/dental or call 1-800-ASK-4-MET \(800-275-4638\) to have a list faxed or mailed to you based upon) Tj ET BT /F3 10 Tf 1 0 0 1 0 483.48 Tm (the requested ZIP code.) Tj ET BT /F4 10 Tf 1 0 0 1 112.29 483.48 Tm (Please Note:) Tj ET BT /F3 10 Tf 1 0 0 1 172.31 483.48 Tm ( Be sure to verify provider participation when you make your appointment.) Tj ET BT /F4 10 Tf 1 0 0 1 0 460.49 Tm (May I choose a non-participating dentist?) Tj ET BT /F3 10 Tf 1 0 0 1 0 448.99 Tm (Yes. You are always free to select the dentist of your choice. However, if you choose a dentist who does not) Tj ET BT /F3 10 Tf 1 0 0 1 0 437.49 Tm (participate in the MetLife program, your out-of-pocket expenses may be greater, since you will be responsible to pay) Tj ET BT /F3 10 Tf 1 0 0 1 0 425.99 Tm (for any difference between the dentist's fee and your plan's payment for the approved service. If you receive services) Tj ET BT /F3 10 Tf 1 0 0 1 0 414.49 Tm (from a participating dentist, you are only responsible for the difference between the in-network fee for the service) Tj ET BT /F3 10 Tf 1 0 0 1 0 402.99 Tm (provided and your plan's payment for the approved service. Please note: any plan deductibles must be met before) Tj ET BT /F3 10 Tf 1 0 0 1 0 391.49 Tm (benefits are paid.) Tj ET BT /F4 10 Tf 1 0 0 1 0 368.49 Tm (Can) Tj ET BT /F4 10 Tf 1 0 0 1 24.45 368.49 Tm (my dentist apply for participation in network?) Tj ET BT /F3 10 Tf 1 0 0 1 0 356.99 Tm (Yes. If your current dentist does not participate in the MetLife network and you would like to encourage him or her to) Tj ET BT /F3 10 Tf 1 0 0 1 0 345.5 Tm (apply, tell your dentist to visit www.metdental.com, or call 1-877-MET-DDS9 for an application. The website and) Tj ET BT /F3 10 Tf 1 0 0 1 0 334 Tm (phone number are designed for use by dental professionals only.) Tj ET BT /F4 10 Tf 1 0 0 1 0 311 Tm (How are claims processed?) Tj ET BT /F3 10 Tf 1 0 0 1 0 299.5 Tm (Dentists may submit your claims for you, which means you have little or no paperwork. You can track your claims) Tj ET BT /F3 10 Tf 1 0 0 1 0 288 Tm (online and even receive e-mail alerts when a claim has been processed. If you need a claim form, you) Tj ET BT /F3 10 Tf 1 0 0 1 456.35 288 Tm (can find one) Tj ET BT /F3 10 Tf 1 0 0 1 0 276.5 Tm (online at www.metlife.com/dental or request one by calling 1-800-ASK-4-MET \(800-275-4638\).) Tj ET BT /F4 10 Tf 1 0 0 1 0 253.5 Tm (Can I find out what my out-of-pocket expenses will be before receiving a service?) Tj ET BT /F3 10 Tf 1 0 0 1 0 242 Tm (Yes. With pre-treatment estimates, you never have to wonder what your out-of-pocket expense will be. MetLife) Tj ET BT /F3 10 Tf 1 0 0 1 0 230.51 Tm (recommends that you request a pre-treatment estimate for services in excess of $300 \(This often applies to services) Tj ET BT /F3 10 Tf 1 0 0 1 0 219.01 Tm (such as crowns, bridges, inlays, and periodontics\). To receive a benefit estimate, simply have your dentist submit a) Tj ET BT /F3 10 Tf 1 0 0 1 0 207.51 Tm (request for a pre-treatment estimate online at www.metdental.com or call 1-877-MET-DDS9 \(638-3379\). You and) Tj ET BT /F3 10 Tf 1 0 0 1 0 196.01 Tm (your dentist will receive a benefit estimate online or by fax for most procedures while you are still in the office so you) Tj ET BT /F3 