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Your Dental Coverage—2018

One plan with two ways to receive benefits:

  • Standard dental benefit: You can see any dentist, but you’ll pay more for care.
  • Network dental benefit: If you use only MetLife participating dentists, you’ll pay less for care.
Plan Features Standard Benefit Network Benefit
Annual deductible $25 per person; $75 per family
Annual benefit maximum
(all services except orthodontia)
$1,500 per person
Preventive services Plan pays
  • 2 exams per calendar year
  • 2 cleanings per calendar year
  • 2 supplementary bitewing X-rays per calendar year
  • Complete X-rays every 36 months
  • Fluoride treatments
  • Sealants for children under age 19 (once in a lifetime, permanent molars only)
  • Space maintainers
100% R&C*, no deductible 100% of network negotiated cost, no deductible
Restorative services
  • Fillings, including composite (white) fillings
  • Extractions
  • Root canals
  • Gum treatment
  • Night guard
80% R&C*, after deductible 90% of network negotiated cost, after deductible
Prosthodontics
  • Crowns, inlays and onlays
  • Implants
  • Installation and repair of bridgework and/or dentures
50% R&C*, after deductible 60% of network negotiated cost, after deductible
Orthodontics
  • Braces to straighten teeth for children through the end of the month they turn age 19
50% R&C* 60% of network negotiated cost
Up to a $1,500 lifetime benefit

* You pay any charges above reasonable and customary (R&C). R&C cost is the amount MetLife considers reasonable in your geographic area for the same service.

Pre-Treatment Approval—It’s a Good Idea

If you or your dentist expects a treatment to cost more than $100, you should ask your dentist to submit a pre-treatment estimate to MetLife before your treatment begins. Here’s why this is a good idea:

  • You’ll receive confirmation that the treatment is covered under the plan.
  • You’ll know exactly the amount the plan covers and what your out-of-pocket costs will be.

Filing a Dental Claim

Present your dental ID card or a dental claim form to your provider at the time of service. Need a claim form? Use this form or call the Dominion Energy HelpLine to have a form sent to you.

Question About Coverage or Claims?

MetLife
1-800-942-0854
MetLife website (select company name: Dominion Energy)

Want to Know More?