Dental Plan

For a detailed description of covered procedures and services, please refer to the MetLife materials available from MetLife. A brief set of examples of what may be covered include:

Oral exams and cleaning of teeth once in a 6 month period

X-rays as defined by MetLife materials.

Amalgam or composite fillings

Root canal treatment as defined by MetLife materials

Extractions

Orthodontia as defined by MetLife materials.

For a detailed description of procedures and services not covered, please refer to the MetLife materials available from MetLife. A brief set of examples of what are not covered include:

Services or supplies received before the dental expense benefits start for the covered person.

Services not performed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling and polishing of teeth or for fluoride treatments.

Cosmetic surgery, treatment or supplies, unless required for the treatment or correction of a congenital defect of a newborn dependent child.

Services which are covered under other non-dental insurance plans, which are covered through workers’ compensation or employer liability laws or for which coverage exists through any municipality, county, military or other political entity or which are covered by any medical policy. This plan does not duplicate coverage for dental services.

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.