10 Tf 1 0 0 1 0 184.51 Tm (can discuss treatment and payment options and have the procedure scheduled on the spot. Actual payments may) Tj ET BT /F3 10 Tf 1 0 0 1 0 173.01 Tm (vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.) Tj ET BT /F4 10 Tf 1 0 0 1 0 150.01 Tm (Do I need an ID card?) Tj ET BT /F3 10 Tf 1 0 0 1 0 138.51 Tm (No, you do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you) Tj ET BT /F3 10 Tf 1 0 0 1 0 127.01 Tm (participate in MetLife's PDP. Your dentist can easily verify information about your coverage through a toll-free) Tj ET BT /F3 10 Tf 1 0 0 1 0 115.52 Tm (automated Computer Voice Response system.) Tj ET BT /F4 10 Tf 1 0 0 1 0 92.52 Tm (Do my dependents have to visit the same dentist that I select?) Tj ET BT /F3 10 Tf 1 0 0 1 0 81.02 Tm (No, you and your dependents each have the freedom to choose any dentist.) Tj ET BT /F4 10 Tf 1 0 0 1 0 58.02 Tm (If I do not enroll during my initial enrollment period can I still purchase Dental Insurance at a later date?) Tj ET BT /F3 10 Tf 1 0 0 1 0 46.52 Tm (Yes, eligible employees who do not elect coverage during their 31-day application period may still elect coverage) Tj ET BT /F3 10 Tf 1 0 0 1 0 35.02 Tm (later. Dental coverage elected after the 31-day application period is subject to the following waiting periods:*) Tj ET BT /F3 10 Tf 1 0 0 1 18 23.52 Tm ( No waiting period for Preventive Services) Tj ET BT /F3 10 Tf 1 0 0 1 18 12.02 Tm ( 6 months on Basic Restorative \(Fillings\)) Tj ET Q q Q Q endstream endobj 22 0 obj <>>>>> endobj 23 0 obj <>/Border[ 0 0 0]/Rect[ 191.46 581.21 318.15 592.71]/Subtype/Link>> endobj 24 0 obj <>stream q 0 0 612 792 re W n q 1 0 0 1 47.5 28.8 cm 0 0 0 rg BT /F3 9 Tf 1 0 0 1 0 12.95 Tm (DN-ONECLK-LG Benefit Summary One Click) Tj ET BT /F3 9 Tf 1 0 0 1 0 2.6 Tm (2023-10-09_5957643_9999_9999 _Dental_1) Tj ET BT /F3 9 Tf 1 0 0 1 249.16 23.3 Tm (Page) Tj ET BT /F3 9 Tf 1 0 0 1 272.68 23.3 Tm (7) Tj ET BT /F3 9 Tf 1 0 0 1 277.68 23.3 Tm ( of) Tj ET BT /F3 9 Tf 1 0 0 1 290.19 23.3 Tm (8) Tj ET BT /F3 9 Tf 1 0 0 1 375.38 23.3 Tm (200 Park Ave., New York, NY 10166) Tj ET BT /F3 9 Tf 1 0 0 1 344.22 12.95 Tm ( 2023 MetLife Services and Solutions, LLC) Tj ET BT /F3 9 Tf 1 0 0 1 383.34 2.6 Tm (L0522023151[exp0524][All States]) Tj ET Q q Q q 1 0 0 1 47.5 84.25 cm 0 0 0 rg BT /F3 10 Tf 1 0 0 1 18 651.2 Tm ( 12 months on all other Basic Services) Tj ET BT /F3 10 Tf 1 0 0 1 18 639.7 Tm ( 24 months on Major Services) Tj ET BT /F3 10 Tf 1 0 0 1 18 628.2 Tm ( 24 months on Orthodontia Services \(if applicable\)) Tj ET BT /F3 6 Tf 1 0 0 1 0 608.82 Tm (*If the policy holder participates in a section 125 plan) Tj ET BT /F3 6 Tf 1 0 0 1 141.75 608.82 Tm (and) Tj ET 2 J 0.439 w [] 0 d 0 0 0 RG 141.97 607.97 m 151.54 607.97 l S 1 w [] 0 d BT /F3 6 Tf 1 0 0 1 151.76 608.82 Tm ( has an annual open enrollment period, the dental coverage will not be subject to any waiting periods.) Tj ET BT /F3 6 Tf 1 0 0 1 423.94 608.82 Tm (Please consult your Benefits) Tj ET BT /F3 6 Tf 1 0 0 1 0 601.92 Tm (Administrator or your certificate for this plan information.) Tj ET BT /F4 10 Tf 1 0 0 1 0 579.9 Tm (Am I eligible for all benefits the first day of coverage?) Tj ET BT /F3 10 Tf 1 0 0 1 0 568.41 Tm (Your plan may include benefit waiting periods.) Tj ET BT /F3 10 Tf 1 0 0 1 209.57 568.41 Tm (Please refer to the certificate of insurance or your Benefits) Tj ET BT /F3 10 Tf 1 0 0 1 0 556.91 Tm (Administrator for details about the services that are subject to the waiting periods and the length of time they apply.) Tj ET BT /F4 10 Tf 1 0 0 1 0 533.91 Tm (How can I learn about what dentists in my area charge for different procedures?) Tj ET BT /F3 10 Tf 1 0 0 1 0 522.41 Tm (If you have MyBenefits you can access the Dental Procedure Tool.) Tj ET BT /F3 10 Tf 1 0 0 1 300.71 522.41 Tm (You can use the tool to look up average in- and) Tj ET BT /F3 10 Tf 1 0 0 1 0 510.91 Tm (out-of-network fees for dental services in your area.) Tj ET BT /F3 10 Tf 1 0 0 1 233.44 510.91 Tm (* Youll find fees for services such as exams, cleanings, fillings,) Tj ET BT /F3 10 Tf 1 0 0 1 0 499.41 Tm (crowns, and more. Just log in at) Tj ET 0 0 1 rg BT /F3 10 Tf 1 0 0 1 143.96 499.41 Tm (www.metlife.com/mybenefits) Tj ET 0 0 0 rg BT /F3 10 Tf 1 0 0 1 270.65 499.41 Tm (.) Tj ET BT /F3 10 Tf 1 0 0 1 0 476.41 Tm (* The Dental Procedure Fee Tool application is provided by VerifPoint, an independent vendor. Network fee) Tj ET BT /F3 10 Tf 1 0 0 1 0 464.91 Tm (information is supplied to VerifPoint by MetLife and is not available for providers who participate with MetLife through) Tj ET BT /F3 10 Tf 1 0 0 1 0 453.42 Tm (a third-party. Out-of-network fee information is provided by VerifPoint. This tool does not provide the payment) Tj ET BT /F3 10 Tf 1 0 0 1 0 441.92 Tm (information used by MetLife when processing your claims. Prior to receiving services, pretreatment estimates through) Tj ET BT /F3 10 Tf 1 0 0 1 0 430.42 Tm (your dentist will provide the most accurate fee and payment information) Tj ET BT /F4 10 Tf 1 0 0 1 0 407.42 Tm (Can MetLife help me find a dentist outside of the U.S. if I am traveling?) Tj ET BT /F3 10 Tf 1 0 0 1 0 395.92 Tm (Yes. Through MetLifes International Dental Travel Assistance program) Tj ET BT /F3 6 Tf 1 0 0 1 314.04 398.92 Tm (1) Tj ET BT /F3 10 Tf 1 0 0 1 317.38 395.92 Tm ( you can obtain a referral to a local dentist by) Tj ET BT /F3 10 Tf 1 0 0 1 0 384.42 Tm (calling 1-312-356-5970 \(collect\) when outside the U.S. to receive immediate care until you can see your dentist.) Tj ET BT /F3 10 Tf 1 0 0 1 0 372.92 Tm (Coverage will be considered under your out-of-network) Tj ET BT /F3 6 Tf 1 0 0 1 242.91 375.92 Tm (2) Tj ET BT /F3 10 Tf 1 0 0 1 246.24 372.92 Tm ( benefits. Please remember to hold on to all receipts to submit) Tj ET BT /F3 10 Tf 1 0 0 1 0 361.42 Tm (a dental claim.) Tj ET BT /F3 8 Tf 1 0 0 1 0 351.73 Tm (1 International Dental Travel Assistance services are administered by AXA Assistance USA, Inc.) Tj ET BT /F3 8 Tf 1 0 0 1 345.04 351.73 Tm (Certain benefits provided under the Travel) Tj ET BT /F3 8 Tf 1 0 0 1 0 342.54 Tm (Assistance program are underwritten by Virginia Surety Company, Inc. AXA Assistance and Virginia Surety are not affiliated with MetLife, and the) Tj ET BT /F3 8 Tf 1 0 0 1 0 333.34 Tm (services and benefits they provide are separate and apart from the insurance provided by MetLife. Referral services are not available in all) Tj ET BT /F3 8 Tf 1 0 0 1 0 324.14 Tm (locations.) 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